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Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship.
Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression.
Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies.
Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non–ID-trained pharmacists and clinicians in antibiotic stewardship.
Hurricane Harvey made landfall in southeast Texas in August 2017, causing unprecedented flooding throughout the Texas coastal region. Residents of affected regions were forced to evacuate to nearby unaffected areas, including Dallas, TX, where a large shelter operation was opened for 23 days to care for those evacuees. Retrospective evaluation of pharmaceutical prescribing patterns for the evacuees who self-presented to the Megashelter Medical Clinic (MMC) established in the shelter contributes to developing evidence-based planning strategies for healthcare delivery in the post-disaster setting.
To describe the pharmacy needs of a displaced population following a large-scale evacuation after a hurricane
De-identified prescription records written and filled at a shelter pharmacy were reviewed, looking at both cost and category of medications dispensed over time.
Approximately 41% of evacuees with a total of 2,654 visits utilized the MMC clinic, resulting in 1,590 prescriptions filled with an associated cost of $78,039. The most commonly prescribed drug categories were cardiovascular (21.2%), neuropsychotropic (15.6%), infectious disease (12.5%), and endocrine (9.6%). While the most commonly dispensed were antihypertensives, diabetes treatment-related prescriptions, antibacterials, antidepressants, and NSAIDs, the costliest individual prescriptions were antiretrovirals and antipsychotics.
Prescribing patterns for the MMC differed from normal prescribing patterns of a general population. Of the prescriptions dispensed at the MMC, pharmaceutical prescription patterns suggest the immediate needs of evacuees differ from later needs. There is a greater need for chronic disease management in the early phase of shelter operations, and an increasing need for neuropsychotropic and infectious disease prescriptions over time. Understanding overall patterns of drug utilization over the duration of the shelter provides valuable insight on post-disaster medical resource utilization in evacuee populations.
After Hurricane Harvey and the flooding that ensued, 3,829 displaced persons were transported from their homes and sheltered in the Dallas Convention Center. This large general population sheltering operation was medically supported by the onsite Mega-Shelter Medical Clinic (MMC). In an altered standard of care environment, a number of multi-disciplinary medical services were provided including emergent management, acute pediatric and adult care, psychiatric/behavioral services, onsite pharmaceutical, and durable medical equipment distribution, epidemiologic surveillance, and select laboratory services.
To describe how onsite medical care in the adapted environment of a large population shelter can provide comparable services and limit the direct impact on the local medical community.
A retrospective chart review of medical records was generated for all clinical encounters at the MMC. Data were sorted by daily census, disease surveillance, medical decision making, treatment, and transport destinations.
40.7% of registered evacuees utilized the MMC accounting for a total of 2,654 clinic visits by 1,560 unique patients representing all age groups. During the sustained MMC operations, 8% of patients required emergency transport and 500 additional patient transports were arranged for clinic appointments. No deaths occurred and no iatrogenic morbidity was reported.
Medical care was provided for a large number of evacuees which mitigated the potential impact on the local medical infrastructure. The provision of medical services in a large population shelter may necessitate adaptation to the standard of care. However, despite the nontraditional clinical setting, care delivery was not compromised.
The Dallas Convention Center received over 3800 evacuees because of the unprecedented flooding caused by Hurricane Harvey. A multidisciplinary medical clinic was established onsite to address evacuee needs for medical evaluations, emergency care, chronic disease management, pharmaceuticals, durable medical equipment, and local health services integration. To operate efficiently, the Dallas Mega-Shelter Emergency Operations Center (EOC) worked with the Mega-Shelter Medical Clinic (MMC) under a fluid incident command (IC) structure that was National Incident Management System (NIMS) compliant. Iterations of MMC IC demonstrated maturations in organizational structure while supporting MMC operations that varied from rigid NIMS doctrine.
To explore the use of a fluid IC structure at a large evacuation medical shelter after Hurricane Harvey.
We observed evolutions of IC organizational charts and operational impacts.
