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We evaluated the impact of an electronic health record based 72-hour antimicrobial time-out (ATO) on antimicrobial utilization. We observed that 6 hours after the ATO, 21% of empiric antimicrobials were discontinued or de-escalated. There was a significant reduction in the duration of antimicrobial therapy but no impact on overall antimicrobial usage metrics.
Following publication, errors were discovered in the y-axis labels of the electron and hole concentration plots in the following figure panels: figure 4c, figure 4d, figure 5c, figure 5d, figure 6c, figure 6d, figure 8c and figure 8d. The error does not affect the description, analysis or conclusions. The correct representation of the figure panels are shown here.
Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.
Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.
Eta Carinae is the most massive active binary within 10,000 light-years. While famous for the largest non-terminal stellar explosion ever recorded, observations reveal a supermassive (∼120 M⊙) binary consisting of an LBV and either a WR or extreme O star in a very eccentric orbit (e=0.9) with a 5.54-year period. Dramatic changes across multiple wavelengths are routinely observed as the stars move about in their highly elliptical orbits, especially around periastron when the hot (∼40 kK) companion star delves deep into the denser and much cooler (∼15 kK) extended wind photosphere of the LBV primary. Many of these changes are due to a dynamic wind-wind collision region (WWCR) that forms between the stars, plus expanding radiation-illuminated fossil WWCRs formed one, two, and three 5.54-year orbital cycles ago. These fossil WWCRs have been spatially and spectrally resolved by the Hubble Space Telescope/Space Telescope Imaging Spectrograph (HST/STIS) at multiple epochs, resulting in data cubes that spatially map Eta Carinae’s innermost WWCRs and follow temporal changes in several forbidden emission lines (e.g. [Fe iii] 4659 Å, [Fe ii] 4815 Å) across the 5.54-year cycle. We present initial results of 3D time-dependent hydrodynamical and radiative-transfer simulations of the Eta Carinae binary and its WWCRs with the goal of producing synthetic data cubes of forbidden emission lines for comparison to the available HST/STIS observations. Comparison of the theoretical models to the observations reveals important details about the binary’s orbital motion, photoionization properties, and recent (5–15year) mass loss history. Such an analysis also provides a baseline for following future changes in Eta Carinae, essential for understanding the late-stage evolution of a nearby supernova progenitor. Our modeling methods can also be adapted to a number of other colliding wind binary systems (e.g. WR 140) that are scheduled to be studied with future observatories (e.g. the James Webb Space Telescope).
Ion flow in charged nanopores is strongly influenced by the ratio of the Debye length to the pore radius. We investigate the asymptotic behaviour of solutions to the Poisson–Nernst–Planck (PNP) system in narrow pore like geometries and study the influence of the pore geometry and surface charge on ion transport. The physical properties of real pores motivate the investigation of distinguished asymptotic limits, in which either the Debye length and pore radius are comparable or the pore length is very much greater than its radius This results in a quasi-one-dimensional (1D) PNP model, which can be further simplified, in the physically relevant limit of strong pore wall surface charge, to a fully 1D model. Favourable comparison is made to the two-dimensional (2D) PNP equations in typical pore geometries. It is also shown that, for physically realistic parameters, the standard 1D area averaged PNP model for ion flow through a pore is a very poor approximation to the (real) 2D solution to the PNP equations. This leads us to propose that the quasi-1D PNP model derived here, whose computational cost is significantly less than 2D solution of the PNP equations, should replace the use of the 1D area averaged PNP equations as a tool to investigate ion and current flows in ion pores.
Following a cluster of serious pseudomonas skin infections linked to a body piercing and tattooing premises, a look-back exercise was carried out to offer clients a screen for blood-borne viruses. Of those attending for screening 72% (581/809) had a piercing procedure in the premises of interest: 94 (16%) were under 16 years of age at the time of screening. The most common site of piercing was ear (34%), followed by nose (27%), nipple (21%) and navel (21%). A small number (<5) tested positive for hepatitis B and C, with no evidence this was linked to the premises. However, 36% (211/581) of clients reported a skin infection associated with their piercing. Using data from client forms, 36% provided a false age. Those aged under 16 years (OR 4.5, 95% CI 2.7–7.7) and those receiving a piercing at an intimate site (OR 2.1, 95% CI 1.3–3.6) were more likely to provide a false age. The findings from this exercise were used to support the drafting of the Public Health (Wales) Bill which proposed better regulation of piercing premises and the need to provide proof of being 18 years of age or over before having a piercing of an intimate site.
