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The effectiveness of alcohol-based hand rub (ABHR) is correlated with drying time, which depends on the volume applied. Evidence suggests that there is considerable variation in the amount of ABHR used by healthcare providers.
We sought to identify the volume of ABHR preferred for use by nurses.
A prospective observation study was performed in 8 units at a tertiary-care hospital. Nurses were provided pocket-sized ABHR bottles with caps to record each bottle opening. Nurses were instructed to use the volume of ABHR they felt was best. The average ABHR volume used per hand hygiene event was calculated using cap data and changes in bottle mass.
In total, 53 nurses participated and 140 nurse shifts were analyzed. The average ABHR dose was 1.09 mL. This value was greater for non-ICU nurses (1.18 mL) than ICU nurses (0.96 mL), but this difference was not significant. We detected no significant association between hand surface area and preferred average dose volume. The ABHR dose volume was 0.006 mL less per use as the number of applications per shift increased (P = .007).
The average dose of ABHR used was similar to the dose provided by the hospital’s automated dispensers, which deliver 1.1 mL per dose. The volume of ABHR dose was inversely correlated with the number of applications of ABHR per shift and was not correlated with hand size. Further research to understand differences and drivers of ABHR volume preferences and whether automated ABHR dosing may create a risk for people with larger hands is warranted.
To evaluate the association between novel pre- and post-operative biomarker levels and 30-day unplanned readmission or mortality after paediatric congenital heart surgery.
Children aged 18 years or younger undergoing congenital heart surgery (n = 162) at Johns Hopkins Hospital from 2010 to 2014 were enrolled in the prospective cohort. Collected novel pre- and post-operative biomarkers include soluble suppression of tumorgenicity 2, galectin-3, N-terminal prohormone of brain natriuretic peptide, and glial fibrillary acidic protein. A model based on clinical variables from the Society of Thoracic Surgery database was developed and evaluated against two augmented models.
Unplanned readmission or mortality within 30 days of cardiac surgery occurred among 21 (13%) children. The clinical model augmented with pre-operative biomarkers demonstrated a statistically significant improvement over the clinical model alone with a receiver-operating characteristics curve of 0.754 (95% confidence interval: 0.65–0.86) compared to 0.617 (95% confidence interval: 0.47–0.76; p-value: 0.012). The clinical model augmented with pre- and post-operative biomarkers demonstrated a significant improvement over the clinical model alone, with a receiver-operating characteristics curve of 0.802 (95% confidence interval: 0.72–0.89; p-value: 0.003).
Novel biomarkers add significant predictive value when assessing the likelihood of unplanned readmission or mortality after paediatric congenital heart surgery. Further exploration of the utility of these novel biomarkers during the pre- or post-operative period to identify early risk of mortality or readmission will aid in determining the clinical utility and application of these biomarkers into routine risk assessment.
Hand hygiene compliance rates were estimated using direct observations. An AHHMS, installed on 4 nursing units in a sequential manner, determined hand hygiene performance rates, expressed as the number of hand hygiene events performed upon entering and exiting patient rooms divided by the number of room entries and exits. Additional strategies implemented to improve hand hygiene included goal setting, hospital leadership support, feeding AHHMS data back to healthcare personnel, and use of Toyota Kata performance improvement methods. HAIs were defined using National Healthcare Safety Network criteria.
Hand hygiene compliance rates generated by direct observation were substantially higher than performance rates generated by the AHHMS. Installation of the AHHMS without supplementary activities did not yield sustained improvement in hand hygiene performance rates. Implementing several supplementary strategies resulted in a statistically significant 85% increase in hand hygiene performance rates (P < .0001). The incidence density of non–Clostridioies difficile HAIs decreased by 56% (P = .0841), while C. difficile infections increased by 60% (P = .0533) driven by 2 of the 4 study units.
Implementation of an AHHMS, when combined with several supplementary strategies as part of a multimodal program, resulted in significantly improved hand hygiene performance rates. Reductions in non–C. difficile HAIs occurred but were not statistically significant.
