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We evaluated the utility of vancomycin-resistant Enterococcus (VRE) surveillance by varying 2 parameters: admission versus weekly surveillance and perirectal swabbing versus stool sampling.
Prospective, patient-level surveillance program of incident VRE colonization.
Liver transplant surgical intensive care unit (SICU) of a tertiary-care referral medical center with a high prevalence of VRE.
All patients admitted to the SICU from June to August 2015.
We conducted a point-prevalence estimate followed by admission and weekly surveillance by perirectal swabbing and/or stool sampling. Incident colonization was defined as a negative screen followed by positive surveillance. VRE was detected by culture on Remel Spectra VRE chromogenic agar. Microbiologically-confirmed VRE bloodstream infections (BSIs) were tracked for 2 months. Statistical analyses were calculated using the McNemar test, the Fisher exact test, the t test, and the χ2 test.
In total, 91 patients underwent VRE surveillance testing. The point prevalence of VRE colonization was 60.9%; VRE prevalence on admission was 30.1%. Weekly surveillance identified an additional 7 of 28 patients (25.0%) with incident colonization. VRE BSIs were more common in VRE-colonized patients than in noncolonized patients (8 of 43 vs 2 of 48; P=.028). In a direct comparison, perirectal swabs were more sensitive than stool samples in detecting VRE (64 of 67 vs 56 of 67; P=.023). Compliance with perirectal swabbing was 89% (201 of 226) compared to 56% (127 of 226) for stool collection (P≤0.001).
We recommend weekly VRE surveillance over admission-only screening in high-burden units such as liver transplant SICUs. Perirectal swabs had greater collection compliance and sensitivity than stool samples, making them the preferred methodology. Further work may have implications for antimicrobial stewardship and infection control.
We asked whether bilinguals’ benefits reach beyond the auditory modality to benefit multisensory processing. We measured audiovisual integration of auditory and visual cues in monolinguals and bilinguals via the double-flash illusion where the presentation of multiple auditory stimuli concurrent with a single visual flash induces an illusory perception of multiple flashes. We varied stimulus onset asynchrony (SOA) between auditory and visual cues to measure the “temporal binding window” where listeners fuse a single percept. Bilinguals showed faster responses and were less susceptible to the double-flash illusion than monolinguals. Moreover, monolinguals showed poorer sensitivity in AV processing compared to bilinguals. The width of bilinguals’ AV temporal integration window was narrower than monolinguals’ for both leading and lagging SOAs (Biling.: -65–112 ms; Mono.: -193 – 112 ms). Our results suggest the plasticity afforded by speaking multiple languages enhances multisensory integration and audiovisual binding in the bilingual brain.
Advance care planning (ACP) increases quality of life and satisfaction with care for those with cancer and their families, yet these important conversations often do not occur. Barriers include patients’ and families’ emotional responses to cancer, such as anxiety and sadness, which can lead to avoidance of discussing illness-related topics such as ACP. Interventions that address psychological barriers to ACP are needed. The purpose of this study was to explore the effects of a mindfulness intervention designed to cultivate patient and caregiver emotional and relational capacity to respond to the challenges of cancer with greater ease, potentially decreasing psychological barriers to ACP and enhancing ACP engagement.
The Mindfully Optimizing Delivery of End-of-Life (MODEL) Care intervention provided 12 hours of experiential training to two cohorts of six to seven adults with advanced-stage cancer and their family caregivers (n = 13 dyads). Training included mindfulness practices, mindful communication skills development, and information about ACP. Patient and caregiver experiences of the MODEL Care program were assessed using semistructured interviews administered immediately postintervention and open-ended survey questions delivered immediately and at 4 weeks postintervention. Responses were analyzed using qualitative methods.
Four salient themes were identified. Patients and caregivers reported the intervention (1) enhanced adaptive coping practices, (2) lowered emotional reactivity, (3) strengthened relationships, and (4) improved communication, including communication about their disease.
