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Background: Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, California (SHIELD OC) was a CDC-funded regional decolonization intervention from April 2017 through July 2019 involving 38 hospitals, nursing homes (NHs), and long-term acute-care hospitals (LTACHs) to reduce MDROs. Decolonization in NH and LTACHs consisted of universal antiseptic bathing with chlorhexidine (CHG) for routine bathing and showering plus nasal iodophor decolonization (Monday through Friday, twice daily every other week). Hospitals used universal CHG in ICUs and provided daily CHG and nasal iodophor to patients in contact precautions. We sought to evaluate whether decolonization reduced hospitalization and associated healthcare costs due to infections among residents of NHs participating in SHIELD compared to nonparticipating NHs. Methods: Medicaid insurer data covering NH residents in Orange County were used to calculate hospitalization rates due to a primary diagnosis of infection (counts per member quarter), hospital bed days/member-quarter, and expenditures/member quarter from the fourth quarter of 2015 to the second quarter of 2019. We used a time-series design and a segmented regression analysis to evaluate changes attributable to the SHIELD OC intervention among participating and nonparticipating NHs. Results: Across the SHIELD OC intervention period, intervention NHs experienced a 44% decrease in hospitalization rates, a 43% decrease in hospital bed days, and a 53% decrease in Medicaid expenditures when comparing the last quarter of the intervention to the baseline period (Fig. 1). These data translated to a significant downward slope, with a reduction of 4% per quarter in hospital admissions due to infection (P < .001), a reduction of 7% per quarter in hospitalization days due to infection (P < .001), and a reduction of 9% per quarter in Medicaid expenditures (P = .019) per NH resident. Conclusions: The universal CHG bathing and nasal decolonization intervention adopted by NHs in the SHIELD OC collaborative resulted in large, meaningful reductions in hospitalization events, hospitalization days, and healthcare expenditures among Medicaid-insured NH residents. The findings led CalOptima, the Medicaid provider in Orange County, California, to launch an NH incentive program that provides dedicated training and covers the cost of CHG and nasal iodophor for OC NHs that enroll.
Disclosures: Gabrielle M. Gussin, University of California, Irvine, Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.
In 2015, excavations at Stainton Quarry, Furness, Cumbria, recovered remains that provide a unique insight into Early Neolithic farming in the vicinity. Five pits, a post-hole, and deposits within a tree-throw and three crevices in a limestone outcrop were investigated. The latter deposits yielded potentially the largest assemblage of Carinated Bowl fragments yet recovered in Cumbria. Lipid analysis identified dairy fats within nine of these sherds. This was consistent with previous larger studies but represents the first evidence that dairying was an important component of Early Neolithic subsistence strategies in Cumbria. In addition, two deliberately broken polished stone axes, an Arran pitchstone core, a small number of flint tools and debitage, and a tuff flake were retrieved. The site also produced moderate amounts of charred grain, hazelnut shell, charcoal, and burnt bone. Most of the charred grain came from an Early Neolithic pit and potentially comprises the largest assemblage of such material recovered from Cumbria to date. Radiocarbon dating indicated activity sometime during the 40th–35th centuries cal bc as well as an earlier presence during the 46th–45th centuries. Later activity during the Chalcolithic and the Early Bronze Age was also demonstrated. The dense concentration of material and the fragmentary and abraded nature of the pottery suggested redeposition from an above-ground midden. Furthermore, the data recovered during the investigation has wider implications regarding the nature and use of the surrounding landscape during the Early Neolithic and suggests higher levels of settlement permanence, greater reliance on domesticated resources, and a possible different topographical focus for settlement than currently proposed.
The spread of invasive, non-native species is a key threat to biodiversity. Parasites can play a significant role by influencing their invasive host's survival or behaviour, which can subsequently alter invasion dynamics. The North American signal crayfish (Pacifastacus leniusculus) is a known carrier of Aphanomyces astaci, an oomycete pathogen that is the causative agent of crayfish plague and fatal to European crayfish species, whereas North American species are considered to be largely resistant. There is some evidence, however, that North American species, can also succumb to crayfish plague, though how A. astaci affects such ‘reservoir hosts’ is rarely considered. Here, we tested the impact of A. astaci infection on signal crayfish, by assessing juvenile survival and adult behaviour following exposure to A. astaci zoospores. Juvenile signal crayfish suffered high mortality 4-weeks post-hatching, but not as older juveniles. Furthermore, adult signal crayfish with high-infection levels displayed altered behaviours, being less likely to leave the water, explore terrestrial areas and exhibit escape responses. Overall, we reveal that A. astaci infection affects signal crayfish to a much greater extent than previously considered, which may not only have direct consequences for invasions, but could substantially affect commercially harvested signal crayfish stocks worldwide.
