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Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes.
A multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015–2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes.
Of 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (>1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P < .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22).
Antibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.
An electron microprobe analyzer shielded and modified to accept for analysis radioactive samples reading up to 100 R/hr is described. The following features will be illustrated and discussed: (1) biological shielding, (2) detector shielding, (3) sample transfer system, (4) remote sample loading and focusing system, (5) laboratory layout, and (6) experimental results.
Although most hospitals report very high levels of hand hygiene compliance (HHC), the accuracy of these overtly observed rates is questionable due to the Hawthorne effect and other sources of bias. In the study, we aimed (1) to compare HHC rates estimated using the standard audit method of overt observation by a known observer and a new audit method that employed a rapid (<15 minutes) “secret shopper” method and (2) to pilot test a novel feedback tool.
Quality improvement project using a quasi-experimental stepped-wedge design.
This study was conducted in 5 acute-care hospitals (17 wards, 5 intensive care units) in the Midwestern United States.
Sites recruited a hand hygiene observer from outside the acute-care units to rapidly and covertly observe entry and exit HHC during the study period, October 2016–September 2017. After 3 months of observations, sites received a monthly feedback tool that communicated HHC information from the new audit method.
The absolute difference in HHC estimates between the standard and new audit methods was ~30%. No significant differences in HHC were detected between the baseline and feedback phases (OR, 0.92; 95% CI, 0.84–1.01), but the standard audit method had significantly higher estimates than the new audit method (OR, 9.83; 95% CI, 8.82–10.95).
HHC estimates obtained using the new audit method were substantially lower than estimates obtained using the standard audit method, suggesting that the rapid, secret-shopper method is less subject to bias. Providing feedback using HHC from the new audit method did not seem to impact HHC behaviors.
In recent years, ethnoarchaeology and the use of ethnographic analogy have come under increasing criticism. Analogy seems necessary because, as post-industrial academics, archaeologists worry that they do not possess the knowledge necessary to interpret archaeological materials directly and thus must consult with coeval ‘premodern’ peoples to develop interpretive baselines. In this paper, we draw attention to a form of scholarly enquiry – 19th-century Bible customs books – that faced a similar challenge and used methodologies that parallel archaeology's use of ethnoarchaeological data. These were books written by missionaries who lived in Palestine for extended periods of time and studied Palestinian life to make sense of obscure elements of the biblical text, believing that life there had remained fundamentally unchanged for the past three thousand years. Using the Bible customs books as a kind of ‘cautionary tale’ typical of ethnoarchaeology, we argue that a consideration of this literature brings into focus some of the challenges faced by archaeologists’ use of analogy. Specifically, Bible customs books expose significant issues in how relations are conceptualized between archaeologists, others and ancients, and show how a strict empirical focus in ethnographic research can insulate key assumptions from critical scrutiny.
In Cameroon, there is a national programme engaged in the control of schistosomiasis and soil-transmitted helminthiasis. In certain locations, the programme is transitioning from morbidity control towards local interruption of parasite transmission. The volcanic crater lake villages of Barombi Mbo and Barombi Kotto are well-known transmission foci and are excellent context-specific locations to assess appropriate disease control interventions. Most recently they have served as exemplars of expanded access to deworming medications and increased environmental surveillance. In this paper, we review infection dynamics through time, beginning with data from 1953, and comment on the short- and long-term success of disease control. We show how intensification of local control is needed to push towards elimination and that further environmental surveillance, with targeted snail control, is needed to consolidate gains in preventive chemotherapy as well as empower local communities to take ownership of interventions.
Previous reports investigating adiposity and cognitive function in the population allude to a negative association, although the relationship in older adults is unclear. The aim of this study was to investigate the association of adiposity (BMI and waist:hip ratio (WHR)) with cognitive function in community-dwelling older adults (≥60 years). Participants included 5186 adults from the Trinity Ulster Department of Agriculture ageing cohort study. Neuropsychological assessment measures included the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB) and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Multi-variable linear regression models were used to assess the association between adiposity and cognitive function adjusting for insulin resistance, inflammation and cerebrovascular disease. The mean ages were 80·3 (sd 6·7), 71·0 (sd 7·3) and 70·2 (sd 6·3) years on the cognitive, bone and hypertensive cohorts, respectively. In the cognitive cohort, BMI was positively associated with immediate and delay memory, visuospatial/constructional ability, language and MMSE, and negatively with FAB (log-transformed), whereas WHR was negatively associated with attention. In the bone cohort, BMI was not associated with any cognitive domain, whereas WHR was negatively associated with visuospatial/constructional ability, attention and MMSE. In the hypertensive cohort, BMI was not associated with any cognitive domain, whereas WHR was negatively associated with immediate and delayed memory, visuospatial/constructional ability, language and MMSE and positively with FAB (log-transformed). In the cognitive and bone cohorts, the association of WHR and attention disappeared by further controlling for C-reactive protein and HbA1C. In this study of older adults, central adiposity was a stronger predictor of poor cognitive performance than BMI. Older adults could benefit from targeted public health strategies aimed at reducing obesity and obeseogenic risk factors to avoid/prevent/slow cognitive dysfunction.
