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To update current estimates of non–device-associated pneumonia (ND pneumonia) rates and their frequency relative to ventilator associated pneumonia (VAP), and identify risk factors for ND pneumonia.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. Pneumonia (device associated and non–device associated) were captured through comprehensive, hospital-wide active surveillance using CDC definitions and methodology.
From 2013 to 2017, there were 163,386 hospitalizations (97,485 unique patients) and 771 pneumonia cases (520 ND pneumonia and 191 VAP). The rate of ND pneumonia remained stable, with 4.15 and 4.54 ND pneumonia cases per 10,000 hospitalization days in 2013 and 2017 respectively (P = .65). In 2017, 74% of pneumonia cases were ND pneumonia. Male sex and increasing age we both associated with increased risk of ND pneumonia. Additionally, patients with chronic bronchitis or emphysema (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.40–3.06), congestive heart failure (HR, 1.48; 95% CI, 1.07–2.05), or paralysis (HR, 1.72; 95% CI, 1.09–2.73) were also at increased risk, as were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18–2.00) or in the ICU (HR, 1.49; 95% CI, 1.06–2.09). We did not detect a change in ND pneumonia risk with use of chlorhexidine mouthwash, total parenteral nutrition, all medications of interest, and prior ventilation.
The incidence rate of ND pneumonia did not change from 2013 to 2017, and 3 of 4 nosocomial pneumonia cases were non–device associated. Hospital infection prevention programs should consider expanding the scope of surveillance to include non-ventilated patients. Future research should continue to look for modifiable risk factors and should assess potential prevention strategies.
Six and a half centuries after his birth, Richard II remains as intriguing and beguiling as ever. Scholarly interest in the king and his reign flourished around the sexcentenary of the revolution of 1399 and has shown little sign of flagging. Chris Given-Wilson, our honorand, has made a major contribution to building serious interest in the field, not least because his work has never been narrowly concerned with the king himself. His monograph on the royal household and king's affinity, published in the lean 1980s, provided a new frame, chronological and thematic, for an assessment of Richard's rule. His work on chronicles, notably his Chronicles of the Revolution and his exemplary edition of the Chronicle of Adam Usk, has provided a sound foundation for scholarship. If his approach to the chronicles is appropriately critical, Chris always pays them the courtesy of taking them seriously. For all their limitations, the chronicles provide insights on Richard's personality and politics which, though corroborated in other sources, would not be so evident without them. A good example is Richard's interest in English royal history. Three chronicles record separate incidents – the most celebrated being Adam Usk's report of Richard's lamenting England's record of regicide – that show the king's interest in antiquities and England's kings. Following in their wake, historians have revealed a king who had a strong interest in his heritage, the history of the crown and the legacy of the past. In a brilliant study, Chris himself showed Richard's historical consciousness in the late 1390s, in seeking not only to avenge his humiliation in 1387–8 but also to reverse the political outcomes of Edward II's reign.
In seeking to understand Richard's personal and political formation, this paper complements the focus on his interest in his royal predecessors by exploring his engagement with contemporary princes. It suggests that Richard's awareness of himself as a king among kings played a significant role in the development of his ideas about kingship and his sense of his destiny as ruler. England's kings naturally paid close attention to their French rivals, but Richard's relationship with Charles VI of France was unusually collegial and warm.
To update current estimates of non–device-associated urinary tract infection (ND-UTI) rates and their frequency relative to catheter-associated UTIs (CA-UTIs) and to identify risk factors for ND-UTIs.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. UTIs (device and non-device associated) were captured through comprehensive, hospital-wide active surveillance using Centers for Disease Control and Prevention case definitions and methodology.