Significance of results
The MODEL Care intervention enhanced patient and caregiver capacity to respond to the emotional challenges that often accompany advanced cancer and decreased patient and caregiver psychological barriers to ACP.
To make pragmatic recommendations on best practices for the engagement of patients in emergency medicine (EM) research.
We created a panel of expert Canadian EM researchers, physicians, and a patient partner to develop our recommendations. We used mixed methods consisting of 1) a literature review; 2) a survey of Canadian EM researchers; 3) qualitative interviews with key informants; and 4) feedback during the 2017 Canadian Association of Emergency Physicians (CAEP) Academic Symposium.
We synthesized our literature review into categories including identification and engagement, patients’ roles, perceived benefits, harms, and barriers to patient engagement; 40/75 (53% response rate) invited researchers completed our survey. Among respondents, 58% had engaged patients in research, and 83% intended to engage patients in future research. However, 95% stated that they need further guidance to engage patients. Our qualitative interviews revealed barriers to patient engagement, including the need for training and patient partner recruitment.
Our panel recommends 1) an overarching positive recommendation to support patient engagement in EM research; 2) seven policy-level recommendations for CAEP to support the creation of a national patient council, to develop, adopt and adapt training material, guidelines, and tools for patient engagement, and to support increased patient engagement in EM research; and 3) nine pragmatic recommendations about engaging patients in the preparatory, execution, and translational phases of EM research.
Patient engagement can improve EM research by helping researchers select meaningful outcomes, increase social acceptability of studies, and design knowledge translation strategies that target patients’ needs.
Many of the world's contemporary social problems are linked to issues associated with population, including birthrates, death rates, and migration. These issues are especially important in that the global population continues to grow by about 2 percent, or 140 million persons, each year. In this chapter, basic concepts of demography and population geography are reviewed. The review begins with birth and death rates, followed by discussion of issues associated with international migration. These concepts are then discussed in the context of population control policy, gender, and illegal immigration. Most significantly, the question of whether the population will be able to feed itself in the future as it continues to increase is addressed.
To describe pathogen distribution and antimicrobial resistance patterns for healthcare-associated infections (HAIs) reported to the National Healthcare Safety Network (NHSN) from pediatric locations during 2011–2014.
Device-associated infection data were analyzed for central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated pneumonia (VAP), and surgical site infection (SSI). Pooled mean percentage resistance was calculated for a variety of pathogen-antimicrobial resistance pattern combinations and was stratified by location for device-associated infections (neonatal intensive care units [NICUs], pediatric intensive care units [PICUs], pediatric oncology and pediatric wards) and by surgery type for SSIs.
From 2011 to 2014, 1,003 hospitals reported 20,390 pediatric HAIs and 22,323 associated pathogens to the NHSN. Among all HAIs, the following pathogens accounted for more than 60% of those reported: Staphylococcus aureus (17%), coagulase-negative staphylococci (17%), Escherichia coli (11%), Klebsiella pneumoniae and/or oxytoca (9%), and Enterococcus faecalis (8%). Among device-associated infections, resistance was generally lower in NICUs than in other locations. For several pathogens, resistance was greater in pediatric wards than in PICUs. The proportion of organisms resistant to carbapenems was low overall but reached approximately 20% for Pseudomonas aeruginosa from CLABSIs and CAUTIs in some locations. Among SSIs, antimicrobial resistance patterns were similar across surgical procedure types for most pathogens.
This report is the first pediatric-specific description of antimicrobial resistance data reported to the NHSN. Reporting of pediatric-specific HAIs and antimicrobial resistance data will help identify priority targets for infection control and antimicrobial stewardship activities in facilities that provide care for children.
Introduction: Waterpipe use is a significant health concern in low- and middle-income countries like Viet Nam, yet there is a lack of research on factors that may influence use and self-efficacy to quit among adults.
Aims: This study examined the relationship between social norms related to waterpipe use and self-efficacy to quit among male waterpipe smokers in Viet Nam.
