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To quantify the frequency and outcomes of receiving an antibiotic prescription upon discharge from the hospital to long-term care facilities (LTCFs).
Retrospective cohort study.
A 576-bed, academic hospital in Portland, Oregon.
Adult inpatients (≥18 years of age) discharged to an LTCF between January 1, 2012, and June 30, 2016.
Our primary outcome was receiving a systemic antibiotic prescription upon discharge to an LTCF. We also quantified the association between receiving an antibiotic prescription and 30-day hospital readmission, 30-day emergency department (ED) visit, and Clostridium difficile infection (CDI) on a readmission or ED visit at the index facility within 60 days of discharge.
Among 6,701 discharges to an LTCF, 22.9% were prescribed antibiotics upon discharge. The most prevalent antibiotic classes prescribed were cephalosporins (20.4%), fluoroquinolones (19.1%), and penicillins (16.7%). The medical records of ~82% of patients included a diagnosis code for a bacterial infection on the index admission. Among patients prescribed an antibiotic upon discharge, the incidence of 30-day hospital readmission to the index facility was 15.9%, the incidence of 30-day ED visit at the index facility was 11.0%, and the incidence of CDI on a readmission or ED visit within 60 days of discharge was 1.6%. Receiving an antibiotic prescription upon discharge was significantly associated with 30-day ED visits (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.02–1.5) and with CDI within 60 days (aOR, 1.7; 95% CI, 1.02–2.8) but not with 30-day readmissions (aOR, 1.01; 95% CI, 0.9–1.2).
Antibiotics were frequently prescribed upon discharge to LTCFs, which may be associated with increased risk of poor outcomes post discharge.
Introduction: Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). Current established protocols (e.g. RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. Recently the SHoC Protocol was published, recommending 3 core scans; cardiac, lung, and IVC; plus other scans when indicated clinically. We report the abnormal ultrasound findings from our international multicenter randomized controlled trial, to assess if the recommended 3 core SHoC protocol scans were chosen appropriately for this population. Methods: Recruitment occurred at seven centres in North America (4) and South Africa (3). Screening at triage identified patients (SBP<100 or shock index>1) who were randomized to PoCUS or control (standard care with no PoCUS) groups. All scans were performed by PoCUS-trained physicians within one hour of arrival in the ED. Demographics, clinical details and study findings were collected prospectively. A threshold incidence for positive findings of 10% was established as significant for the purposes of assessing the appropriateness of the core recommendations. Results: 138 patients had a PoCUS screen completed. All patients had cardiac, lung, IVC, aorta, abdominal, and pelvic scans. Reported abnormal findings included hyperdynamic LV function (59; 43%); small collapsing IVC (46; 33%); pericardial effusion (24; 17%); pleural fluid (19; 14%); hypodynamic LV function (15; 11%); large poorly collapsing IVC (13; 9%); peritoneal fluid (13; 9%); and aortic aneurysm (5; 4%). Conclusion: The 3 core SHoC Protocol recommendations included appropriate scans to detect all pathologies recorded at a rate of greater than 10 percent. The 3 most frequent findings were cardiac and IVC abnormalities, followed by lung. It is noted that peritoneal fluid was seen at a rate of 9%. Aortic aneurysms were rare. This data from the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients, supports the use of the prioritized SHoC protocol, though a larger study is required to confirm these findings.
Introduction: Point of care ultrasound has become an established tool in the initial management of patients with undifferentiated hypotension. Current established protocols (RUSH, ACES, etc) were developed by expert user opinion, rather than objective, prospective data. We wished to use reported disease incidence to develop an informed approach to PoCUS in hypotension using a “4 F’s” approach: Fluid; Form; Function; Filling. Methods: We summarized the incidence of PoCUS findings from an international multicentre RCT, and using a modified Delphi approach incorporating this data we obtained the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. The modified Delphi tool was developed to reach an international consensus on how to integrate PoCUS for hypotensive emergency department patients. Results: Rates of abnormal PoCUS findings from 151 patients with undifferentiated hypotension included left ventricular dynamic changes (43%), IVC abnormalities (27%), pericardial effusion (16%), and pleural fluid (8%). Abdominal pathology was rare (fluid 5%, AAA 2%). After two rounds of the survey, using majority consensus, agreement was reached on a SHoC-hypotension protocol comprising: A. Core: 1. Cardiac views (Sub-xiphoid and parasternal windows for pericardial fluid, cardiac form and ventricular function); 2. Lung views for pleural fluid and B-lines for filling status; and 3. IVC views for filling status; B. Supplementary: Additional cardiac views; and C. Additional views (when indicated) including peritoneal fluid, aorta, pelvic for IUP, and proximal leg veins for DVT. Conclusion: An international consensus process based on prospectively collected disease incidence has led to a proposed SHoC-hypotension PoCUS protocol comprising a stepwise clinical-indication based approach of Core, Supplementary and Additional PoCUS views.