Modifications through just-in-time iterations of the IC organizational chart were posted and reviewed with MMC IC and EOC sector chiefs. Changes in the organizational chart were noted to improve identification of logistical needs, supply delivery, coordinate with other agencies, and to make decisions for resource typing and personnel utilization. Adaptations also improved communication, which led to timely situational awareness and reporting accuracy.
MMC medical services were improved by allowing modifications and adaptations to NIMS compliant MMC IC organizational roles and duty assignments. The fluidity of IC structure with ability for just-in-time modifications directly impacted the provision of disaster medical services. Unique situational awareness, coordination of care pathways within the local innate health infrastructure, compliance with health service regulations, and personnel resource typing all contributed to and benefitted from these IC modifications. MMC and EOC IC collaboration facilitated effective communication and maintained an appropriate span of control and efficient activity reporting.
In the United States, over 50% of people have at least one chronic medical condition, access, or functional limitation. In 2017 during Hurricane Harvey, the establishment of a comprehensive multidisciplinary onsite medical clinic provided health and medical services to over 3,800 evacuees at the Dallas Mega Shelter, providing large-scale general population sheltering support to all evacuees and prioritizing family unit integrity by meeting physical, sensory, and cognitive limitations, and chronic medical conditions. The effectiveness of the Dallas Mega Shelter onsite medical operations supporting this aim is reviewed.
To utilize onsite health and medical resources to meet access and functional needs of evacuees seeking general population mass sheltering in Dallas, Texas during Hurricane Harvey.
Over 3,800 evacuees were evaluated for functional needs support services (FNSS) resulting in over 2,500 evacuee patient encounters during 21 continuous days of onsite health and medical clinic operations.1 A comprehensive array of services were available at no cost to the evacuees and were in accordance with the Federal Emergency Management Association (FEMA) published Guidance on Planning for Integration of Functional Needs Support Service in General Population Shelters.2 The goal to maintain nearly all evacuees choosing to stay in the Mega Shelter was achieved. The challenges, limitations, and risks identified are reviewed.
FNSS guidelines require all persons, regardless of limitations, when evacuated from home be provided all services necessary to allow them to remain in general population sheltering.2 This prioritization of personal choice, functional independence, and family integrity for those with comprehensive FNSS requirements presented notable challenges, including public health and safety risks impacting the wellbeing of others. Meeting these expectations must be balanced with maintaining shelter integrity.
On August 25, 2017, Hurricane Harvey made landfall near Corpus Christi, Texas. The ensuing unprecedented flooding throughout the Texas coastal region affected millions of individuals.1 The statewide response in Texas included the sheltering of thousands of individuals at considerable distances from their homes. The Dallas area established large-scale general population sheltering as the number of evacuees to the area began to amass. Historically, the Dallas area is one familiar with “mega-sheltering,” beginning with the response to Hurricane Katrina in 2005.2 Through continued efforts and development, the Dallas area had been readying a plan for the largest general population shelter in Texas. (Disaster Med Public Health Preparedness. 2019;13:33–37)
A modified discussion of surface nuclear reactions in magnetic stars is given. The anomalous abundance effects found in magnetic stars are briefly described. It is suggested that the processes of particle acceleration are similar to those taking place in the solar atmosphere which give rise to the cosmic ray bursts observed by Wild, Roberts, and Murray, and to the solar component of cosmic radiation. Calculations of the rate of loss of energy following particle acceleration suggests that the duration of the hot spot is 1 ≲ sec. It is estimated that in the region of acceleration (p, n) reactions will enable a ratio nn/np ⋍ 10–2–10–3 to be built up. The majority of these neutrons will diffuse from the excited regions and form deuterium in the quiescent atmosphere. This deuterium will be continuously built up and re-acceleration will lead to the release of neutrons, some of which will be captured by the Fe group, eventually giving rise to the observed anomalous abundances of the heavy elements. Also the reaction H(d, γ) He3 may give rise to the formation of some He3.
Paranoia is one of the commonest symptoms of psychosis but has rarely been studied in a population at risk of developing psychosis. Based on existing theoretical models, including the proposed distinction between ‘poor me’ and ‘bad me’ paranoia, we aimed to test specific predictions about associations between negative cognition, metacognitive beliefs and negative emotions and paranoid ideation and the belief that persecution is deserved (deservedness).