Methods: A cross-sectional survey was conducted with 214 adult male waterpipe smokers enrolled in a large cluster–randomised controlled trial conducted in a rural province in Viet Nam. Associations between social norms related to waterpipe smoking and the participants’ confidence to quit waterpipes were assessed using hierarchical regression models to account for differences among study sites and other covariates.
Results: Self-efficacy to quit smoking was positively associated with immediate family members’ not minding participants smoking and with extended family's encouragement to quit smoking.
Conclusions: The findings suggest the need for a more comprehensive understanding of the functions and characteristics of the social context of waterpipe smoking, including the social networks of waterpipe smokers, to inform effective cessation interventions for waterpipe smokers.
The aim of this study was to evaluate the safety and feasibility of a passive range of motion exercise programme for infants with CHD.
This non-randomised pilot study enrolled 20 neonates following Stage I palliation for single-ventricle physiology. Trained physical therapists administered standardised 15–20-minute passive range of motion protocol, for up to 21 days or until hospital discharge. Safety assessments included vital signs measured before, during, and after the exercise as well as adverse events recorded through the pre-Stage II follow-up. Feasibility was determined by the percent of days that >75% of the passive range of motion protocol was completed.
A total of 20 infants were enrolled (70% males) for the present study. The median age at enrolment was 8 days (with a range from 5 to 23), with a median start of intervention at postoperative day 4 (with a range from 2 to 12). The median hospital length of stay following surgery was 15 days (with a range from 9 to 131), with an average of 13.4 (with a range from 3 to 21) in-hospital days per patient. Completion of >75% of the protocol was achieved on 88% of eligible days. Of 11 adverse events reported in six patients, 10 were expected with one determined to be possibly related to the study intervention. There were no clinically significant changes in vital signs. At pre-Stage II follow-up, weight-for-age z-score (−0.84±1.20) and length-for-age z-score (−0.83±1.31) were higher compared with historical controls from two earlier trials.
A passive range of motion exercise programme is safe and feasible in infants with single-ventricle physiology. Larger studies are needed to determine the optimal duration of passive range of motion and its effect on somatic growth.
Individual rings from 1899–1990 were pooled from four radii of four cross-sections obtained from trees at a managed forest site near Huangling, north of Xian in north central China. Splits of wood ground to 20-mesh were analyzed independently at both the Xian and Arizona laboratories, using their respective methods for cellulose isolation, combustion and mass-spectrometric analysis. The δ13C results were highly correlated (r2 = 0.66) and absolute values typically within 0.2–0.3‰. Inter-tree variability was estimated as 1–1.5‰. The Huangling δ13C curve shows an overall downward trend with year-to-year fluctuations of up to 1.5‰ superimposed. A subset of δ13C maxima corresponded with below-normal precipitation and above-normal temperature in May and June, and minima were associated with above-normal precipitation and below-normal temperature in May and June, perhaps signaling early arrival of the East Asian Summer Monsoon. The generally poor climate correlations with all δ13C values, however, could be a consequence of the fairly mesic environment or of human disturbance. Chronologies of isotopic discrimination (δ) and Ci/Ca had flat slopes, suggesting the δ13C trend was driven by global rather than local effects.
To determine the clinical diagnoses associated with the National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance events
Retrospective chart review
A convenience sample of 8 acute-care hospitals in Pennsylvania
All patients hospitalized during 2011–2012
Medical records were reviewed from a random sample of patients reported to the NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU and LRI events were recorded.
We reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to the NHSN; 29 reported events (12%) fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassifications. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia; of these, 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or noninfectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI patients, 84% were mechanically ventilated and 21% had no corresponding clinical diagnosis documented.
In adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded with compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015.
During mass-casualty incidents (MCIs), patient volume often overwhelms available Emergency Medical Services (EMS) personnel. First responders are expected to triage, treat, and transport patients in a timely fashion. If other responders could triage accurately, prehospital EMS resources could be focused more directly on patients that require immediate medical attention and transport.