Introduction: Point of care ultrasound (PoCUS) provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We consider that a consensus-based priority checklist using a “4 F’s” approach (Fluid; Form; Function; Filling), would provide a better algorithm during ACLS. Methods: The ultrasound subcommittee of the Australasian College for Emergency Medicine (ACEM) drafted a checklist incorporating PoCUS into the ACLS algorithm. This was further developed using the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. A modified Delphi tool was developed to reach an international consensus on how to integrate ultrasound into cardiac arrest algorithms for emergency department patients. Results: Consensus was reached following 3 rounds. The agreed protocol focuses on the timing of PoCUS as well as the specific clinical questions. Core cardiac windows performed during the rhythm check pause in chest compressions are the sub-xiphoid and parasternal cardiac views. Either view should be used to detect pericardial fluid, as well as examining ventricular form (e.g. right heart strain) and function, (e.g. asystole versus organized cardiac activity). Supplementary views include lung views (for absent lung sliding in pneumothorax and for pleural fluid), and IVC views for filling. Additional ultrasound applications are for endotracheal tube confirmation, proximal leg veins for DVT, or for sources of blood loss (AAA, peritoneal/pelvic fluid). Conclusion: The authors hope that this process will lead to a consensus-based SHoC-cardiac arrest guideline on incorporating PoCUS into the ACLS algorithm.
Salmonella enterica serovar Typhimurium definitive phage type (DT) 8 is uncommon in humans in the UK. In July 2010, the Health Protection Agency reported an excess isolation rate of pan-susceptible S. Typhimurium DT8 in England and Northern Ireland. By the end of October, this amounted to 81 laboratory-confirmed human cases for all regions of England and Northern Ireland in 2010, an increase of 26% and 41% on 2009 and 2008, respectively. Descriptive epidemiological investigation found a strong association with infection and consumption of duck eggs. Duck eggs contaminated with S. Typhimurium DT8 were collected from a patient's home and also at farms in the duck-egg supply chain. Although duck eggs form a small part of total UK eggs sales, there has been significant growth in sales in recent years. This is the first known outbreak of salmonellosis linked to duck eggs in the UK since 1949 and highlighted the impact of a changing food source and market on the re-emergence of salmonellosis linked to duck eggs. Control measures by the duck-egg industry should be improved along with a continued need to remind the public and commercial caterers of the potential high risks of contracting salmonellosis from duck eggs.
Endemic infection in male surgical wards has been studied during three periods. There was some infection due to gram-negative bacilli, though Staphylococcus aureus remained as the single most important pathogen even in the absence of epidemic spread. Beta haemolytic streptococci were isolated in large numbers from the lesions of four patients with deep wound infection. Changes introduced in the pattern of post-operative care reduced sepsis due to Staph. aureus, reduced the severity of wound infection and apparently decreased the need for antibiotic therapy. Patients who became infected were retained in hospital longer than those who escaped clinically apparent infection.
Topical medicaments used by patients with diseases of the skin were examined for microbial contamination. Ps. aeruginosa was isolated from stock pots of a diluted emulsifying ointment used as a soap substitute in the bath. Cross-con tamination between patients and medicament was subsequently shown to have occurred.
Non-specific and specific mechanisms of adherence have been examined in two collections of methicillin–resistant Staphylococcus aureus (MRSA). Determination of hydrophobicity by salt aggregation, hydrophobicity indices and of adherence to the extra–cellular matrix proteins fibronectin, vitronectin, laminin and collagen type 1 have failed to reveal any correlation with phage-type, plasmid profile or antibiogram. Further, the strain collections, made over a period of years in two countries, differ markedly in their adherence characteristics; MRSA are heterogeneous in this respect. Such heterogeneity may explain the polarization of views on the epidemicity or ‘virulence’ of MRSA. With the exception of adherence to collagen a small group of methicillin sensitive S. aureus had characteristics intermediate between the two groups of MRSA.
