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Introduction: Controversy exists in antiepileptic drug (AED) prophylaxis prescribing in patients with aneurysmal subarachnoid hemorrhage (SAH). We undertook the Use of Antiepileptic Drugs in Aneurysmal Subarachnoid Hemorrhage (ALIBI) study to identify factors associated with prescribing practices. Methods: A retrospective chart review of all consecutive patients requiring Level 1 care with aneurysmal SAH admitted between 2012 and 2014 to the intensive care unit at Toronto Western Hospital, Ontario, Canada, was conducted. Data were collected on clinical and imaging characteristics. Primary and secondary outcomes were AED prophylaxis and clinical seizure activity during hospitalization. Data were compared using chi-square or Mann–Whitney U-tests. Those variables found to be significant, or trending toward significance, on univariate analysis were fitted to multivariate regression. Results: Sixty-eight patients were included. Mean age was 62 ± 12.2, and 42.6% of patients were male. Of these, 21 patients (30.9%) received AED prophylactically, while 18 (26.5%) had reported seizures at some point during hospitalization. Female gender and presence of midline shift (MLS) were significantly associated or approached significance with AED prophylaxis in univariate analysis (p = 0.036 and p = 0.062, respectively). In multivariate analysis, only MLS was an independent predictor (odds ratio 5.09, p = 0.04). Conclusion: The presence of MLS was an independent predictor of seizure activity in patients with aneurysmal SAH. AED prophylaxis prescribing patterns seemed arbitrary and was not informed by identifiable clinical factors or true risk factors for seizure. A current lack of evidence guiding AED prescribing practice highlights the need for larger studies in this patient population.
Clinicians need guidance to address the heterogeneity of treatment responses of patients with major depressive disorder (MDD). While prediction schemes based on symptom clustering and biomarkers have so far not yielded results of sufficient strength to inform clinical decision-making, prediction schemes based on big data predictive analytic models might be more practically useful.
We review evidence suggesting that prediction equations based on symptoms and other easily-assessed clinical features found in previous research to predict MDD treatment outcomes might provide a foundation for developing predictive analytic clinical decision support models that could help clinicians select optimal (personalised) MDD treatments. These methods could also be useful in targeting patient subsamples for more expensive biomarker assessments.
Approximately two dozen baseline variables obtained from medical records or patient reports have been found repeatedly in MDD treatment trials to predict overall treatment outcomes (i.e., intervention v. control) or differential treatment outcomes (i.e., intervention A v. intervention B). Similar evidence has been found in observational studies of MDD persistence-severity. However, no treatment studies have yet attempted to develop treatment outcome equations using the full set of these predictors. Promising preliminary empirical results coupled with recent developments in statistical methodology suggest that models could be developed to provide useful clinical decision support in personalised treatment selection. These tools could also provide a strong foundation to increase statistical power in focused studies of biomarkers and MDD heterogeneity of treatment response in subsequent controlled trials.
Coordinated efforts are needed to develop a protocol for systematically collecting information about established predictors of heterogeneity of MDD treatment response in large observational treatment studies, applying and refining these models in subsequent pragmatic trials, carrying out pooled secondary analyses to extract the maximum amount of information from these coordinated studies, and using this information to focus future discovery efforts in the segment of the patient population in which continued uncertainty about treatment response exists.
In a 1-year survey at a university hospital we found that 20·6% (81/392) of patients with antibiotic associated diarrohea where positive for C. difficile. The most common PCR ribotypes were 012 (14·8%), 027 (12·3%), 046 (12·3%) and 014/020 (9·9). The incidence rate was 2·6 cases of C. difficile infection for every 1000 outpatients.
The first aim was to use confirmatory factor analysis (CFA) to test a hypothesis that two factors (internalizing and externalizing) account for lifetime co-morbid DSM-IV diagnoses among adults with bipolar I (BPI) disorder. The second aim was to use confirmatory latent class analysis (CLCA) to test the hypothesis that four clinical subtypes are detectible: pure BPI; BPI plus internalizing disorders only; BPI plus externalizing disorders only; and BPI plus internalizing and externalizing disorders.
