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Surveillance of non–ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses.
We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans’ Affairs (VA) hospitals from January 1, 2015, to November 30, 2020. We randomly selected 250 hospitalizations meeting NV-HAP surveillance criteria for independent review by 2 clinicians and calculated the percent of hospitalizations with (1) clinical deterioration, (2) CDC National Healthcare Safety Network (CDC-NHSN) criteria, (3) NV-HAP according to a reviewer, (4) NV-HAP according to a treating clinician, (5) pneumonia diagnosis in discharge summary; and (6) discharge diagnosis codes for HAP. We assessed interrater reliability by calculating simple agreement and the Cohen κ (kappa).
Among 3.1 million hospitalizations, 14,023 met NV-HAP electronic surveillance criteria. Among reviewed cases, 98% had a confirmed clinical deterioration; 67% met CDC-NHSN criteria; 71% had NV-HAP according to a reviewer; 60% had NV-HAP according to a treating clinician; 49% had a discharge summary diagnosis of pneumonia; and 82% had NV-HAP according to any definition according to at least 1 reviewer. Only 8% had diagnosis codes for HAP. Interrater agreement was 75% (κ = 0.50) for CDC-NHSN criteria and 78% (κ = 0.55) for reviewer diagnosis of NV-HAP.
Electronic NV-HAP surveillance criteria correlated moderately with existing manual surveillance criteria. Reviewer variability for all manual assessments was high. Electronic surveillance using clinical data may therefore allow for more consistent and efficient surveillance with similar accuracy compared to manual assessments or diagnosis codes.
Alcohol use disorder and other substance use disorders are a growing, yet under recognized, health problem in older adults. Generally, screening tests and diagnostic examinations for these disorders are geared toward a younger population. There is a growing body of literature, however, that specifically addresses screening, diagnosis, and treatment substance use disorders in older adults. Several treatment strategies and medications are being used successfully to treat this older population. Physicians and other health-care providers must remain diligent in considering a diagnosis of substance use disorder in all their patients, regardless of age, gender, socioeconomic status, and comorbid conditions.
Colleges and universities around the world engaged diverse strategies during the COVID-19 pandemic. Baylor University, a community of ˜22,700 individuals, was 1 of the institutions which resumed and sustained operations. The key strategy was establishment of multidisciplinary teams to develop mitigation strategies and priority areas for action. This population-based team approach along with implementation of a “Swiss Cheese” risk mitigation model allowed small clusters to be rapidly addressed through testing, surveillance, tracing, isolation, and quarantine. These efforts were supported by health protocols including face coverings, social distancing, and compliance monitoring. As a result, activities were sustained from August 1 to December 8, 2020. There were 62,970 COVID-19 tests conducted with 1435 people testing positive for a positivity rate of 2.28%. A total of 1670 COVID-19 cases were identified with 235 self-reports. The mean number of tests per week was 3500 with approximately 80 of these positive (11/d). More than 60 student tracers were trained with over 120 personnel available to contact trace, at a ratio of 1 per 400 university members. The successes and lessons learned provide a framework and pathway for similar institutions to mitigate the ongoing impacts of COVID-19 and sustain operations during a global pandemic.
The vagus nerve performs many different functions in the human body. Understanding these functions helps inform the potential side effects of vagus nerve stimulation (VNS). The nerve consists of 80% afferent fibres [1,2]. These include visceral sensory and taste fibres which travel primarily to the nucleus of the tractus solitarius, as well as cutaneous sensation fibres from the external auditory meatus which project to the spinal nucleus of the trigeminal nerve. The efferent component includes branchial motor fibres from the nucleus ambiguus, parasympathetic fibres primarily from the dorsal nucleus of the vagus and parasympathetic fibres from the nucleus ambiguus to the heart. The motor fibres innervate skeletal muscles in the head and neck involved in speech production and swallowing, while the parasympathetic fibres innervate most of the viscera serving to control heart rate, respiration, gastrointestinal motility and many other autonomic functions. The majority of fibres in the vagus nerve consist of unmyelinated C fibres, but commensurate with its wide variety of functions, it also contains larger and faster-conducting A- and B-type fibres. The brainstem nuclei that receive vagal inputs integrate homeostatic information, provide commensurate adjustments to autonomic functions and also send this information to other brainstem nuclei projecting widely throughout the brain.
Fifty million people worldwide have epilepsy and yet up to 35% of patients experience seizures that are resistant to anti-epileptic drugs. Patients with medication-resistant epilepsy have increased risks of premature death, psychosocial dysfunction and a reduced quality of life. This key resource delivers guidance for all clinicians involved in caring for patients with medication-resistant epilepsy in order to reduce these risks. Covering the epidemiology, biology, causes and potential treatments for medication-resistant epilepsy, this definitive and focused text reviews the clinical care needs of patients. Guidance is practical and includes treatment for specialized groups including pediatric patients and those with psychiatric comorbidities. Several promising non-pharmacologic interventions available for patients, such as surgery, neuromodulation diet therapy and botanical treatment are explored in detail. Leading international figures from a range of disciplines bring their expertise together holistically in this essential manual.