While measurement of magnetostriction in bulk materials is readily accomplished using a strain gauge, measurement of this quantity for thin films presents a greater challenge, and typically involves measurement of the overall wafer curvature (for a film of uniform composition) as a function of field. In order to evaluate magnetostriction locally in composition-spread samples, we have developed a method using a dense array of pre-fabricated cantilever beams on a silicon substrate prepared using MEMS techniques. Differential strain in the thin film/cantilever system results in curvature which is detected using an optical (laser/position-sensitive-detector) system. A magnetic field is applied using two orthogonal Helmholtz coils, and the resulting deflection-field curves are used to determine the saturation magnetostriction λs as well as dλ/dH. Our composition-spread films are prepared using a three gun on-axis magnetron cosputtering system. The position-dependent composition is inferred using rate calibrations and verified with electron microprobe and Rutherford Backscattering Spectroscopy. Preliminary experiments have validated the technique and the system has been used to measure magnetostriction in the Ni-Fe system. Our approach can also be used to measure properties of giant magnetostrictive materials (e.g. TbFe/Fe multilayers) as a function of layer thicknesses, or thin film shape-memory alloys, including magnetic shape-memory alloys.
The cercariae of Schistosoma mansoni become transformed into schistosomula during host skin penetration. We have found that large acidophilic compartments are detected in schistosomula but not in cercariae or in any other stages of the parasite by use of the fluorescent dye LysoTracker, a dye specific for mammalian lysosomes. Some of these large acidic compartments incorporated monodansylcadaverine, a specific dye for autophagosomes. We have used potent inhibitors (wortmannin and 3-methyladenine) and a potent inducer (starvation) of autophagy to show that the pathway to the formation of the acidic compartments requires specific molecular signals from the environment and from the genome. Certain doses of ultraviolet light inhibited significantly the formation of the acidic compartments, which may indicate disruption of the lysosome/autophagosome pathway. We have also defined two proteins that are commonly associated with lysosomes and autophagosomes in mammalian cells, the microtubule-associated membrane protein (MAP-LC3) and lysosome-associated membrane protein (LAMP-1), in extracts of schistosomula. We suggest that the autophagy pathway could be developed in transformed schistosomula.
Hyperprolactinaemia induced by D2 dopamine receptor antagonist antipsychotic medication can result in significant health problems.
To examine the role of DRD2 polymorphism on prolactin levels in patients treated with antipsychotic medication.
Antipsychotic drugs with different degrees of D2 receptor binding were given to 144 patients with schizophrenia. Serum prolactin levels were obtained and Taq1A DRD2 alleles were determined.
Prolactin levels increased across medication groups reflecting increasingly tight D2 receptor binding (clozapine, olanzapine, typical antipsychotics and risperidone). In the combined medication group, patients with the DRD2∗A1 allele had 40% higher prolactin levels than patients without this allele. In patients treated with clozapine (the loosest D2 receptor binding agent), patients with the DRD2∗A1 allele had prolactin levels twice those of patients without this allele.
Patients with the DRD2A1 allele receiving antipsychotic medications had higher prolactin levels and were overrepresented among those with hyperprolactinaemia, suggesting greater functional D2 receptor binding in this group.
Proliferative kidney disease (PKD) is a parasitic infection of salmonid fish characterized by an apparently abnormal immune response to the presence of the myxozoan parasite, Tetracapsuloides bryosalmonae. In order to examine the nature of the immune response at the molecular level, the expression of a range of immune regulatory genes, including cytokines and cyclooxygenase (COX)-2 was examined in naive unexposed fish and in naive fish exposed to parasite-infected water at three points during the course of a natural outbreak of PKD. Since fish with advanced PKD pathology generally exhibit increased susceptibility to secondary infections which is typical of stress/cortisol-mediated immune suppression, a further aim of this work was to examine in vitro the influence of the glucocorticoid cortisol on the bacterial lipopolysaccharide (LPS)-induced expression of the trout cytokine genes studied. Two weeks after the initial sampling, naive exposed fish showed a specific profile of up-regulated tumor necrosis factor (TNF)-α2, COX-2 and, to a lesser extent, transforming growth factor (TGF)-β1 expression. As the disease pathology increased, TNF-α2 and COX-2 expression returned to normal levels. Stress levels of cortisol suppressed the LPS inducibility of pro-inflammatory cytokine genes, although TGF-β1 and TNF-α2 appeared to be refractory. These data demonstrate that specific immune responses at the molecular level are affected during PKD infection, with the cortisol suppression of cytokine expression in vitro providing a possible link to PKD-mediated cytokine down-regulation and immune suppression.