A cohort of 699 multiplex BPI families was studied, ascertained and assessed (1998–2003) by the National Institute of Mental Health Genetics Initiative Bipolar Consortium: 1156 with BPI disorder (504 adult probands; 594 first-degree relatives; and 58 more distant relatives) and 563 first-degree relatives without BPI. Best-estimate consensus DSM-IV diagnoses were based on structured interviews, family history and medical records. MPLUS software was used for CFA and CLCA.
The two-factor CFA model fit the data very well, and could not be improved by adding or removing paths. The four-class CLCA model fit better than exploratory LCA models or post-hoc-modified CLCA models. The two factors and four classes were associated with distinctive clinical course and severity variables, adjusted for proband gender. Co-morbidity, especially more than one internalizing and/or externalizing disorder, was associated with a more severe and complicated course of illness. The four classes demonstrated significant familial aggregation, adjusted for gender and age of relatives.
The BPI two-factor and four-cluster hypotheses demonstrated substantial confirmatory support. These models may be useful for subtyping BPI disorders, predicting course of illness and refining the phenotype in genetic studies.
To examine cross-national patterns and correlates of lifetime and 12-month comorbid DSM-IV anxiety disorders among people with lifetime and 12-month DSM-IV major depressive disorder (MDD).
Nationally or regionally representative epidemiological interviews were administered to 74 045 adults in 27 surveys across 24 countries in the WHO World Mental Health (WMH) Surveys. DSM-IV MDD, a wide range of comorbid DSM-IV anxiety disorders, and a number of correlates were assessed with the WHO Composite International Diagnostic Interview (CIDI).
45.7% of respondents with lifetime MDD (32.0–46.5% inter-quartile range (IQR) across surveys) had one of more lifetime anxiety disorders. A slightly higher proportion of respondents with 12-month MDD had lifetime anxiety disorders (51.7%, 37.8–54.0% IQR) and only slightly lower proportions of respondents with 12-month MDD had 12-month anxiety disorders (41.6%, 29.9–47.2% IQR). Two-thirds (68%) of respondents with lifetime comorbid anxiety disorders and MDD reported an earlier age-of-onset (AOO) of their first anxiety disorder than their MDD, while 13.5% reported an earlier AOO of MDD and the remaining 18.5% reported the same AOO of both disorders. Women and previously married people had consistently elevated rates of lifetime and 12-month MDD as well as comorbid anxiety disorders. Consistently higher proportions of respondents with 12-month anxious than non-anxious MDD reported severe role impairment (64.4 v. 46.0%; χ21 = 187.0, p < 0.001) and suicide ideation (19.5 v. 8.9%; χ21 = 71.6, p < 0.001). Significantly more respondents with 12-month anxious than non-anxious MDD received treatment for their depression in the 12 months before interview, but this difference was more pronounced in high-income countries (68.8 v. 45.4%; χ21 = 108.8, p < 0.001) than low/middle-income countries (30.3 v. 20.6%; χ21 = 11.7, p < 0.001).
Patterns and correlates of comorbid DSM-IV anxiety disorders among people with DSM-IV MDD are similar across WMH countries. The narrow IQR of the proportion of respondents with temporally prior AOO of anxiety disorders than comorbid MDD (69.6–74.7%) is especially noteworthy. However, the fact that these proportions are not higher among respondents with 12-month than lifetime comorbidity means that temporal priority between lifetime anxiety disorders and MDD is not related to MDD persistence among people with anxious MDD. This, in turn, raises complex questions about the relative importance of temporally primary anxiety disorders as risk markers v. causal risk factors for subsequent MDD onset and persistence, including the possibility that anxiety disorders might primarily be risk markers for MDD onset and causal risk factors for MDD persistence.