MD-PhD training programs train physician-scientists to pursue careers involving both clinical care and research, but decreasing numbers of physician-scientists stay engaged in clinical research. We sought to identify current clinical research training methods utilized by MD–PhD programs and to assess how effective they are in promoting self-efficacy for clinical research.
The US MD–PhD students were surveyed in April–May 2018. Students identified the clinical research training methods they participated in, and self-efficacy in clinical research was determined using a modified 12-item Clinical Research Appraisal Inventory.
Responses were received from 61 of 108 MD–PhD institutions. Responses were obtained from 647 MD–PhD students in all years of training. The primary methods of clinical research training included no clinical research training, and various combinations of didactics, mentored clinical research, and a clinical research practicum. Students with didactics plus mentored clinical research had similar self-efficacy as those with didactics plus clinical research practicum. Training activities that differentiated students who did and did not have the clinical research practicum experience and were associated with higher self-efficacy included exposure to Institutional Review Boards and participation in human subject recruitment.
A clinical research practicum was found to be an effective option for MD–PhD students conducting basic science research to gain experience in clinical research skills. Clinical research self-efficacy was correlated with the amount of clinical research training and specific clinical research tasks, which may inform curriculum development for a variety of clinical and translational research training programs, for example, MD–PhD, TL1, and KL2.
Spotted fever group rickettsiae (SFG) are a neglected group of bacteria, belonging to the genus Rickettsia, that represent a large number of new and emerging infectious diseases with a worldwide distribution. The diseases are zoonotic and are transmitted by arthropod vectors, mainly ticks, fleas and mites, to hosts such as wild animals. Domesticated animals and humans are accidental hosts. In Asia, local people in endemic areas as well as travellers to these regions are at high risk of infection. In this review we compare SFG molecular and serological diagnostic methods and discuss their limitations. While there is a large range of molecular diagnostics and serological assays, both approaches have limitations and a positive result is dependent on the timing of sample collection. There is an increasing need for less expensive and easy-to-use diagnostic tests. However, despite many tests being available, their lack of suitability for use in resource-limited regions is of concern, as many require technical expertise, expensive equipment and reagents. In addition, many existing diagnostic tests still require rigorous validation in the regions and populations where these tests may be used, in particular to establish coherent and worthwhile cut-offs. It is likely that the best strategy is to use a real-time quantitative polymerase chain reaction (qPCR) and immunofluorescence assay in tandem. If the specimen is collected early enough in the infection there will be no antibodies but there will be a greater chance of a PCR positive result. Conversely, when there are detectable antibodies it is less likely that there will be a positive PCR result. It is therefore extremely important that a complete medical history is provided especially the number of days of fever prior to sample collection. More effort is required to develop and validate SFG diagnostics and those of other rickettsial infections.
Depression is a leading cause of disability, with older people particularly susceptible to poor outcomes.
To investigate whether the prevalence of depression and antidepressant use have changed across two decades in older people.
The Cognitive Function and Ageing Studies (CFAS I and CFAS II) are two English population-based cohort studies of older people aged ≥65 years, with baseline measurements for each cohort conducted two decades apart (between 1990 and 1993 and between 2008 and 2011). Depression was assessed by the Geriatric Mental State examination and diagnosed with the Automated Geriatric Examination for Computer-Assisted Taxonomy algorithm.
In CFAS I, 7635 people aged ≥65 years were interviewed, of whom 1457 were diagnostically assessed. In CFAS II, 7762 people were interviewed and diagnostically assessed. Age-standardised depression prevalence in CFAS II was 6.8% (95% CI 6.3–7.5%), representing a non-significant decline from CFAS I (risk ratio 0.82, 95% CI 0.64–1.07, P = 0.14). At the time of CFAS II, 10.7% of the population (95% CI 10.0–11.5%) were taking antidepressant medication, more than twice that of CFAS I (risk ratio 2.79, 95% CI 1.96–3.97, P < 0.0001). Among care home residents, depression prevalence was unchanged, but the use of antidepressants increased from 7.4% (95% CI 3.8–13.8%) to 29.2% (95% CI 22.6–36.7%).
