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Infection prevention program leaders report frequent use of criteria to distinguish recently recovered coronavirus disease 2019 (COVID-19) cases from actively infectious cases when incidentally positive asymptomatic patients were identified on routine severe acute respiratory coronavirus virus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing. Guidance on appropriate interpretation of high-sensitivity molecular tests can prevent harm from unnecessary precautions that delay admission and impede medical care.
In October 2021, a majority of the UK gambling industry implemented a new UK safer gambling message, ‘take time to think’, which features on gambling advertising and websites. An effective safer gambling message could plausibly affect several relevant gambling behaviours, with previous research suggesting that message effectiveness is maximised via messages that are displayed prominently immediately prior to gambling. We experimentally tested this message's effect on four contemporaneous gambling behaviours (the proportion of available funds bet, clicks for help service information, the mean speed of play, and the total number of roulette spins made) in an incentivised online roulette game in a sample of UK-based online gamblers. Participants (n = 2,305) were randomly allocated to either (a) ‘no-message’ control, (b) ‘message’ shown throughout the condition or (c) a ‘message+’ condition, where the message was shown throughout and also via a popup immediately prior to the roulette game. Overall, the results showed no credible effects across the four outcome measures when comparing either of the message conditions to the no-message control. Even the prominent display of the ‘take time to think’ message did not lead to credible beneficial effects on a range of contemporaneous gambling behaviours.
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.
Transcranial direct current stimulation (tDCS) could be a side-effect-free alternative to psychostimulants in attention-deficit/hyperactivity disorder (ADHD). Although there is limited evidence for clinical and cognitive effects, most studies were small, single-session and stimulated left dorsolateral prefrontal cortex (dlPFC). No sham-controlled study has stimulated the right inferior frontal cortex (rIFC), which is the most consistently under-functioning region in ADHD, with multiple anodal-tDCS sessions combined with cognitive training (CT) to enhance effects. Thus, we investigated the clinical and cognitive effects of multi-session anodal-tDCS over rIFC combined with CT in double-blind, randomised, sham-controlled trial (RCT, ISRCTN48265228).
Fifty boys with ADHD (10–18 years) received 15 weekday sessions of anodal- or sham-tDCS over rIFC combined with CT (20 min, 1 mA). ANCOVA, adjusting for baseline measures, age and medication status, tested group differences in clinical and ADHD-relevant executive functions at posttreatment and after 6 months.
ADHD-Rating Scale, Conners ADHD Index and adverse effects were significantly lower at post-treatment after sham relative to anodal tDCS. No other effects were significant.
This rigorous and largest RCT of tDCS in adolescent boys with ADHD found no evidence of improved ADHD symptoms or cognitive performance following multi-session anodal tDCS over rIFC combined with CT. These findings extend limited meta-analytic evidence of cognitive and clinical effects in ADHD after 1–5 tDCS sessions over mainly left dlPFC. Given that tDCS is commercially and clinically available, the findings are important as they suggest that rIFC stimulation may not be indicated as a neurotherapy for cognitive or clinical remediation for ADHD.
The objectives of this study were (1) to develop and validate a simulation model to estimate daily probabilities of healthcare-associated infections (HAIs), length of stay (LOS), and mortality using time varying patient- and unit-level factors including staffing adequacy and (2) to examine whether HAI incidence varies with staffing adequacy.
The study was conducted at 2 tertiary- and quaternary-care hospitals, a pediatric acute care hospital, and a community hospital within a single New York City healthcare network.
All patients discharged from 2012 through 2016 (N = 562,435).
We developed a non-Markovian simulation to estimate daily conditional probabilities of bloodstream, urinary tract, surgical site, and Clostridioides difficile infection, pneumonia, length of stay, and mortality. Staffing adequacy was modeled based on total nurse staffing (care supply) and the Nursing Intensity of Care Index (care demand). We compared model performance with logistic regression, and we generated case studies to illustrate daily changes in infection risk. We also described infection incidence by unit-level staffing and patient care demand on the day of infection.
Most model estimates fell within 95% confidence intervals of actual outcomes. The predictive power of the simulation model exceeded that of logistic regression (area under the curve [AUC], 0.852 and 0.816, respectively). HAI incidence was greatest when staffing was lowest and nursing care intensity was highest.
This model has potential clinical utility for identifying modifiable conditions in real time, such as low staffing coupled with high care demand.
Through legislative changes, tariff wars, and executive actions, the Trump Administration has injected a new urgency into international technology and supply chain management, particularly between the United States and China. Analytically, the situation invites a perspective that links practical/on-the-ground responses by commercial actors in the politics of technological competition between superpowers, i.e. a discussion that bridges the gap between policy and process. This article therefore approaches management of supply chain disruption in terms of a key security issue motivating recent changes to the trade environment: the protection of intellectual property. After reviewing critical policy developments and trade statistics, we draw upon data on IP-intensive industries from global patent offices, trade classifications for products made by these IP-intensive industries, and concordance data on patent classifications to illustrate the centrality of IP to extended supply chains. With these key relationships in mind, we outline specific opportunities that intellectual property licensing provides for managing supply chain linkages between the United States and China in the current geopolitical environment. Viewing intellectual property as both a driver of and a solution to trade difficulties highlights the sorts of cross-jurisdictional nuances that can better inform policy and business decisions alike in the broader international trade regime.