There is an opportunity for scaling up, optimizing, and controlling the process of production of nanoparticles due to their numerous diverse applications. We present a system for continuous, high rate production of nanoparticles, particularly those of carbon, using large volume thermal plasma based on a three-phase diverging electrode configuration. The goal of using this 3-phase plasma reactor is to have a plasma arc that is scalable, self-stabilizing, and low maintenance, with sufficient plasma volume to maximize residence time of feed materials for evaporation to atomic species. Plasma carrier gas, typically inert gas such as helium, is injected into the reactor allowing the vaporization of any feedstock due to plasma temperatures >5000 °C. Controlling plasma enthalpy, diffusion/temperature gradients and carbon feed rates allow the controlled growth of clusters leading to nanoparticles less than 100 nm. Once the desired size is achieved the gas stream is expanded to reduce the reaction rate and quenched by natural cooling to chamber walls or injection of a cooling gas stream, preferably of the same composition as plasma carrier gas. Recoverable yields in the nanoparticle-laden gas stream are then isolated by standard means (filtration, cyclone separation, electrostatic precipitation), and the plasma gas and unreacted feedstock are routed to the plasma reactor for recycling. Computational Fluid Dynamics (CFD) is employed to measure and predict fluid flow, energy/temperature, and other species distributions in the plasma process.
State programs promoting their agricultural products have proliferated in response to increased consumer interest in locally grown foods. Tennessee, for example, currently has two state-funded programs promoting its agricultural products. This study examines the factors associated with participation by Tennessee fruit and vegetable farmers in those programs. The results suggest that farmer participation is associated with farm income, use of extension resources, and fresh produce sales. These results should be of interest to anyone attempting to increase producer participation in such programs.
Although variation in the long-term course of major depressive disorder (MDD) is not strongly predicted by existing symptom subtype distinctions, recent research suggests that prediction can be improved by using machine learning methods. However, it is not known whether these distinctions can be refined by added information about co-morbid conditions. The current report presents results on this question.
Data came from 8261 respondents with lifetime DSM-IV MDD in the World Health Organization (WHO) World Mental Health (WMH) Surveys. Outcomes included four retrospectively reported measures of persistence/severity of course (years in episode; years in chronic episodes; hospitalization for MDD; disability due to MDD). Machine learning methods (regression tree analysis; lasso, ridge and elastic net penalized regression) followed by k-means cluster analysis were used to augment previously detected subtypes with information about prior co-morbidity to predict these outcomes.
Predicted values were strongly correlated across outcomes. Cluster analysis of predicted values found three clusters with consistently high, intermediate or low values. The high-risk cluster (32.4% of cases) accounted for 56.6–72.9% of high persistence, high chronicity, hospitalization and disability. This high-risk cluster had both higher sensitivity and likelihood ratio positive (LR+; relative proportions of cases in the high-risk cluster versus other clusters having the adverse outcomes) than in a parallel analysis that excluded measures of co-morbidity as predictors.
Although the results using the retrospective data reported here suggest that useful MDD subtyping distinctions can be made with machine learning and clustering across multiple indicators of illness persistence/severity, replication with prospective data is needed to confirm this preliminary conclusion.
Methane (CH4) emissions by dairy cows vary with feed intake and diet composition. Even when fed on the same diet at the same intake, however, variation between cows in CH4 emissions can be substantial. The extent of variation in CH4 emissions among dairy cows on commercial farms is unknown, but developments in methodology now permit quantification of CH4 emissions by individual cows under commercial conditions. The aim of this research was to assess variation among cows in emissions of eructed CH4 during milking on commercial dairy farms. Enteric CH4 emissions from 1964 individual cows across 21 farms were measured for at least 7 days/cow using CH4 analysers at robotic milking stations. Cows were predominantly of Holstein Friesian breed and remained on the same feeding systems during sampling. Effects of explanatory variables on average CH4 emissions per individual cow were assessed by fitting a linear mixed model. Significant effects were found for week of lactation, daily milk yield and farm. The effect of milk yield on CH4 emissions varied among farms. Considerable variation in CH4 emissions was observed among cows after adjusting for fixed and random effects, with the CV ranging from 22% to 67% within farms. This study confirms that enteric CH4 emissions vary among cows on commercial farms, suggesting that there is considerable scope for selecting individual cows and management systems with reduced emissions.