We used data from 117 participants from the Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2) trial of cognitive–behaviour therapy, comparing them with samples of psychiatric in-patients and healthy students from a previous study. Multi-level modelling was utilized to examine predictors of both paranoia and deservedness, with post-hoc planned comparisons conducted to test whether person-level predictor variables were associated differentially with paranoia or with deservedness.
Our sample of at-risk mental state participants was not as paranoid, but reported higher levels of ‘bad-me’ deservedness, compared with psychiatric in-patients. We found several predictors of paranoia and deservedness. Negative beliefs about self were related to deservedness but not paranoia, whereas negative beliefs about others were positively related to paranoia but negatively with deservedness. Both depression and negative metacognitive beliefs about paranoid thinking were specifically related to paranoia but not deservedness.
This study provides evidence for the role of negative cognition, metacognition and negative affect in the development of paranoid beliefs, which has implications for psychological interventions and our understanding of psychosis.
We surveyed 571 US hospitals about practices used to prevent Clostridium difficile infection (CDI). Most hospitals reported regularly using key CDI prevention practices, and perceived their strength of evidence as high. The largest discrepancy between regular use and perceived evidence strength occurred with antimicrobial stewardship programs.
Infect. Control Hosp. Epidemiol. 2015;36(8):969–971
We assessed hand hygiene adherence in 2 infectious disease units. In one unit, adherence declined slightly from year 1 (84.2%) to year 4 (71.0%) after a multimodal intervention but remained much higher than before intervention. Adherence dropped in the second unit after a loss of leadership (from 50.7% to 5.7%). Strong leadership presence may improve hand hygiene adherence.
Intrauterine factors important for cognitive development, such as birth weight, chorionicity and umbilical cord characteristics were investigated. A total of 663 twin pairs completed the Wechsler Intelligence Scale for Children-Revised and scores were available for Performance, Verbal and Total Intelligence Quotient (IQ). The intrauterine factors examined were birth weight, placental weight and morphology, cord knots, cord length and cord insertion. IQ scores for the varying levels of the intrauterine markers adjusting for gender and gestational age were calculated. The heritability of IQ and the association between IQ and intrauterine environment were examined. Twins with lower birth weight and cord knots had lower IQ scores. The aetiology of IQ is largely distinct from that of birth weight and cord knots, and non-shared environment may influence the observed relationships.
Meta-analyses show that cognitive behaviour therapy for psychosis (CBT-P) improves distressing positive symptoms. However, it is a complex intervention involving a range of techniques. No previous study has assessed the delivery of the different elements of treatment and their effect on outcome. Our aim was to assess the differential effect of type of treatment delivered on the effectiveness of CBT-P, using novel statistical methodology.
The Psychological Prevention of Relapse in Psychosis (PRP) trial was a multi-centre randomized controlled trial (RCT) that compared CBT-P with treatment as usual (TAU). Therapy was manualized, and detailed evaluations of therapy delivery and client engagement were made. Follow-up assessments were made at 12 and 24 months. In a planned analysis, we applied principal stratification (involving structural equation modelling with finite mixtures) to estimate intention-to-treat (ITT) effects for subgroups of participants, defined by qualitative and quantitative differences in receipt of therapy, while maintaining the constraints of randomization.
Consistent delivery of full therapy, including specific cognitive and behavioural techniques, was associated with clinically and statistically significant increases in months in remission, and decreases in psychotic and affective symptoms. Delivery of partial therapy involving engagement and assessment was not effective.
Our analyses suggest that CBT-P is of significant benefit on multiple outcomes to patients able to engage in the full range of therapy procedures. The novel statistical methods illustrated in this report have general application to the evaluation of heterogeneity in the effects of treatment.
A preliminary investigation of the defect structure of the monoclinic zeta phase, within the interfacial region of Fe-Zn couples, has been performed using cross-section transmission electron microscopy (TEM). Twin boundaries and dislocations have been unambiguously identified, however, examples of defects which, as of yet are unknown, are also presented. The monoclinic zeta phase was found to twin by a rotation of 180° about the normal to the (110) plane.