Background: In the past few decades, the epidemiology of Clostridioides difficile infection (CDI) has evolved. Given recent changes in the incidence of CDI and prevention efforts, we investigated temporal changes over a period of 8 years (2009–2016) in the incidence of and risk factors for CDI. Methods: Both pediatric and adult inpatients discharged from hospitals in metropolitan New York City were included. Individual and environmental (eg, pharmacological) risk factors were identified through a matched case-control by the length of stay at a ratio of 1:4. A Cochran–Armitage test or Mann-Kendall test was used to investigate trends of incidence and risk factors. Results: During the study period, 6,038 of 694,849 (0.87%) patients had a positive test for C. difficile during their hospitalization. Of these, 2,659 of 6,038 (44.04%) were identified as hospital-acquired CDI (HA-CDI) and just over half (3,379 of 6,038, 55.96%) were identified as community-acquired CDI (CA-CDI). There were no trends in total CDI incidence rates; rather, we detected downward trends in HA-CDI and upward trends in CA-CDI (Ptrend < .05). Younger patients and patients with lower risk of illness had HA-CDI over time (Ptrend < .05). Antibiotics were administered to more patients over time and in longer cumulative days (+3% and +3.1% per year). We detected a reduction in the receipt of high-risk antibiotics in all cohorts (−0.12% per year) and a decrease in cumulative days of high-risk antibiotics in the cohort with HA-CDI (−1.1% per year). When stratified by the type of high-risk antibiotics, the use of carbapenem, cephalosporins, clindamycin, and monobactam increased (+0.53%, +1.8%, +0.5%, and +0.39% per year, respectively), whereas the use of broad-spectrum penicillins and glycylcycline significantly decreased over time in all cohorts (−1.8% and −0.22% per year). Among the cohorts with HA-CDI, only cephalosporins showed a significant upward trend (+ 5.7% per year) and only fluoroquinolones showed a significant downward trend (−2.2% per year). Lastly, a reduction of proton pump inhibitors and an increased use of histamine-2 blockers were detected in all cohorts (−3.8% and +7.3% per year) (all Ptrend < .05). Conclusions: Although the incidence of HA-CDI decreased, more effort to decrease all antibiotics use and cumulative days should be emphasized as part of antibiotic stewardship. The downward trends of high-risk antibiotics might have been associated with the decrease in the trend of HA-CDI; however, the impact of the trends of risk factors on the trend of HA-CDI should be further investigated.
Background:Pseudomonas aeruginosa is an important nosocomial pathogen associated with intrinsic and acquired resistance mechanisms to major classes of antibiotics. To better understand clinical risk factors for drug-resistant P. aeruginosa infection, decision-tree models for the prediction of fluoroquinolone and carbapenem-resistant P. aeruginosa were constructed and compared to multivariable logistic regression models using performance characteristics. Methods: In total, 5,636 patients admitted to 4 hospitals within a New York City healthcare system from 2010 to 2016 with blood, respiratory, wound, or urine cultures growing PA were included in the analysis. Presence or absence of drug-resistance was defined using the first culture of any source positive for P. aeruginosa during each hospitalization. To train and validate the prediction models, cases were randomly split (60 of 40) into training and validation datasets. Clinical decision-tree models for both fluoroquinolone and carbapenem resistance were built from the training dataset using 21 clinical variables of interest, and multivariable logistic regression models were built using the 16 clinical variables associated with resistance in bivariate analyses. Decision-tree models were optimized using K-fold cross validation, and performance characteristics between the 4 models were compared. Results: From 2010 through 2016, prevalence of fluoroquinolone and carbapenem resistance was 32% and 18%, respectively. For fluoroquinolone resistance, the logistic regression algorithm attained a positive predictive value (PPV) of 0.57 and a negative predictive value (NPV) of 0.73 (sensitivity, 0.27; specificity, 0.90) and the decision-tree algorithm attained a PPV of 0.65 and an NPV of 0.72 (sensitivity 0.21, specificity 0.95). For carbapenem resistance, the logistic regression algorithm attained a PPV of 0.53 and a NPV of 0.85 (sensitivity 0.20, specificity 0.96) and the decision-tree algorithm attained a PPV of 0.59 and an NPV of 0.84 (sensitivity 0.22, specificity 0.96). The decision-tree partitioning algorithm identified prior fluoroquinolone resistance, SNF stay, sex, and length-of-stay as variables of greatest importance for fluoroquinolone resistance compared to prior carbapenem resistance, age, and length-of-stay for carbapenem resistance. The highest-performing decision tree for fluoroquinolone resistance is illustrated in Fig. 1. Conclusions: Supervised machine-learning techniques may facilitate prediction of P. aeruginosa resistance and risk factors driving resistance patterns in hospitalized patients. Such techniques may be applied to readily available clinical information from hospital electronic health records to aid with clinical decision making.