The aim of this study was to investigate how innovation is defined with respect to new medicines.
MEDLINE, Embase, and EconLit databases were searched for articles published between January 1, 2010 and May 25, 2016 that described a relevant definition of innovation. Identified definitions were analyzed by mapping the concepts described onto a set of ten dimensions of innovation.
In total, thirty-six articles were included, and described a total of twenty-five different definitions of innovation. The most commonly occurring dimension was therapeutic benefit, with novelty and the availability of existing treatments the second and third most common dimensions. Overall, there was little agreement in the published literature on what characteristics of new medicines constitute rewardable innovation.
Alignment across countries and among regulators, health technology assessment bodies and payers would help manufacturers define research policies that can drive innovation, but may be challenging, as judgements about what aspects of innovation should be rewarded vary among stakeholders, and depend on political and societal factors.
Structured, empirically supported psychological interventions are lacking for patients who require organ transplantation. This stage IA psychotherapy development project developed and tested the feasibility, acceptability, tolerability, and preliminary efficacy of an 8-week group cognitive behavioral stress management intervention adapted for patients with end-stage liver disease awaiting liver transplantation.
Twenty-nine English-speaking United Network for Organ Sharing–registered patients with end-stage liver disease from a single transplantation center enrolled in 8-week, group cognitive-behavioral liver stress management and relaxation training intervention adapted for patients with end-stage liver disease. Patients completed pre- and postintervention surveys that included the Beck Depression Inventory II and the Beck Anxiety Inventory. Feasibility, acceptability, tolerability, and preliminary efficacy were assessed.
Attendance rate was 69.40%. The intervention was rated as “good” to “excellent” by 100% of participants who completed the postintervention survey in teaching them new skills to relax and to cope with stress, and by 94.12% of participants in helping them feel supported while waiting for a liver transplant. No adverse events were recorded over the course of treatment. Attrition was 13.79%. Anxious and depressive symptoms were not statistically different after the intervention.
Significance of results
The liver stress management and relaxation training intervention is feasible, acceptable, and tolerable to end-stage liver disease patients within a transplant clinic setting. Anxious and depressive symptoms remained stable postintervention. Randomized controlled trials are needed to study the intervention's effectiveness in this population.
The history of hill farming is traced from early times and the changes in practices described. The economic problems are analysed and the role of Government intervention has been outlined and assessed.
Research has created a basket of methods to exploit the potential of the ‘upland’ areas and these are discussed in relation to their up-take in practice and the role of the extension services in promotion.
The physical resources are briefly outlined and the contemporary economic development of the industry as influenced by the EEC and other agencies is discussed.
The impact of the demand for recreation, the need to conserve habitats and wildlife and the importance of rural amenity are examined in relation to upland agriculture and the several official organisations involved and proposals are offered. The conflicts in land use and the socio-economic problems of remote areas are discussed and appropriate policy initiatives are proposed.
22q11.2 deletion syndrome (22q11.2DS) is associated with high rates of neurodevelopmental disorder, however, the links between developmental coordination disorder (DCD), intellectual function and psychiatric disorder remain unexplored.
To establish the prevalence of indicative DCD in children with 22q11.2DS and examine associations with IQ, neurocognition and psychopathology.
Neurocognitive assessments and psychiatric interviews of 70 children with 22q11.2DS (mean age 11.2, s.d. = 2.2) and 32 control siblings (mean age 11.5, s.d. = 2.1) were carried out in their homes. Nine children with 22q11.2DS and indicative DCD were subsequently assessed in an occupational therapy clinic.
Indicative DCD was found in 57 (81.4%) children with 22q11.2DS compared with 2 (6.3%) control siblings (odds ratio (OR) = 36.7, P < 0.001). Eight of nine (89%) children with indicative DCD met DSM-5 criteria for DCD. Poorer coordination was associated with increased numbers of anxiety, (P < 0.001), attention-deficit hyperactivity disorder (ADHD) (P < 0.001) and autism-spectrum disorder (ASD) symptoms (P < 0.001) in children with 22q11.2DS. Furthermore, 100% of children with 22q11.2DS and ADHD had indicative DCD (20 of 20), as did 90% of children with anxiety disorder (17 of 19) and 96% of children who screened positive for ASD (22 of 23). The Developmental Coordination Disorder Questionnaire score was related to sustained attention (P = 0.006), even after history of epileptic fits (P = 0.006) and heart problems (P = 0.009) was taken into account.
Clinicians should be aware of the high risk of coordination difficulties in children with 22q11.2DS and its association with risk of mental disorder and specific neurocognitive deficits.
To determine the scope, source, and mode of transmission of a multifacility outbreak of extensively drug-resistant (XDR) Acinetobacter baumannii.
SETTING AND PARTICIPANTS
Residents and patients in skilled nursing facilities, long-term acute-care hospital, and acute-care hospitals.