A substantial increase in the proportion of the population reporting taking antidepressant medication is seen across two decades for people aged ≥65 years. However there was no evidence for a change in age-specific prevalence of depression.
Most research on the causes of women's underrepresentation examines one of two stages of the political pipeline: the development of nascent political ambition or specific aspects of the campaign and election process. In this article, we make a different kind of contribution. We build on the growing literature on gender, psychology, and representation to provide an analysis of what kinds of men and women make it through the political pipeline at each stage. This allows us to draw some conclusions about the ways in which the overall process is similar and different for women and men. Using surveys of the general U.S. population (N = 1,939) and elected municipal officials such as mayors and city councilors (N = 2,354) that measure the distribution of Big Five personality traits, we find that roughly the same types of men and women have nascent political ambition; there is just an intercept shift for sex. In contrast, male and female elected officials have different personality profiles. These differences do not reflect underlying distributions in the general population or the population of political aspirants. In short, our data suggest that socialization into political ambition is similar for men and women, but campaign and election processes are not.
At the centre of medieval Christendom in the West was the Latin Vulgate Bible, to varying degrees inaccessible to the many people— the laity, conversi, and some women religious— who received little or no Latin training and who, even if they could recite passages of Latin liturgy, sometimes had only the most pragmatic understanding of the language, in the most specific liturgical contexts. Vernacular drama was a particularly effective tool for teaching Scriptural narratives and their Christological significance, at the same time as encouraging appropriate affective responses in an audience of believers; vernacular drama also offered a gloss on the biblical stories that were the primary influence on the Latin liturgy. This chapter considers a specific example in which biblical material moves through time and space through the medium of dramatic representation in the fifteenth-century medieval convent; it will explore the outcomes of the interpretation and transformation of scripture through its translation into dramatic form, and consider the adaptation and transmission of the resulting material into the seventeenth century.
Like civic Scriptural drama, nuns’ plays translated Vulgate Latin into the vernacular in order to teach biblical narrative; also like civic drama, but perhaps to an even greater degree, convent drama referenced liturgical elements to explain their function. The objective of the liturgy was the worship of God and petition directed heavenward: medieval congregations may not have contributed to its words or action but they were thoroughly engaged in the intention of the celebration. Medieval plays complicate neat distinctions between performers and spectators that characterize later theatre, and convent plays blur distinctions between actors and audience much further, as in some cases there may have been nobody watching who was not also performing, and if there were “audiences” then their responses— active, as well as affective— were integrated into the work of the plays. Scriptural plays written and performed by medieval nuns necessarily differed from plays written for the medieval city street because they were performed in contexts that were inaccessible to the general public, and free from the influence of civic authorities for whom public playing was an opportunity for the display of power and prestige.
What follows is an experiment in reading practice. I propose that we read some key passages of the Aeneid and the Metamorphoses in the active pursuit of acrostics and telestics, just as we have been accustomed to read them in the active pursuit of allusions and intertexts; and that we do so with the same willingness to make sense of what we find. The measure of success of this reading practice will be the extent to which our understanding of these familiar and well-studied texts can be usefully enriched by our interpretation of our discoveries (or rediscoveries). These will include an undiscovered authorial signature NASO in the ‘second proem’ of the Metamorphoses; an unnoticed self-referential response to Horace with NITIDO at the centre of Ovid's epic and a similarly self-referential AVSVM at the centre of Virgil's epic; in the Aeneid we will also find glances to Aratus with LEPTE and an Aratean anagram on Aeneas’ shield; and two new acrostics connecting Dido, Ajax and Lavinia.