Every four years leading researchers gather to survey the latest developments in all aspects of group theory. Initially held in St Andrews, these meetings have become the premier forum for group theory across the whole of the UK. Since 1981, the proceedings of 'Groups St Andrews' have provided a regular snapshot of the state-of-the-art in group theory and helped to shape the direction of research in the field. This volume contains papers from the 2017 meeting held in Birmingham. It includes expository articles from the invited speakers, and further surveys contributed by the participants. Topics include: generation of finite simple groups, block theory, fusion systems, algebraic groups, one-relator groups, geometric group theory, and Beauville groups.
OBJECTIVES/SPECIFIC AIMS: Aim 1: To compare frozen MOM to fresh MOM over time as an agent to inoculate DHM and measure the enrichment of commensal microbes and their beneficial bioactive components similar to MOM. Hypothesis: Frozen or fresh MOM inoculated in DHM will produce similar microbial content to MOM over time allowing for the production of beneficial bacterial compounds that may contribute to host immune response. Aim 2: To determine the effect of MOM storage (fresh vs frozen) on the expansion of bioactive components from live microbiota in DHM. Hypothesis: Both fresh and frozen MOM will produce similar results when inoculated into DHM to restore the microbial content (including their bioactive components) similar to each MOM sample. Aim 3: To compare the microbiome found in a mother’s MOM to the microbiome in her infant’s stool. Hypothesis: The mother/infant pair will share a common microbiome between the mother’s MOM and her infant’s stool. METHODS/STUDY POPULATION: Subjects will include 12 pump-dependent mothers of infants born < 34 weeks gestation admitted to the University of Florida Health Shands Hospital, Neonatal Intensive Care Unit (NICU). Inclusion criteria consists of mothers expressing over 100 ml of MOM per day, producing at least 45 ml of MOM at an expression session, at least 18 years of age, and speak English. Mothers are excluded if they have taken antibiotics within 3 days of sample collection, are HIV+, or delivered an infant who has a chromosomal abnormality or is severely ill. An expressed MOM sample will be collected and divided into two fractions: (A) fresh and (B) frozen at -20C for 24 h. The fresh fraction (A) will be processed immediately while the frozen fraction (B) will be processed after 24 h. Each MOM will be inoculated in DHM at dilutions of 10% and 30% and incubated at different time points: 0 h (T0), 2 h (T2), 4 h (T4) at 37°C. At each time point, total viable cell counts as well as microbiome analysis through 16S ribosomal shotgun sequencing will be performed and compared for differences. Bacteria isolated from each MOM will be saved, identified through 16S ribosomal sequencing and grown in culture for future studies. Fecal samples from each corresponding infant will be collected within 48 h after collection of the MOM sample. Stools will be homogenized and subjected to DNA extraction to perform 16S ribosomal shotgun sequencing. Microbiome analysis will be conducted, compared between fecal samples as well as with the microbiome of the MOM. RESULTS/ANTICIPATED RESULTS: Study is ongoing. We anticipate similar results with fresh or frozen MOM to that of a previous pilot study, where enriched microbiota similar to MOM was found when fresh MOM was inoculated and incubated in DHM. The microbiome analysis of the infant fecal samples may illustrate the influence that the microbiome of the MOM may have on the development of the infants’ gastrointestinal microbiota. DISCUSSION/SIGNIFICANCE OF IMPACT: The purpose of this study is to provide evidence on the ability, timing, and efficacy of inoculating DHM with fresh and frozen MOM. Study results will inform future studies to support the implementation of an inoculation procedural protocol to be used in clinical practice and human milk banking. The description of the MOM microbiome, as well as the gastrointestinal microbiome, will expand scientific knowledge on the role breast milk has on the origins of health and disease.