Increasing evidence suggests that the presence of mobile ions in perovskite solar cells (PSCs) can cause a current–voltage curve hysteresis. Steady state and transient current–voltage characteristics of a planar metal halide CH3NH3PbI3 PSC are analysed with a drift-diffusion model that accounts for both charge transport and ion vacancy motion. The high ion vacancy density within the perovskite layer gives rise to narrow Debye layers (typical width ~2 nm), adjacent to the interfaces with the transport layers, over which large drops in the electric potential occur and in which significant charge is stored. Large disparities between (I) the width of the Debye layers and that of the perovskite layer (~600 nm) and (II) the ion vacancy density and the charge carrier densities motivate an asymptotic approach to solving the model, while the stiffness of the equations renders standard solution methods unreliable. We derive a simplified surface polarisation model in which the slow ion dynamics are replaced by interfacial (non-linear) capacitances at the perovskite interfaces. Favourable comparison is made between the results of the asymptotic approach and numerical solutions for a realistic cell over a wide range of operating conditions of practical interest.
This study aimed to compare the quality of beef from suckler bulls raised on a high-energy concentrate ration and slaughtered at different carcass weights (CW)/ages. In total, 42 spring-born, Charolais and Limousin-sired, weaned suckler bulls were provided with a finishing diet of ad libitum concentrates and grass silage until they reached target CW of 340, 380 and 420 kg. Intramuscular fat (IMF) content tended (P<0.06) to be higher for 420 kg CW than for 380 and 340 kg CW. Sensory tenderness was lower (P<0.001) for 420 kg CW than for 380 and 340 kg CW. Juiciness was higher (P<0.05) for 420 kg CW than for 380 kg CW. Flavour liking was higher (P<0.05) for 420 and 380 kg CW (which did not differ) than for 340 kg CW. Overall, an increase in CW resulted in a slight increase in IMF content which could be responsible for the increase in juiciness and flavour liking of the beef. An increase in CW led to a decrease in the tenderness of the beef even though the overall liking of the beef was not affected.
Many studies of teacher motivation have been conducted in different contexts over time. However, until fairly recently there has not been a reliable measure available to allow comparisons across samples and settings. This has resulted in an abundance of findings which cannot be directly compared or synthesised. The FIT-Choice instrument offers the opportunity to examine motivations across settings. The various studies in this book suggest that people who choose teaching as a career are motivated by a complex interaction of factors embedded within communities and cultural expectations, but seem generally to embrace a desire to undertake meaningful work that makes for a better society. Unlike some careers, where rewards are in the form of salary and status, by and large these factors are not strong drivers for people who want to become teachers. They want to work with children and adolescents, and believe they have the ability to teach.
The motivational profiles, perceptions about teaching, and background demographic characteristics of beginning English and Mathematics teachers were compared within an Australian sample, from the start of their teacher education studies (NT1 = 325; 213 English) until early career teaching (NT2 = 132; 89 English). Beginning Mathematics teachers tended to be older, to study through graduate-entry mode, were less likely to have chosen teaching as their first career, and more likely to have parents who worked in STEM (Science, Technology, Engineering and Mathematics) fields. Relative to beginning English teachers, there was a higher proportion from non-English speaking and less advantaged socioeconomic backgrounds. Preservice English teachers tended to have parents who worked in education, were more highly motivated to enhance social equity, less motivated to teach as a “fallback” career, and regarded teaching as more demanding. From initial teacher education until early career teaching, the only significant change was that perceptions of teaching demand increased for beginning English and Mathematics teachers; overall, there were more similarities than differences between the motivations and perceptions of beginning English and Mathematics teachers.
The Subantarctic island of South Georgia lost most of its birds to predation by rodents introduced by people over 2 centuries. In 2011 a UK charity began to clear brown rats Rattus norvegicus and house mice Mus musculus from the 170 km long, 3,500 km2 island using helicopters to spread bait containing Brodifacoum as the active ingredient. South Georgia's larger glaciers were barriers to rodent movement, resulting in numerous independent sub-island populations. The eradication could therefore be spread over multiple seasons, giving time to evaluate results before recommencing, and also reducing the impact of non-target mortality across the island as a whole. Eradication success was achieved in the 128 km2 Phase 1 trial operation. Work in 2013 (Phase 2) and early 2015 (Phase 3) covered the remaining 940 km2 occupied by rodents. By July 2017, 28 months after baiting was concluded, there was no sign of surviving rodents, other than one apparently newly introduced by ship in October 2014. A survey using detection dogs and passive devices will search the Phase 2 and Phase 3 land for rodents in early 2018. Seven (of 30) species of breeding birds suffered losses from poisoning, but all populations appear to have recovered within 5 years. The endemic South Georgia pipit Anthus antarcticus was the first bird to breed in newly rat-free areas, but there were also signs that cavity-nesting seabirds were exploring scree habitat denied them for generations. Enhanced biosecurity measures on South Georgia are needed urgently to prevent rodents being reintroduced.