A case was defined as the incident isolate from clinical or surveillance cultures of XDR Acinetobacter baumannii resistant to imipenem or meropenem and nonsusceptible to all but 1 or 2 antibiotic classes in a patient in an Oregon healthcare facility during January 2012–December 2014. We queried clinical laboratories, reviewed medical records, oversaw patient and environmental surveillance surveys at 2 facilities, and recommended interventions. Pulsed-field gel electrophoresis (PFGE) and molecular analysis were performed.
We identified 21 cases, highly related by PFGE or healthcare facility exposure. Overall, 17 patients (81%) were admitted to either long-term acute-care hospital A (n=8), or skilled nursing facility A (n=8), or both (n=1) prior to XDR A. baumannii isolation. Interfacility communication of patient or resident XDR status was not performed during transfer between facilities. The rare plasmid-encoded carbapenemase gene blaOXA-237 was present in 16 outbreak isolates. Contact precautions, chlorhexidine baths, enhanced environmental cleaning, and interfacility communication were implemented for cases to halt transmission.
Interfacility transmission of XDR A. baumannii carrying the rare blaOXA-237 was facilitated by transfer of affected patients without communication to receiving facilities.
Far-UV photons (FUV, E < 13.6 eV) from hot massive stars regulate, or at least influence, the heating, ionization, and chemistry of most of the neutral interstellar medium (H i and H2 clouds). Investigating the interaction between FUV radiation and interstellar matter (molecules, atoms and grains) thus plays an important role in astrochemistry.
The Orion Bar, an interface region between the Orion A molecular cloud and the H ii region around the Trapezium cluster, is a textbook example of a strongly illuminated dense PDR (photodissociation region). The Bar is illuminated by a FUV field of a few 104 times the mean interstellar radiation field. Because of its proximity and nearly edge-on orientation, it provides a very good template to investigate the chemical content, structure, and dynamics of a strongly irradiated molecular cloud edge. We have used ALMA to mosaic a small field of the Bar where the critical transition from atomic to molecular gas takes place. These observations provide an unprecedented sharp view of this transition layer (≲ 1″ resolution or ≲ 414 AU). The resulting images (so far in the rotational emission of CO, HCO+, H13CO+, SO+, SO, and reactive ions SH+ and HOC+) show the small-scale structure in gas density and temperature, and the steep abundance gradients. The images reveal a pattern of high-density substructures, photo-ablative gas flows and instabilities at the edge of the molecular cloud. These first ALMA images thus show a more complex morphology than the classical clump/interclump static model of a PDR.
In order to quantify the chemical content in strongly FUV-irradiated gas, we have also used the IRAM-30 m telescope to carry out a complete line-survey of the illuminated edge of the Bar in the millimeter domain. Our observations reveal the presence of complex organic molecules (and precursors) that were not expected in such a harsh environment. In particular, we have reported the first detection of the unstable cis conformer of formic acid (HCOOH) in the ISM. The energy barrier to internal rotation (the conversion from trans to cis) is approximately 4827 cm−1 (≈7000 K). Hence, this detection is surprising. The low inferred trans-to-cis abundance ratio of 2.8±1.0 supports a photoswitching mechanism: a given conformer absorbs a FUV stellar photon that radiatively excites the molecule to electronic states above the interconversion barrier. Subsequent fluorescent decay leaves the molecule in a different conformer form. This mechanism, which we have specifically studied with ab initio quantum calculations, was not considered so far in astrochemistry although it can affect the structure of a variety of molecules in PDRs.
Silicon carbide dust grains are ubiquitous in circumstellar envelopes around C-rich AGB stars. However, the main gas-phase precursors leading to the formation of SiC dust have not yet been identified. To date, only three molecules containing an Si–C bond have been identified to have significant abundances in C-rich AGB stars: SiC2, SiC, and Si2C. The ring molecule SiC2 has been observed in a handful of evolved stars, while SiC and Si2C have only been detected in the C-star envelope IRC +10216. We aim to study how widespread and abundant SiC2, SiC, and Si2C are in envelopes around C-rich AGB stars and whether or not these species play an active role as gas-phase precursors of silicon carbide dust in the ejecta of carbon stars.
The molecular composition of the stellar outflows of AGB stars is determined by the stellar elemental carbon-to-oxygen abundance ratio, together with the physical circumstances in the innermost region of the outflow. Near the stellar surface, thermal equilibrium (TE) can be assumed. This leads to a certain molecular composition with a O- or C-rich signature. However, several molecular species have been detected that are not expected to be present in the inner region under the assumption of TE chemistry. As a solution to explain the presence of these unexpected species, non-equilibrium chemistry in the inner region of the outflow has been proposed. The outflows of AGB stars are generally not spherically symmetric or homogeneous, which influences the penetration of interstellar UV photons throughout the outflow. We investigate the effect of a clumpy, non-homogeneous outflow on the composition of the inner region by introducing a simple porosity formalism in our chemical model.