Morphological variation was investigated in hatchling squid Loligo forbesi Steenstrup 1856 reared at three constant temperatures. Twenty-seven morphometric and chromatophore characters were measured on 180 hatchlings. Hatchlings were randomly sampled from 15 egg strings, representing six egg mops and spread across two spawning seasons. Size at hatching varied inversely with temperature and was significantly reduced at 16°C (mean mantle length 2.87±0.04 se mm) compared to 8°C (3.26±0.03 se mm). Hatchlings reared at 12°C developed significantly narrower mantles than those reared at 8 or 16°C. Principal components, stepwise elimination and canonical variates analyses performed using all 27 measured characters revealed that nine characters were vital in discriminating between temperature groups. Canonical structure values associated with eight of these characters were used in the construction of a canonical equation. By measuring the same eight characters on field-sampled L. forbesi, this equation can be used to estimate mean thermal history of wild hatchlings. Field-application of the techniques developed during the present study may allow assessment of realized thermal niche in a mobile marine invertebrate.
Freshwater snails of the Bulinus forskalii group are one of four Bulinus species complexes responsible for the transmission of schistosomes in Africa and adjacent regions. The species status of these conchologically variable and widely distributed planorbids remains unclear, and parasite compatibility varies considerably amongst the eleven taxa defined, making unambiguous identification and differentiation important prerequisites for determining their distributions and evolutionary relationships. Random Amplified Polymorphic DNA (RAPD) analyses were used to investigate relationships between taxa, with particular emphasis on Central and West African representatives. RAPD-derived phylogenies were compared with those from other independent molecular markers, including partial sequences of mitochondrial cytochrome oxidase subunit I (COI) gene, and the nuclear ribosomal RNA internal transcribed spacer 1 region (ITS1). The phylogenetic reconstructions from the three approaches were essentially congruent, in that all methods of analysis gave unstable tree topologies or largely unresolved branches. There were large sequence divergence estimates between species, with few characters useful for determining relationships between species and limited within species differentiation. Nuclear and mtDNA sequence data from Central and East African representatives of the pan-African B. forskalii showed little evidence of geographical structuring. Despite the unresolved structure within the phylogenies, specimens from the same species clustered together indicating that all methods were capable of differentiating taxa but could not establish the inter-specific relationships with confidence. The limited genetic variation displayed by B. forskalii, and the evolution and speciose nature of the group, are discussed in the context of the increasingly arid climate of the late Miocene and early Pliocene of Africa.
Gene mapping and the generation of linkage groups are fundamental to an understanding of the organization and relationships of genes and marker sequences, providing a framework with which to investigate their association with traits of interest. The abundance of techniques available for generating polymorphic molecular markers, and recent advances in high throughput screening, have allowed the extension of map analysis to the tropical freshwater snail Biomphalaria glabrata, an important intermediate host for Schistosoma mansoni. Direct comparison of gene expression by differential display screening, without prior identification of candidate genes, can be combined with mapping to quantify the involvement of specific sequences in the schistosome resistance response, and other important host–parasite interactions. Here we discuss the application of current and emergent technologies to gene characterization and linkage analysis in snail–schistosome interactions. Preliminary results from the analysis of comparative gene expression in resistant and susceptible snails are also presented.
Changes in gene expression in Biomphalaria glabrata following infection with Schistosoma mansoni have been investigated
using a modified differential display approach. RNA was extracted from ovotestis, mantle tissue and anterior nephridium
of control and exposed snails at 2 time-points (4 h and 24 h) post-exposure and analysed by RNA fingerprinting. A number
of transcripts were identified; some novel and some homologous to mRNAs in GenEMBL that were previously unknown
in B. glabrata. Down regulation of one 241 bp mRNA expressed sequence fragment – with an open reading frame showing
48% identity to a cytochrome p450 over 80 residues – has been confirmed using semi-quantitative RT-PCR. Preliminary
classification of B. glabrata cyp450 sequence shows it to fall into CLAN 2 of the cytochrome p450 superfamily. Differential
display has been successful in identifying changes in gene expression in Biomphalaria glabrata upon infection with
Schistosoma mansoni and promises to be a useful technique for the investigation of the interaction between host and parasite.