OBJECTIVES/SPECIFIC AIMS: The study aims to determine the current clinical research training interventions of MD-PhD programs and how effective they are in promoting clinical research self-efficacy. METHODS/STUDY POPULATION: A national survey of MD-PhD trainees was conducted in 2018 to identify clinical research training methods and self-efficacy for clinical research skills. MD-PhD program directors and coordinators from 108 institutions were asked to distribute the survey to their students. Responses were received from 61 institutions (56.5%). Responses were obtained from 647 MD-PhD students in all years of training, representing 17.9% of the 3613 possible participants at the 61 medical schools represented. No compensation was provided for this study. RESULTS/ANTICIPATED RESULTS: The primary methods of clinical research training reported by students included didactics, mentored clinical research, didactics plus mentored clinical research, didactics plus clinical research practicum, and didactics plus mentored clinical research plus clinical research practicum. A quarter of all participants reported having no clinical research training. Clinical research self-efficacy was then correlated with the amount of clinical research training. Students exposed to no clinical research had the lowest self-efficacy in clinical research skills and students experiencing didactics plus mentored clinical research plus clinical research practicum had the highest perceived self-efficacy in clinical research domains. DISCUSSION/SIGNIFICANCE OF IMPACT: This is one of the first studies assessing clinical research training methods for MD-PhD students and assessing their efficacy. We found that of all students questioned, 25% mentioned had not received any type of clinical research training. The remaining students identified 5 research training methods that institutions currently use. This work highlights the importance of clinical research experience students need to improve their self-efficacy, a major influence on research career outcomes.
The US Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) program sponsors the development of systematic reviews to inform clinical policy and practice. The EPC program sought to better understand how health systems identify and use this evidence.
Representatives from eleven EPCs, the EPC Scientific Resource Center, and AHRQ developed a semi-structured interview script to query a diverse group of nine Key Informants (KIs) involved in health system quality, safety and process improvement about how they identify and use evidence. Interviews were transcribed and qualitatively summarized into key themes.
All KIs reported that their organizations have either centralized quality, safety, and process improvement functions within their system, or they have partnerships with other organizations to conduct this work. There was variation in how evidence was identified, with larger health systems having medical librarians and central bureaus to gather and disseminate information and smaller systems having local chief medical officers or individual clinicians do this work. KIs generally prefer guidelines, especially those with treatment algorithms, because they are actionable. They like systematic reviews because they efficiently condense study results and reconcile conflicting data. They prefer information from systematic reviews to be presented as short digestible summaries with the full report available on demand. KIs preferred systematic reviews from reputable entities and those without commercial bias. Some of the challenges KIs reported include how to resolve conflicting evidence, the generalizability of evidence to local needs, determining whether the evidence is up-to-date, and the length of time required to generate reviews. The topics of greatest interest included predictive analytics, high-value care, advance care planning, and care coordination. To increase awareness of AHRQ EPC reviews, KIs suggest alerting people at multiple levels in a health-system when new evidence reports are available and making reports easier to find in common search engines.
Systematic reviews are valued by health system leaders. To be most useful they should be easy to locate and available in different formats targeted to the needs of different audiences.
To investigate an outbreak of Pseudomonas aeruginosa infections and colonization in a neonatal intensive care unit.
Infection control assessment, environmental evaluation, and case-control study.
Newly built community-based hospital, 28-bed neonatal intensive care unit.
Neonatal intensive care unit patients receiving care between June 1, 2013, and September 30, 2014.
Case finding was performed through microbiology record review. Infection control observations, interviews, and environmental assessment were performed. A matched case-control study was conducted to identify risk factors for P. aeruginosa infection. Patient and environmental isolates were collected for pulsed-field gel electrophoresis to determine strain relatedness.
In total, 31 cases were identified. Case clusters were temporally associated with absence of point-of-use filters on faucets in patient rooms. After adjusting for gestational age, case patients were more likely to have been in a room without a point-of-use filter (odds ratio [OR], 37.55; 95% confidence interval [CI], 7.16–∞). Case patients had higher odds of exposure to peripherally inserted central catheters (OR, 7.20; 95% CI, 1.75–37.30) and invasive ventilation (OR, 5.79; 95% CI, 1.39–30.62). Of 42 environmental samples, 28 (67%) grew P. aeruginosa. Isolates from the 2 most recent case patients were indistinguishable by pulsed-field gel electrophoresis from water-related samples obtained from these case-patient rooms.
This outbreak was attributed to contaminated water. Interruption of the outbreak with point-of-use filters provided a short-term solution; however, eradication of P. aeruginosa in water and fixtures was necessary to protect patients. This outbreak highlights the importance of understanding the risks of stagnant water in healthcare facilities.