Given recent changes in the epidemiology of Clostridioides difficile infection (CDI) and prevention efforts, we investigated temporal changes over a period of 11 years (2006–2016) in incidence and risk factors for CDI.
Retrospective matched case-control study.
Pediatric and adult inpatients (n = 694,849) discharged from 3 hospitals (tertiary and quaternary care, community, and pediatric) in a large, academic health center in New York City.
Risk factors were identified in cases and controls matched by length of stay at a ratio of 1:4. A Cochran–Armitage or Mann-Kendall test was used to investigate trends of incidence and risk factors.
Of 694,849 inpatients, 6,038 (0.87%) had CDI: 44% of these cases were hospital acquired (HA-CDI) and 56% were community acquired (CA-CDI). We observed temporal downward trends in HA-CDI (−0.03% per year) and upward trends in CA-CDI (+0.04% per year). Over time, antibiotics were administered to more patients (+3% per year); the use of high-risk antibiotics declined (–1.2% per year); and antibiotic duration increased in patients with HA-CDI (+4.4% per year). Fewer proton-pump inhibitors and more histamine-2 blockers were used (−3.8% and +7.3% per year, respectively; all Ptrend <.05).
Although the incidence of HA-CDI decreased over time, CA-CDI simultaneously increased. Continued efforts to assure judicious use of antibiotics in inpatient and community settings is clearly vital. Measuring the actual the level of exposure of an antibiotic (incidence density) should be used for ongoing surveillance and assessment.
This white paper identifies knowledge gaps and new challenges in healthcare epidemiology research, assesses the progress made toward addressing research priorities, provides the Society for Healthcare Epidemiology of America (SHEA) Research Committee's recommendations for high-priority research topics, and proposes a road map for making progress toward these goals. It updates the 2010 SHEA Research Committee document, “Charting the Course for the Future of Science in Healthcare Epidemiology: Results of a Survey of the Membership of SHEA,” which called for a national approach to healthcare-associated infections (HAIs) and a prioritized research agenda. This paper highlights recent studies that have advanced our understanding of HAIs, the establishment of the SHEA Research Network as a collaborative infrastructure to address research questions, prevention initiatives at state and national levels, changes in reporting and payment requirements, and new patterns in antimicrobial resistance.
Experimental investigation of the generation and decay of coherent structures, namely, streaks (accompanied by a counter-rotating vortex pair) and hairpin vortices in pipe flow, is carried out by artificial injection of continuous disturbances. Flow visualization and velocity measurements show that for small amplitudes of disturbances (v0) streaks are produced, and increasing v0 produces instability waves on the streaks, which further break down into an array of hairpin vortices. However, the streaks and hairpins decay along the downstream direction (X). In fact, the critical value of v0 required for the initiation of hairpins at a given Re (Reynolds number) varies with the streamwise distance (in contrast to the previously found scaling of v0 ~ Re−1, valid only close to the location of injection, i.e. smaller X). This is a consequence of the decay of the coherent structures in the pipe. Moreover, the hairpins have been found to decay more slowly with increasing Re. Measurements of energy in the cross-sectional plane of the pipe, and maps of disturbance velocity at various X-locations show the transient growth and decay of energy for relatively low v0. For higher v0 and Re the energy has been seen to increase continuously along the length of the pipe under observation. Owing to the increase in the cross-sectional area occupied by the disturbance along the X-direction, it is observed that energy can transiently increase even when the total disturbance magnitude is decreasing. Observing the similarity of the present work and other investigations wherein decay of turbulence in pipe flow is found, a schematic illustration of the transition surface for pipe flow on a v0−Re−X, three-dimensional coordinate system is presented.
Background. Pharmaceutical industry funding of psychiatric research has increased significantly in recent decades, raising the question of a relationship between pharmaceutical company funding of clinical psychiatric studies and the outcomes of those studies. This study examines this relationship.
Method. Abstracts of articles from 1992 and 2002 in four peer-reviewed psychiatric journals were examined. Drug outcomes (n=542) for clinical studies were evaluated and then compared across sponsorship source. Outcome raters were blind to source of sponsorship. The percentage of these studies sponsored by drug companies in 2002 v. 1992 was also compared. In a secondary analysis, the contribution of a series of potentially mediating variables to the relationship between sponsorship source and study outcome was assessed via logistic regression.
Results. The percentage of studies sponsored by drug companies increased from 25% in 1992 to 57% in 2002. Favorable outcomes were significantly more common in studies sponsored by the drug manufacturer (78%) than in studies without industry sponsorship (48%) or sponsored by a competitor (28%). These relationships remained after controlling for the effects of journal, year, drug studied, time since FDA drug approval, diagnosis, sample size, and selected study design variables.
Conclusions. These data indicate an association between pharmaceutical industry funding of clinical studies and positive outcomes of those studies. Further research is needed to elucidate the mechanisms underlying this relationship.