Triage accuracy, error patterns, and time to triage completion are similar between second-year primary care paramedic (PCP) and fire science (FS) students participating in a simulated MCI using the Sort, Assess, Life-saving interventions, Treatment/Transport (SALT) triage algorithm.
All students in the second-year PCP program and FS program at two separate community colleges were invited to participate in this study. Immediately following a 30-minute didactic session on SALT, participants were given a standardized briefing and asked to triage an eight-victim, mock MCI using SALT. The scenario consisted of a four-car motor vehicle collision with each victim portrayed by volunteer actors given appropriate moulage and symptom coaching for their pattern of injury. The total number and acuity of victims were unknown to participants prior to arrival to the mock scenario.
Thirty-eight PCP and 29 FS students completed the simulation. Overall triage accuracy was 79.9% for PCP and 72.0% for FS (∆ 7.9%; 95% CI, 1.2-14.7) students. No significant difference was found between the groups regarding types of triage errors. Over-triage, under-triage, and critical errors occurred in 10.2%, 7.6%, and 2.3% of PCP triage assignments, respectively. Fire science students had a similar pattern with 15.2% over-triaged, 8.7% under-triaged, and 4.3% critical errors. The median [IQR] time to triage completion for PCPs and FSs were 142.1 [52.6] seconds and 159.0 [40.5] seconds, respectively (P=.19; Mann-Whitney Test).
Primary care paramedics performed MCI triage more accurately than FS students after brief SALT training, but no difference was found regarding types of error or time to triage completion. The clinical importance of this difference in triage accuracy likely is minimal, suggesting that fire services personnel could be considered for MCI triage depending on the availability of prehospital medical resources and appropriate training.
LeeCWC, McLeodSL, Van AarsenK, KlingelM, FrancJM, PeddleMB. First Responder Accuracy Using SALT during Mass-casualty Incident Simulation. Prehosp Disaster Med. 2016;31(2):150–154.
To examine the association between urinary excretion of isoflavonoids and risk of type 2 diabetes (T2D), we conducted a nested case–control study among 1111 T2D pairs identified during 1995–2008 in the Nurses’ Health Study (NHS) and NHSII, who were free of diabetes, CVD and cancer at urine sample collection. Urinary excretion of daidzein and genistein, as well as their metabolites O-desmethylangolensin (O-DMA), dihydrogenistein (DHGE) and dihydrodaidzein (DHDE) was assayed using liquid chromatography MS. Self-reported T2D incident cases were confirmed using a validated questionnaire. Higher urinary excretion of daidzein and genistein was associated with a lower risk of T2D in the combined cohorts. Comparing extreme tertiles of the urinary markers, the OR of T2D were 0·71 (95 % CI 0·55, 0·93) for daidzein and 0·74 (95 % CI 0·56, 0·97) for genistein, although the test for linear trend was not significant for genistein (Ptrend=0·03 and 0·15, respectively). DMA, DHDE and DHGE were non-significantly associated with a lower T2D risk. The inverse association of daidzein with T2D risk was stronger among post-menopausal women who did not use hormone replacement therapy (Pinteraction=0·001): the OR was 0·58 (95 % CI 0·34, 0·97) comparing extreme tertiles among these women. In conclusion, urinary excretion of isoflavones was associated with a lower T2D risk in US women, especially among post-menopausal women who did not use hormone. Further research is warranted to replicate these observations among western populations with similarly low overall isoflavone intake.