Rayleigh–Bénard convection is one of the most well-studied models in fluid mechanics. Atmospheric convection, one of the most important components of the climate system, is by comparison complicated and poorly understood. A key attribute of atmospheric convection is the buoyancy source provided by the condensation of water vapour, but the presence of radiation, compressibility, liquid water and ice further complicate the system and our understanding of it. In this paper we present an idealized model of moist convection by taking the Boussinesq limit of the ideal-gas equations and adding a condensate that obeys a simplified Clausius–Clapeyron relation. The system allows moist convection to be explored at a fundamental level and reduces to the classical Rayleigh–Bénard model if the latent heat of condensation is taken to be zero. The model has an exact, Rayleigh-number-independent ‘drizzle’ solution in which the diffusion of water vapour from a saturated lower surface is balanced by condensation, with the temperature field (and so the saturation value of the moisture) determined self-consistently by the heat released in the condensation. This state is the moist analogue of the conductive solution in the classical problem. We numerically determine the linear stability properties of this solution as a function of Rayleigh number and a non-dimensional latent-heat parameter. We also present some two-dimensional, time-dependent, nonlinear solutions at various values of Rayleigh number and the non-dimensional condensational parameters. At sufficiently low Rayleigh number the system converges to the drizzle solution, and we find no evidence that two-dimensional self-sustained convection can occur when that solution is stable. The flow transitions from steady to turbulent as the Rayleigh number or the effects of condensation are increased, with plumes triggered by gravity waves emanating from other plumes. The interior dries as the level of turbulence increases, because the plumes entrain more dry air and because the saturated boundary layer at the top becomes thinner. The flow develops a broad relative humidity minimum in the domain interior, only weakly dependent on Rayleigh number when that is high.
In my response to the reviews of my book by Marianne Constable, Shai Lavi, and Renisa Mawani, I situate the argument of Common Law, History, and Democracy in America, 1790–1900: Legal Thought Before Modernism within a concern with contemporary forms of historical knowledge. Where contemporary historical knowledge practices subsume their objects of investigation, I adopt the temporality of the object of investigation—namely, the common law—as the structure my book. In different registers, Constable, Lavi, and Mawani urge me to take up more explicitly the foundational questioning about which they care. I welcome their readings. However, given the distinct problematic from which I start, I argue, the book is not in the first instance an argument about the ontology of history or law.
We reviewed all patients who were supported with extracorporeal membrane oxygenation and/or ventricular assist device at our institution in order to describe diagnostic characteristics and assess mortality.
A retrospective cohort study was performed including all patients supported with extracorporeal membrane oxygenation and/or ventricular assist device from our first case (8 October, 1998) through 25 July, 2016. The primary outcome of interest was mortality, which was modelled by the Kaplan–Meier method.
A total of 223 patients underwent 241 extracorporeal membrane oxygenation runs. Median support time was 4.0 days, ranging from 0.04 to 55.8 days, with a mean of 6.4±7.0 days. Mean (±SD) age at initiation was 727.4 days (±146.9 days). Indications for extracorporeal membrane oxygenation were stratified by primary indication: cardiac extracorporeal membrane oxygenation (n=175; 72.6%) or respiratory extracorporeal membrane oxygenation (n=66; 27.4%). The most frequent diagnosis for cardiac extracorporeal membrane oxygenation patients was hypoplastic left heart syndrome or hypoplastic left heart syndrome-related malformation (n=55 patients with HLHS who underwent 64 extracorporeal membrane oxygenation runs). For respiratory extracorporeal membrane oxygenation, the most frequent diagnosis was congenital diaphragmatic hernia (n=22). A total of 24 patients underwent 26 ventricular assist device runs. Median support time was 7 days, ranging from 0 to 75 days, with a mean of 15.3±18.8 days. Mean age at initiation of ventricular assist device was 2530.8±660.2 days (6.93±1.81 years). Cardiomyopathy/myocarditis was the most frequent indication for ventricular assist device placement (n=14; 53.8%). Survival to discharge was 42.2% for extracorporeal membrane oxygenation patients and 54.2% for ventricular assist device patients. Kaplan–Meier 1-year survival was as follows: all patients, 41.0%; extracorporeal membrane oxygenation patients, 41.0%; and ventricular assist device patients, 43.2%. Kaplan–Meier 5-year survival was as follows: all patients, 39.7%; extracorporeal membrane oxygenation patients, 39.7%; and ventricular assist device patients, 43.2%.
This single-institutional 18-year review documents the differential probability of survival for various sub-groups of patients who require support with extracorporeal membrane oxygenation or ventricular assist device. The indication for mechanical circulatory support, underlying diagnosis, age, and setting in which cannulation occurs may affect survival after extracorporeal membrane oxygenation and ventricular assist device. The Kaplan–Meier analyses in this study demonstrate that patients who survive to hospital discharge have an excellent chance of longer-term survival.