Internal friction measurements have been performed on Ni-20 wt% Cr alloys containing trace additions of Ce ranging from 0 to 180 at ppm, in order to determine grain boundary sliding kinetics and associated stress relaxation phenomena. Two anelastic relaxation peaks have been observed corresponding to intrinsic grain boundary sliding between carbide precipitates and to macroscopic sliding with elastic accommodation at triple points. The effects of Ce on these grain boundary phenomena and resulting alloy ductilities are also presented.
Al with additions of Cu is commonly used as the conductor metallizations for integrated circuits (ICs). As the packing density of ICs increases, interconnect lines are required to carry ever higher current densities. Consequently, reliability due to electromigration failure becomes an increasing concern. Cu has been found to increase the lifetimes of these conductors, but the mechanism by which electromigration is improved is not yet fully understood. In order to evaluate certain theories of electromigration it is necessary to have a detailed description of the Cu distribution in the Al microstructure, with emphasis on the distribution of Cu at the grain boundaries. In this study analytical electron microscopy (AEM) has been used to characterize grain boundary regions in an Al-2 wt.% Cu thin film metallization on Si after a variety of thermal treatments. The results of this study indicate that the Cu distribution is dependent on the thermal annealing conditions. At temperatures near the θ phase (CuAl2) solvus, the Cu distribution may be modelled by the collector plate mechanism, in which the grain boundary is depleted in Cu relative to the matrix. At lower temperatures, Cu enrichment of the boundaries occurs, perhaps as a precursor to second phase formation. Natural cooling from the single phase field produces only grain boundary depletion of Cu consistent with the collector-plate mechanism. The kinetic details of the elemental segregation behavior derived from this study can be used to describe microstructural evolution in actual interconnect alloys.
We report the results of photoelectron forward scattering studies of Co-Pt interfaces during the growth of epitaxial superlattices by MBE. These studies reveal that the interfaces are not atomically abrupt but exhibit limited interdiffusion. The dependence of magnetic anisotropy on growth axis and the strong 2-fold in-plane anisotropy for  oriented superlattices suggests that magnetocrystalline anisotropy is a major factor in determining the anisotropy in Co/Pt superlatticcs. The possibility that this anisotropy may arise from a combination of structural defects and local ordering is discussed.
The morphology of directionally solidified CuAl-Pb monotectic alloys has been studied. The structure consisted of a hexagonal array of Pb rods in a Cu-based matrix. In addition, elongated grain boundaries in the Cu-based matrix with lens-shaped Pb fibers on the boundary and a “denuded zone”, depleted of Pb rods, were observed. Existence of these boundaries is shown to reduce the overall surface energy of the system leading to the formation of the elongated grain boundaries.
A reference process for immobilizing the high-level radioactive waste in borosilicate glass has been developed at the Savannah River Plant. This waste contains a substantial amount of mercury from separations processing. Because mercury will not remain in borosilicate glass at the processing temperature, mercury must be removed before vitrification or must be handled in the off-gas system. A process has been developed to remove mercury by reduction with formic acid prior to vitrification. Additional benefits of formic acid treatment include improved sludge handling and glass melter redox control.
Changes in electrical resistance measured by the four probe method was adopted as a structure sensitive physical property used to trace changes in the atomic microstructure below and above the δ'-solvus line in the Al-Li binary alloys. The kinetics of the growth and dissolution of δ' phase (Al3Li) and the formation of δ phase (AlLi), below and above δ'-solvus line, during the coarsening process were studied by isochronal and isothermal investigations. The diffusional growth of δ'-phase, below the δ'-solvus line, was found to be activated by 0.24 eV. Interpretation of the results showed that this energy involved two events during the coarsening process. The first event seemed to be a breakdown of the bonding between the vacancy-Lithium pair and the second event involved the transport of Li atoms to Al-particles to coarsen δ'; (Al3Li) particles. Furthermore, the study of the temperature dependence of electrical resistance of the stable phases δ' and δ of Al-Li alloys was found to be accompanied by difference in the temperature coefficient of the electrical resistance and was attributed to the change in structure of the two phases considered.