Antibiotic susceptibilities of large cohorts of Enterobacteriaceae isolated from urine collected in the community are scarce. We report the susceptibilities of Enterobacteriaceae isolated from urine of non-selected community populations in a metropolitan area (Leeds and Bradford, UK) over 2 years. Isolates (n = 6614) were identified as follows: Escherichia coli (n = 5436), Klebsiella spp. (n = 525), Proteus mirabilis (n = 305), and 15 other species (n = 290); 58 isolates were unidentified. Ampicillin resistance was observed in 53% E. coli and 28% P. mirabilis; ⩾34% E. coli and P. mirabilis were non-susceptible to trimethoprim compared to 20% Klebsiella spp.; nitrofurantoin resistance was observed in 3% E. coli and 15% Klebsiella spp. The occurrence of extended-spectrum β-lactamases (ESBL) was low (6%), as was non-susceptibility to carbapenems, cefipime and tigecycline (<2%). Further surveillance is required to monitor this level of resistance and additional clinical studies are needed to understand the impact on the outcome of current empirical prescribing decisions.
Severe sepsis and septic shock are common and often fatal medical problems. The Prehospital Sepsis Project is a multifaceted study that aims to improve the out-of-hospital care of patients with sepsis by means of education and enhancement of skills. The objective of this Project was to assess the knowledge and attitudes in the principles of diagnosis and management of sepsis in a cohort of United States out-of-hospital care providers.
This was cross-sectional study. A 15-item survey was administered via the Web and e-mailed to multiple emergency medical services list-servers. The evaluation consisted of four clinical scenarios as well as questions on the basics of sepsis. For intra-rater reliability, the first and the fourth scenarios were identical. Chi-square and Fisher's Exact testing were used to assess associations. Relative risk (RR) was used for strength of association. Statistical significance was set at .05.
A total of 226 advanced EMS providers participated with a 85.4% (n = 193) completion rate, consisting of a 30.7% rural, 32.3% urban, and 37.0% suburban mix; 82.4% were paramedics and 72.5% had worked in EMS >10 years. Only 57 (29.5%) participants scored both of the duplicate scenarios correctly, and only 19 of the 193 (9.8%) responded to all scenarios correctly. Level of training was not a predictor of correctly scoring scenarios (P = .71, RR = 1.25, 95% CI = 0.39-4.01), nor was years of service (P = .11, RR = 1.64, 95% CI = 0.16-1.21).
Poor understanding of the principles of diagnosis and management of sepsis was observed in this cohort, suggesting the need for enhancement of education. Survey items will be used to develop a focused, interactive Web-based learning program. Limitations include potential for self-selection and data accuracy.
Báez AA, Hanudel P, Perez MT, Giraldez EM, Wilcox SR. Prehospital Sepsis Project (PSP): Knowledge and Attitudes of United States Advanced Out-of-Hospital Care Providers. Prehosp Disaster Med. 2013;28(2):1-3.
Non-suicidal self-injury (NSSI) is the deliberate and direct injuring of body tissue without suicidal intent for purposes not socially sanctioned. Few studies have examined the correlates of NSSI among young adults. This study aimed to identify predictors of lifetime and past-year NSSI, and describe motives for NSSI and disclosure of NSSI to others.
Interviews were conducted annually with 1081 students enrolled in the College Life Study, a prospective longitudinal study conducted at a large public mid-Atlantic university. NSSI characteristics were assessed at Year 4. Demographic and predictor variables were assessed during Years 1 to 4. Multivariate logistic regression models were used to identify correlates of lifetime NSSI and predictors of past-year NSSI.