From 2013 to 2017 there were 163,386 hospitalizations (97,485 unique patients) and 1,273 UTIs (715 ND-UTIs and 558 CA-UTIs). The rate of ND-UTIs remained stable, decreasing slightly from 6.14 to 5.57 ND-UTIs per 10,000 hospitalization days during the study period (P = .15). However, the proportion of UTIs that were non–device related increased from 52% to 72% (P < .0001). Female sex (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.50–2.50) and increasing age were associated with increased ND-UTI risk. Additionally, the following conditions were associated with increased risk: peptic ulcer disease (HR, 2.25; 95% CI, 1.04–4.86), immunosuppression (HR, 1.48; 95% CI, 1.15–1.91), trauma admissions (HR, 1.36; 95% CI, 1.02–1.81), total parenteral nutrition (HR, 1.99; 95% CI, 1.35–2.94) and opioid use (HR, 1.62; 95% CI, 1.10–2.32). Urinary retention (HR, 1.41; 95% CI, 0.96–2.07), suprapubic catheterization (HR, 2.28; 95% CI, 0.88–5.91), and nephrostomy tubes (HR, 2.02; 95% CI, 0.83–4.93) may also increase risk, but estimates were imprecise.
Greater than 70% of UTIs are now non–device associated. Current targeted surveillance practices should be reconsidered in light of this changing landscape. We identified several modifiable risk factors for ND-UTIs, and future research should explore the impact of prevention strategies that target these factors.
Uncontrolled pain in advanced cancer is a common problem and has significant impact on individuals’ quality of life and use of healthcare resources. Interventions to help manage pain at the end of life are available, but there is limited economic evidence to support their wider implementation. We conducted a case study economic evaluation of two pain self-management interventions (PainCheck and Tackling Cancer Pain Toolkit [TCPT]) compared with usual care.
We generated a decision-analytic model to facilitate the evaluation. This modelled the survival of individuals at the end of life as they moved through pain severity categories. Intervention effectiveness was based on published meta-analyses results. The evaluation was conducted from the perspective of the U.K. health service provider and reported cost per quality-adjusted life-year (QALY).
PainCheck and TCPT were cheaper (respective incremental costs -GBP148 [-EUR168.53] and -GBP474 [-EUR539.74]) and more effective (respective incremental QALYs of 0.010 and 0.013) than usual care. There was a 65 percent and 99.5 percent chance of cost-effectiveness for PainCheck and TCPT, respectively. Results were relatively robust to sensitivity analyses. The most important driver of cost-effectiveness was level of pain reduction (intervention effectiveness). Although cost savings were modest per patient, these were considerable when accounting for the number of potential intervention beneficiaries.
Educational and monitoring/feedback interventions have the potential to be cost-effective. Economic evaluations based on estimates of effectiveness from published meta-analyses and using a decision modeling approach can support commissioning decisions and implementation of pain management strategies.
In Scotland, the base of the Ballagan Formation has traditionally been placed at the first grey mudstone within a contiguous Late Devonian to Carboniferous succession. This convention places the Devonian–Carboniferous boundary within the Old Red Sandstone (ORS) Kinnesswood Formation. The consequences of this placement are that tetrapods from the Ballagan Formation were dated as late Tournaisian in age and that the ranges of typically Devonian fish found in the Kinnesswood Formation continued into the Carboniferous. The Pease Bay specimen of the fish Remigolepis is from the Kinnesswood Formation. Comparisons with its range in Greenland, calibrated against spores, show it was Famennian in age. Detailed palynological sampling at Burnmouth from the base of the Ballagan Formation proves that the early Tournaisian spore zones (VI and HD plus Cl 1) are present. The Schopfites species that occurs through most of the succession is Schopfites delicatus rather than Schopfites claviger. The latter species defines the late Tournaisian CM spore zone. The first spore assemblage that has been found in Upper ‘ORS' strata underlying the Ballagan Formation (Preston, Whiteadder Water), contains Retispora lepidophyta and is from the early latest Famennian LL spore zone. The spore samples are interbedded with volcaniclastic debris, which shows that the Kelso Volcanic Formation is, in part, early latest Famennian in age. These findings demonstrate that the Ballagan Formation includes most of the Tournaisian with the Devonian–Carboniferous boundary positioned close to the top of the Kinnesswood Formation. The Stage 6 calcrete at Pease Bay can be correlated to the equivalent section at Carham, showing that it represents a time gap equivalent to the latest Famennian glaciation(s). Importantly, some of the recently described Ballagan Formation tetrapods are older than previously dated and now fill the key early part of Romer's Gap.