As a discipline, design science has traditionally focused on designing products and associated technical processes to improve usability and performance. Although significant progress has been made in these areas, little research has yet examined the role of human behaviour in the design of socio-technical systems (e.g., organizations). Here, we argue that applying organizational psychology as a design science can address this omission and enhance the capability of both disciplines. Specifically, we propose a method to predict malfunctions in socio-technical systems (PreMiSTS), thereby enabling them to be designed out or mitigated. We introduce this method, describe its nine stages, and illustrate its application with reference to two high-profile case studies of such malfunctions: (1) the severe breakdowns in patient care at the UK’s Mid-Staffordshire NHS Foundation Trust hospital in the period 2005–2009, and (2) the fatal Grayrigg rail accident in Cumbria, UK, in 2007. Having first identified the socio-technical and behavioural antecedents of these malfunctions, we then consider how the PreMiSTS method could be used to predict and prevent future malfunctions of this nature. Finally, we evaluate the method, consider its advantages and disadvantages, and suggest where it can be most usefully applied.
Two studies consisting of six field experiments each were conducted at three locations in southwestern Ontario, Canada, in 2014 and 2015 to evaluate the possible antagonism when dicamba was added to quizalofop-p-ethyl or clethodim for the control of volunteer glyphosate-resistant (GR) corn. At 4 wk after application (WAA), quizalofop-p-ethyl at 24, 30, or 36 g ai ha−1 provided 88, 94, and 95% control of volunteer GR corn, respectively. The addition of dicamba at 300 or 600 g ae ha−1 to quizalofop-p-ethyl (24 g ha−1) reduced the activity of quizalofop-p-ethyl on volunteer GR corn by 12 and 20%. At 4 WAA, clethodim at 30, 37.5, and 45 g ai ha−1 provided 85, 91, and 95% control of volunteer GR corn, respectively. The addition of dicamba at 300 or 600 g ha−1 to clethodim (30 g ha−1) resulted in antagonism, causing a reduction in volunteer GR corn by 12 and 11%, respectively. In general, there was greater antagonism when the high rate of dicamba was tank-mixed with the lower rate of the graminicide. There was no antagonistic effect on soybean yield by tank-mixing dicamba with either graminicide at all rates evaluated. Based on these results, volunteer GR corn can be controlled effectively by increasing the rate of the graminicide when tankmixed with dicamba.
Two important developments in recent policy analysis are behavioral economics and subjective-well-being (SWB) surveys. What is the connection between them? Some have suggested that behavioral economics strengthens the case for SWB surveys as a central policy tool, e.g., in the form of SWB-based cost-benefit analysis. This article reaches a different conclusion. Behavioral economics shows that individuals in their day-to-day, “System 1” behavior are not expected utility (EU-) rational – that they often fail to comply with the norms of rationality set forth by EU theory. Consider now that the standard preference-based view of individual well-being looks to individuals’ rational preferences. If the findings of behavioral economics are correct, an individual’s answer to a question such as “How satisfied are you with your life?” is not going to tell us much about her rational (EU-compliant) preferences. Behavioral economics, by highlighting widespread failures of EU rationality, might actually argue for an objective-good (non-preference-based) view of well-being. However (except in the limiting case of an objective-good view positing a single mentalistic good, happiness), SWB surveys will not be strong evidence of well-being in the objective-good sense. In short, SWB surveys are no “magic cure” for the genuine difficulties in inferring rational preferences and measuring well-being underscored by behavioral economics.
There is growing interest in brief contact interventions for self-harm
and suicide attempt.
To synthesise the evidence regarding the effectiveness of brief contact
interventions for reducing self-harm, suicide attempt and suicide.
A systematic review and random-effects meta-analyses were conducted of
randomised controlled trials using brief contact interventions (telephone
contacts; emergency or crisis cards; and postcard or letter contacts).
Several sensitivity analyses were conducted to examine study quality and
We found 14 eligible studies overall, of which 12 were amenable to
meta-analyses. For any subsequent episode of self-harm or suicide
attempt, there was a non-significant reduction in the overall pooled odds
ratio (OR) of 0.87 (95% CI 0.74–1.04, P = 0119) for
intervention compared with control. The number of repetitions per person
was significantly reduced in intervention v. control
(incidence rate ratio IRR = 066, 95% CI 0.54–0.80,
P<0001). There was no significant reduction in the
odds of suicide in intervention compared with control (OR = 0.58, 95% CI
A non-significant positive effect on repeated self-harm, suicide attempt
and suicide and a significant effect on the number of episodes of
repeated self-harm or suicide attempts per person (based on only three
studies) means that brief contact interventions cannot yet be recommended
for widespread clinical implementation. We recommend further assessment
of possible benefits in well-designed trials in clinical populations.