Objectives: Obstructive sleep apnea (OSA) is associated with cognitive impairment but the relationships between specific biomarkers and neurocognitive domains remain unclear. The present study examined the influence of common health comorbidities on these relationships. Adults with suspected OSA (N=60; 53% male; M age=52 years; SD=14) underwent neuropsychological evaluation before baseline polysomnography (PSG). Apneic syndrome severity, hypoxic strain, and sleep architecture disturbance were assessed through PSG. Methods: Depression (Center for Epidemiological Studies Depression Scale, CESD), pain, and medical comorbidity (Charlson Comorbidity Index) were measured via questionnaires. Processing speed, attention, vigilance, memory, executive functioning, and motor dexterity were evaluated with cognitive testing. A winnowing approach identified 9 potential moderation models comprised of a correlated PSG variable, comorbid health factor, and cognitive performance. Results: Regression analyses identified one significant moderation model: average blood oxygen saturation (AVO2) and depression predicting recall memory, accounting for 31% of the performance variance, p<.001. Depression was a significant predictor of recall memory, p<.001, but AVO2 was not a significant predictor. The interaction between depression and AVO2 was significant, accounting for an additional 10% of the variance, p<.001. The relationship between low AVO2 and low recall memory performance emerged when depression severity ratings approached a previously established clinical cutoff score (CESD=16). Conclusions: This study examined sleep biomarkers with specific neurocognitive functions among individuals with suspected OSA. Findings revealed that depression burden uniquely influence this pathophysiological relationship, which may aid clinical management. (JINS, 2018, 28, 864–875)
Children with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.
Materials and methods
We sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.
A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.
The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.
Erect veldtgrass (Ehrharta erecta Lam.) is an invasive grass actively spreading in California that is capable of invading multiple habitats. Our objective is to contribute to a better understanding of the ecology, impacts, and potential for control of E. erecta in order to guide management practices. In a mixed-evergreen forest in Santa Cruz County, we measured impacts of E. erecta on native plant species richness and abundance in an observational comparison across 11 sites. Strikingly, we measured nearly four times greater total vegetation cover in plots invaded by E. erecta. However, native plants were not significantly less abundant in invaded plots than in reference plots, and native cover was not significantly predicted by E. erecta cover within invaded plots. We did, however, find evidence of change in community composition in response to E. erecta abundance. Our findings demonstrate that native species can persist in the presence of E. erecta, although the long-term impacts on populations of the perennial plants that dominate this forest understory are still unknown.
We also compared the effectiveness of mechanical (hand pulling with volunteers) and chemical (glyphosate) management methods. Twenty-two months following management treatments, we found substantial reductions in E. erecta using both mechanical and herbicide treatments, but herbicide application also produced greater reductions in native species cover and species richness. Transplanting native yerba buena [Clinopodium douglasii (Benth.) Kuntze] into management plots following treatment did not slow regrowth of E. erecta. It did, however, increase total native plant percent cover in herbicide and pull treatments, although largely by increasing C. douglasii cover. Effective management is possible using either manual or chemical removal methods; the optimal method may depend on the availability of manual labor and the sensitivity of the habitat to non-target effects on native plants.
While our fascination with understanding the past is sufficient to warrant an increased focus on synthesis, solutions to important problems facing modern society require understandings based on data that only archaeology can provide. Yet, even as we use public monies to collect ever-greater amounts of data, modes of research that can stimulate emergent understandings of human behavior have lagged behind. Consequently, a substantial amount of archaeological inference remains at the level of the individual project. We can more effectively leverage these data and advance our understandings of the past in ways that contribute to solutions to contemporary problems if we adapt the model pioneered by the National Center for Ecological Analysis and Synthesis to foster synthetic collaborative research in archaeology. We propose the creation of the Coalition for Archaeological Synthesis coordinated through a U.S.-based National Center for Archaeological Synthesis. The coalition will be composed of established public and private organizations that provide essential scholarly, cultural heritage, computational, educational, and public engagement infrastructure. The center would seek and administer funding to support collaborative analysis and synthesis projects executed through coalition partners. This innovative structure will enable the discipline to address key challenges facing society through evidentially based, collaborative synthetic research.