The lower Mississippian Ballagan Formation of northern Britain is one of only two successions worldwide to yield the earliest known tetrapods with terrestrial capability following the end-Devonian mass extinction event. Studies of the sedimentary environments and habitats in which these beasts lived have been an integral part of a major research project into how, why and under what circumstances this profound step in the evolution of life on Earth occurred. Here, a new palaeogeographic map is constructed from outcrop data integrated with new and archived borehole material. The map shows the extent of a very low-relief coastal wetland developed along the tropical southern continental margin of Laurussia. Coastal floodplains in the Midland Valley and Tweed basins were separated from the marginal marine seaway of the Northumberland–Solway Basin to the south by an archipelago of more elevated areas. A complex mosaic of sedimentary environments was juxtaposed, and included fresh and brackish to saline and hypersaline lakes, a diverse suite of floodplain palaeosols and a persistent fluvial system in the east of the region. The strongly seasonal climate led to the formation of evaporite deposits alternating with flooding events, both meteoric and marine. Storm surges drove marine floods from the SW into both the western Midland Valley and Northumberland–Solway Basin; marine water also flooded into the Tweed Basin and Tayside in the east. The Ballagan Formation is a rare example in the geological record of a tropical, seasonal coastal wetland that contains abundant, small-scale evaporite deposits. The diverse sedimentary environments and palaeosol types indicate a network of different terrestrial and aquatic habitats in which the tetrapods lived.
The Libelle of English Policy is a poem of some vigour and originality. Writing in 1436–7, the author describes and assesses England's commerce and strategic position, and commends policies, especially in relation to the promotion of trade and control of the sea, in terms of national interest. Extant in some eighteen manuscripts, the poem appears to have achieved significant early circulation. Outlining England's maritime destiny, it later became an iconic national text. Its inclusion in Richard Hakluyt's Voyages and Discoveries in 1598 and in Thomas Wright's Political Poems and Songs in 1861 assured its availability over the centuries. The first scholarly edition was published in Leipzig in 1878, and the standard edition by Sir George Warner appeared as long ago as 1926. A modern edition based on more manuscripts and engaging with scholarship over the past century is a desideratum. The value of the Libelle as a source of information on English trade and maritime policy has long been recognised. More recently, it has been valued for the insights it offers on the political culture of Lancastrian England. Given the precision with which the Libelle can be dated, and its prominence among a body of other contemporary writing on political themes, the anonymity of the poem is most disappointing. It is unfortunate, too, that the editor of the standard edition identified the author as Adam Moleyns, doctor of canon law, clerk to the council, and subsequently bishop of Chichester. Though the attribution has been shown to be highly implausible, it has proved very hard to dislodge. Furthermore, the focus on a man of formal learning and high official standing has perhaps deflected attention from evidence in the text itself that the author was a man of a rather different stamp.
The first part of this paper introduces the Libelle and the evidence relating to its authorship and context. It sets the poem in the broader context of news, information, policy debate and propaganda in the late 1430s. It acknowledges that the poet was articulate, intelligent and knowledgeable on a range of matters. His literacy and probable competence in Latin suggest that he was well schooled and may have obtained further training in dictamen. There is little in the poem, however, to suggest a university education.
A controversy at the 2016 IUCN World Conservation Congress on the topic of closing domestic ivory markets (the 007, or so-called James Bond, motion) has given rise to a debate on IUCN's value proposition. A cross-section of authors who are engaged in IUCN but not employed by the organization, and with diverse perspectives and opinions, here argue for the importance of safeguarding and strengthening the unique technical and convening roles of IUCN, providing examples of what has and has not worked. Recommendations for protecting and enhancing IUCN's contribution to global conservation debates and policy formulation are given.
A theoretical model and an experimental model of surge motions of an ice floe due to regular waves are presented. The theoretical model is a modified version of Morrison’s equation, valid for small floating bodies. The experimental model is implemented in a wave basin at a scale 1:100, using a thin plastic disc to model the floe. The processed experimental data display a regime change in surge amplitude when the incident wavelength is approximately twice the floe diameter. It is shown that the theoretical model is accurate in the high-wavelength regime, but highly inaccurate in the low-wavelength regime.