Work–life balance facilitates positive affect, happiness, and satisfaction [1–4]; absence of it contributes to depression and anxiety . However, achieving a “balance” is easier said than done. Strategies to increase positive affect, happiness, and quality of life have often been simplistic.
For example, some suggestions to enhance work–life balance include “learn to say no if you are too busy,” “practice self-care,” “don’t take work home with you,” “make time for friends and family outside of work,” and “reduce work email and work phone access” . In contrast, our chapter focuses on how to increase well-being. Well-being and positive affect are well described in the positive psychology literature [6, 7].
The science of studying diamond inclusions for understanding Earth history has developed significantly over the past decades, with new instrumentation and techniques applied to diamond sample archives revealing the stories contained within diamond inclusions. This chapter reviews what diamonds can tell us about the deep carbon cycle over the course of Earth’s history. It reviews how the geochemistry of diamonds and their inclusions inform us about the deep carbon cycle, the origin of the diamonds in Earth’s mantle, and the evolution of diamonds through time.
Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM).
Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators.
Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology.
This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.
We study the implications of patents in an overlapping generations model with horizontal innovation of differentiated physical capital. We show that within this demographic structure of finitely lived agents, weakening patent protection generates two contradicting effects on innovation and growth. Weakening patent protection lowers the (average) price of patented machines, thereby increasing machine utilization, output, aggregate saving, and investment. However, a higher demand for machines shifts investment away from the R&D activity aimed at inventing new machine varieties toward the formation of physical capital. The growth-maximizing level of patent protection is incomplete. Shortening patent length is more effective than loosening patent breadth in spurring growth, due to an additional positive effect on growth, that is decreasing investment in old patents. Welfare can be improved by weakening patent protection beyond the growth-maximizing level.
Objective: To determine whether volumetric measures of the hippocampus, entorhinal cortex, and other cortical measures can differentiate between cognitively normal individuals and subjects with mild cognitive impairment (MCI). Method: Magnetic resonance imaging (MRI) data from 46 cognitively normal subjects and 50 subjects with MCI as part of the Boston University Alzheimer’s Disease Center research registry and the Alzheimer’s Disease Neuroimaging Initiative were used in this cross-sectional study. Cortical, subcortical, and hippocampal subfield volumes were generated from each subject’s MRI data using FreeSurfer v6.0. Nominal logistic regression models containing these variables were used to identify subjects as control or MCI. Results: A model containing regions of interest (superior temporal cortex, caudal anterior cingulate, pars opercularis, subiculum, precentral cortex, caudal middle frontal cortex, rostral middle frontal cortex, pars orbitalis, middle temporal cortex, insula, banks of the superior temporal sulcus, parasubiculum, paracentral lobule) fit the data best (R2 = .7310, whole model test chi-square = 97.16, p < .0001). Conclusions: MRI data correctly classified most subjects using measures of selected medial temporal lobe structures in combination with those from other cortical areas, yielding an overall classification accuracy of 93.75%. These findings support the notion that, while volumes of medial temporal lobe regions differ between cognitively normal and MCI subjects, differences that can be used to distinguish between these two populations are present elsewhere in the brain.
Although attention has been given to how broadband access is related to economic development in rural areas, scant consideration has been given to how it may be associated with voluntary participation. This issue is important in that numerous studies have shown how much more vital community participation is in rural areas as compared to suburban and urban places. Drawing on three diverse data sets, we examine the influence of broadband access on community participation. In addition, we explore whether broadband access exerts its influence through, in conjunction with, or independent of social networks. The results suggest that broadband access and social network size have independent effects on volunteering in rural places.
Anorexia nervosa is an eating disorder, which is associated with many different medical complications as a result of the weight loss and malnutrition that characterise this illness. It has the highest mortality rate of any psychiatric disorder. A large portion of deaths are attributable to the cardiac abnormalities that ensue as a result of the malnutrition associated with anorexia nervosa. In this review, the cardiac complications of anorexia nervosa will be discussed.
A comprehensive literature review on cardiac changes in anorexia nervosa was carried out.
There are structural, functional, and rhythm-type changes that occur in patients with anorexia nervosa. These become progressively significant as ongoing weight loss occurs.
Cardiac changes are inherent to anorexia nervosa and they become more life-threatening and serious as the anorexia nervosa becomes increasingly severe. Weight restoration and attention to these cardiac changes are crucial for a successful treatment outcome.
The low prevalence of extrapyramidal symptoms associated with atypical antipsychotics has led to their widespread use during the past decade. Aripiprazole, the newest medication in this class, has been associated with extrapyramidal symptoms (eg, akathisia) and with improvement of tardive dyskinesia (TD), but to date it has not been associated with the development of TD. We report a case of TD associated with the use of aripiprazole 15 mg/day for 18 months for refractory depression. Symptoms of TD resolved within several weeks of discontinuation of aripiprazole.