Non-alcoholic fatty liver disease (NAFLD) is an independent predictor of CVD in otherwise healthy individuals. Low n-3 PUFA intake has been associated with the presence of NAFLD; however, the relationship between a biomarker of n-3 status – the Omega-3 Index – and liver fat is yet to be elucidated. A total of eighty overweight adults (fifty-six men) completed the anthropometric and biochemical measurements, including the Omega-3 Index, and underwent proton magnetic resonance spectroscopy assessment of liver fat. Bivariate correlations and multiple regression analyses were performed with reference to prediction of liver fat percentage. The mean Omega-3 Index was high in both NAFLD (intrahepatic lipid concentration≥5·5 %) and non-NAFLD groups. The Omega-3 Index, BMI, waist circumference, glucose, insulin, TAG, high-sensitive C-reactive protein (hsCRP) and alanine aminotransferase (ALT) were positively correlated, and HDL and erythrocyte n-6:n-3 ratio negatively correlated with liver fat concentration. Regression analysis found that simple anthropometric and demographic variables (waist, age) accounted for 31 % of the variance in liver fat and the addition of traditional cardiometabolic blood markers (TAG, HDL, hsCRP and ALT) increased the predictive power to 43 %. The addition of the novel erythrocyte fatty acid variable (Omega-3 Index) to the model only accounted for a further 3 % of the variance (P=0·049). In conclusion, the Omega-3 Index was associated with liver fat concentration but did not improve the overall capacity of demographic, anthropometric and blood markers to predict NAFLD.
We study, using both experiment and theory, the coupling of transport and shape dynamics for elastomeric fibres moving through an inhomogeneous flow. The cellular flow, created electromagnetically in our experiment, comprises many identical cells of counter-rotating vortices, with a global flow geometry characterized by a backbone of stable and unstable manifolds connecting hyperbolic stagnation points. Our mathematical model is based upon slender-body theory for the Stokes equations, with the fibres modelled as inextensible elastica. Above a certain threshold of the control parameter, the elasto-viscous number, transport of fibres is mediated by their episodic buckling by compressive stagnation point flows, lending an effectively chaotic component to their dynamics. We use simulations of the model to construct phase diagrams of the fibre state (buckled or not) near stagnation points in terms of two variables that arise in characterizing the transport dynamics. We show that this reduced statistical description quantitatively captures our experimental observations. By carefully reproducing the experimental protocols and time scales of observation within our numerical simulations, we also quantitatively explain features of the measured buckling probability curve as a function of the effective flow forcing. Finally, we show within both experiment and simulation the existence of short and long time scales in the evolution of fibre conformation.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Agency for Toxic Substances and Diseases Registry.
Describe the impact of standardizing state-specific summary measures of antibiotic resistance that inform regional interventions to reduce transmission of resistant pathogens in healthcare settings.
Analysis of public health surveillance data.
Central line–associated bloodstream infection (CLABSI) data from intensive care units (ICUs) of facilities reporting to the National Healthcare Safety Network in 2011 were analyzed. For CLABSI due to methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum cephalosporin (ESC)-nonsusceptible Klebsiella species, and carbapenem-nonsusceptible Klebsiella species, we computed 3 state-level summary measures of nonsusceptibility: crude percent nonsusceptible, model-based adjusted percent nonsusceptible, and crude infection incidence rate.
Overall, 1,791 facilities reported CLABSIs from ICU patients. Of 1,618 S. aureus CLABSIs with methicillin-susceptibility test results, 791 (48.9%) were due to MRSA. Of 756 Klebsiella CLABSIs with ESC-susceptibility test results, 209 (27.7%) were due to ESC-nonsusceptible Klebsiella, and among 661 Klebsiella CLABSI with carbapenem susceptibility test results, 70 (10.6%) were due to carbapenem-nonsusceptible Klebsiella. All 3 state-specific measures demonstrated variability in magnitude by state. Adjusted measures, with few exceptions, were not appreciably different from crude values for any phenotypes. When linking values of crude and adjusted percent nonsusceptible by state, a state’s absolute rank shifted slightly for MRSA in 5 instances and only once each for ESC-nonsusceptible and carbapenem-nonsusceptible Klebsiella species. Infection incidence measures correlated strongly with both percent nonsusceptibility measures.
Crude state-level summary measures, based on existing NHSN CLABSI data, may suffice to assess geographic variability in antibiotic resistance. As additional variables related to antibiotic resistance become available, risk-adjusted summary measures are preferable.