While much is known about dyslexia in school-age children and adolescents, less is known about its effects on quality of life in adults. Using data from the Connecticut Longitudinal Study, we provide the first estimates of the monetary value of improving reading, speaking, and cognitive skills to dyslexic and nondyslexic adults. Using a stated-preference survey, we find that dyslexic and nondyslexic individuals value improvements in their skills in reading speed, reading aloud, pronunciation, memory, and information retrieval at about the same rate. Because dyslexics have lower self-reported levels on these skills, their total willingness to pay to achieve a high level of skill is substantially greater than for nondyslexics. However, dyslexic individuals’ willingness to pay (averaging $3000 for an improvement in all skills simultaneously) is small compared with the difference in earnings between dyslexic and nondyslexic adults. We estimate that dyslexic individuals earn 15% less per year (about $8000) than nondyslexic individuals. Although improvements in reading, speaking, and cognitive skills in adulthood are unlikely to eliminate the earnings difference that reflects differences in educational attainment and other factors, stated-preference estimates of the value of cognitive skills may substantially underestimate the value derived from effects on lifetime earnings and health.
Modes of debris entrainment and subsequent transfer in seven “normal” and five surge-type glaciers in Svalbard (76–79° N) are outlined in the context of the structural evolution of a glacier as the ice deforms during flow. Three main modes of entrainment and transfer are inferred from structural and sedimentological observations: (i) The incorporation of angular rockfall material within the stratified sequence of snow/firn/superimposed ice. This debris takes an englacial path through the glacier, becoming folded. At the margins and at the boundaries of flow units the stratified ice including debris is strongly folded, so that near the snout the debris emerges at the surface on the hinges and limbs of the folds, producing medial moraines which merge towards the snout. The resulting lines of debris are transmitted to the proglacial area in the form of regular trains of angular debris. (ii) Incorporation of debris of both supraglacial and basal character within longitudinal foliation. This is particularly evident at the surface of the glacier at the margins or at flow unit boundaries. It can be sometimes demonstrated that foliation is a product of strong folding, since it usually has an axial planar relationship with folded stratification. Foliation-parallel debris thus represents a more advanced stage of deformation than in (i). Although the presence of basal debris is problematic, it is proposed that this material is tightly folded ice derived from the bed in the manner of disharmonie folding. The readily deformed subglacial sediment or bedrock surface represents the plane of décollement. (iii) Thrusting, whereby debris-rich basal ice (including regelation ice) and subglacial sediments are uplifted into an englacial position, sometimes emerging at the ice surface. This material is much more variable in character than that derived from rockfalls, and reflects the substrate lithologies; diamicton with striated clasts and sandy gravels are the most common facies represented. Thrusting is a dynamic process, and in polythermal glaciers is probably linked mainly to the transition from sliding to frozen bed conditions. It is not therefore a solely ice-marginal or proglacial process.
Mapping of the structural glaciology of Kongsvegen, Svalbard, reveals evidence for four main deformational structures. These are stratification, longitudinal foliation, thrusts and crevasse traces. These structures are considered in terms of their contribution to debris entrainment, transport and subsequent landform development. Stratification is associated with small amounts of supraglacial debris that has been folded with flow-parallel axes; longitudinal foliation in places incorporates basal glacial sediments along folds with flow-parallel axes; and thrusts transport basal debris to the glacier surface. Crevasse traces are not significant in terms of debris entrainment. The entrainment of basal debris along longitudinal foliation is not a universally recognised process. At Kongsvegen this process is attributed to the development of a transposition foliation, in combination with incorporation of debris-rich basal ice or soft basal sediment in the fold complex. Mapping of the landforms in the proglacial area shows that debris incorporated along longitudinal foliation is released as “foliation-parallel ridges” and that transverse ridges mark debris-bearing thrusts. The role of longitudinal foliation in landform development has never been documented in this manner. Although the preservation potential of such ridges may be limited, recognition of foliation-parallel ridges in the Pleistocene landform record has important implications for the interpretation of the dynamics of former ire masses.