The prevalence of past-year and lifetime NSSI was 2% and 7% respectively (>70% were female for both lifetime and past-year NSSI). Seven percent of NSSI cases self-injured once, whereas almost half self-injured six or more times. Independent predictors of past-year NSSI were maternal depression, non-heterosexual orientation, affective dysregulation and depression. Independent predictors of lifetime NSSI were depression, non-heterosexual orientation, paternal depression and female sex. One in six participants with NSSI had attempted suicide by young adulthood. The three most commonly reported motives for NSSI were mental distress, coping and situational stressors. Most (89%) told someone about their NSSI, most commonly a friend (68%).
This study identified unique predictors of NSSI, which should help to elucidate its etiology and has implications for early identification and interventions.
A combustion synthesis technique was used to prepare nanoparticulate LiMgxMn1−xPO4 (x = 0, 0.1, 0.2)/carbon composites. Powders consisted of carbon-coated particles about 30 nm in diameter, which were partly agglomerated into larger secondary particles. The utilization of the active materials in lithium cells depended most strongly on the post-treatment and the Mg content and was not influenced by the amount of carbon. Best results were achieved with a hydrothermally treated LiMg0.2Mn0.8PO4/C composite, which exhibited close to 50% utilization of the theoretical capacity at a C/2 discharge rate.
Methods of transmission of Jembrana disease, an acute and severe disease of Bali cattle (Bos javanicus) caused by a recently-identified bovine lentivirus known as Jembrana disease virus, are described. During the acute disease virus can be detected in saliva and milk. There is evidence of direct transmission from acutely affected animals in close contact with susceptible cattle, possibly by virus in these secretions infecting cattle by the conjunctiva!, intranasal or oral routes, by which it was possible to infect cattle experimentally. During the acute disease the titre of infectious virus in blood is high, about 108 50% cattle infectious units (ID50)/ml, and it is probable that the virus is also transmitted mechanically by haematophagous arthropods. Recovered cattle are also a potential but probably infrequent source of infection; recovered cattle are persistently viraemic but the titre of infectious virus in blood decreases to about 101 ID50/ml by 60 days after recovery from the acute disease, and virus cannot be detected in secretions.
A total of 12902 neonatal samples collected on absorbent paper for routine metabolic screening were tested anonymously for antibodies to toxoplasma. Seroprevalence varied from 19.5% in inner London, to 11.6% in suburban London, and 7.6% in non-metropolitan districts. Much of this variation appeared to be associated with the proportions of livebirths in each district to women born outside the UK. However, additional geographical variation remained and seroprevalence in UK-born women was estimated to be 12.7% in inner London, 7.5% in suburban London, and 5.5% in non-metropolitan areas. These estimates are considerably lower than any previously reported in antenatal sera in the UK. The wide geographical variation highlights a need for further research to determine the relative importance of different routes of transmission.
The physiological behaviour of clinical Aeromonas spp. isolates was compared following culture in a conventional broth and human pooled ileostomy fluid (PIF). Protein expression was markedly affected by the growth medium, with an overall reduction in whole cell proteins in bacteria grown in ileostomy fluid. In addition, novel outer membrane proteins were produced in PIF but not in broth. The majority of A. hydrophila and A. sobria isolates produced toxin in both broth and PIF. whereas no cytotoxin positive A. caviae were found. Toxin titres were at least two doubling dilutions higher in 40% and 21% of A. hydrophila and A. sobria isolates, respectively, following culture in brain heart infusion broth compared with PIF. Bacterial adherence to Vero and A-549 cells was significantly more common in A. hydrophila (53%) and A. sobria (64%) than in A. caviae (15%) (P < 0·01). We observed increased adherence by 6 Aeromonas strains previously classified as adherence-positive, but not by 6 non-adherers, in PIF compared with brain heart infusion broth. The influence of growth medium on the expression of potential virulence determinants by Aeromonas spp. provides a rationale for the use of human ileostomy fluid in future in vitro studies, in order to simulate the nutrient conditions found in vivo.