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To determine the attributable cost and length of stay of hospital-acquired Clostridioides difficile infection (HA-CDI) from the healthcare payer perspective using linked clinical, administrative, and microcosting data.
A retrospective, population-based, propensity-score–matched cohort study.
Acute-care facilities in Alberta, Canada.
Admitted adult (≥18 years) patients with incident HA-CDI and without CDI between April 1, 2012, and March 31, 2016.
Incident cases of HA-CDI were identified using a clinical surveillance definition. Cases were matched to noncases of CDI (those without a positive C. difficile test or without clinical CDI) on propensity score and exposure time. The outcomes were attributable costs and length of stay of the hospitalization where the CDI was identified. Costs were expressed in 2018 Canadian dollars.
Of the 2,916 HA-CDI cases at facilities with microcosting data available, 98.4% were matched to 13,024 noncases of CDI. The total adjusted cost among HA-CDI cases was 27% greater than noncases of CDI (ratio, 1.27; 95% confidence interval [CI], 1.21–1.33). The mean attributable cost was $18,386 (CAD 2018; USD $14,190; 95% CI, $14,312–$22,460; USD $11,046-$17,334). The adjusted length of stay among HA-CDI cases was 13% greater than for noncases of CDI (ratio, 1.13; 95% CI, 1.07–1.19), which corresponds to an extra 5.6 days (95% CI, 3.10–8.06) in length of hospital stay per HA-CDI case.
In this population-based, propensity score matched analysis using microcosting data, HA-CDI was associated with substantial attributable cost.
Non-cholera Vibrio (NCV) species are important causes of disease. These pathogens are thermophilic and climate change could increase the risk of NCV infection. The El Niño Southern Oscillation (ENSO) is a ‘natural experiment’ that may presage ocean warming effects on disease incidence. In order to evaluate possible climatic contributions to observed increases in NCV infection, we obtained NCV case counts for the United States from publicly available surveillance data. Trends and impacts of large-scale oceanic phenomena, including ENSO, were evaluated using negative binomial and distributed non-linear lag models (DNLM). Associations between latitude and changing risk were evaluated with meta-regression. Trend models demonstrated expected seasonality (P < 0.001) and a 7% (6.1%–8.1%) annual increase in incidence from 1999 to 2014. DNLM demonstrated increased vibriosis risk following ENSO conditions over the subsequent 12 months (relative risk 1.940, 95% confidence interval (CI) 1.298–2.901). The ‘relative–relative risk’ (RRR) of annual disease incidence increased with latitude (RRR per 10° increase 1.066, 95% CI 1.027–1.107). We conclude that NCV risk in the United States is impacted by ocean warming, which is likely to intensify with climate change, increasing NCV risk in vulnerable populations.
OBJECTIVES/SPECIFIC AIMS: By combining clinical knowledge of hoarding disorder (HD) with qualitative methods from cultural anthropology, we hope to build a patient-centered approach that will allow us to better understand the clinician perspectives on patient motivations and explanatory models of individuals with HD, and improve treatment outcomes. We describe the ways that these methodologies are productively merged in this project as a result of TL1 collaboration, and present a preliminary picture of methodological and theoretical issues uncovered as part of this processes. We further describe the analytical methods used for this project, and explore issues raised through the combination of psychological and anthropological data and insights. METHODS/STUDY POPULATION: This study represents an attempt to combine the qualitative methodologies of cultural anthropology with the clinical knowledge of psychology and psychiatry in order to better understand gaps between provider and patient beliefs and knowledge about hoarding disorder. This study will present preliminary methodological issues arising from interviews with hoarding experts. RESULTS/ANTICIPATED RESULTS: This study will discuss preliminary issues including shared language, strengths and limitations of both disciplines, and factors for consideration when combining these disparate methodologies. It will close with recommendations for consideration when moving forward with similar collaborations. DISCUSSION/SIGNIFICANCE OF IMPACT: This project seeks to unite psychological and social factors that may contribute to the lived experience of individuals with HD in order to better understand the way that HD is manifested. It also unites disparate methodologies to provide us with a more holistic and complete picture of the experience of HD. While HD has been studied within psychiatry, it has never been assessed using the qualitative methods of anthropology. These methods provide the possibility of expanding knowledge about the ways that this disorder is experienced by individuals and their families, and potentially impacted by shared beliefs and cultures. Furthermore, qualitative data of this nature provides a patient perspective on the experience of HD as a psychiatric illness. This patient perspective can be used to better inform treatment, improve patient outcomes, and to allow providers and researchers to gain a fuller understanding of this complex population.
Recovery Colleges are opening internationally. The evaluation focus has been on outcomes for Recovery College students who use mental health services. However, benefits may also arise for: staff who attend or co-deliver courses; the mental health and social care service hosting the Recovery College; and wider society. A theory-based change model characterising how Recovery Colleges impact at these higher levels is needed for formal evaluation of their impact, and to inform future Recovery College development. The aim of this study was to develop a stratified theory identifying candidate mechanisms of action and outcomes (impact) for Recovery Colleges at staff, services and societal levels.
Inductive thematic analysis of 44 publications identified in a systematised review was supplemented by collaborative analysis involving a lived experience advisory panel to develop a preliminary theoretical framework. This was refined through semi-structured interviews with 33 Recovery College stakeholders (service user students, peer/non-peer trainers, managers, community partners, clinicians) in three sites in England.
Candidate mechanisms of action and outcomes were identified at staff, services and societal levels. At the staff level, experiencing new relationships may change attitudes and associated professional practice. Identified outcomes for staff included: experiencing and valuing co-production; changed perceptions of service users; and increased passion and job motivation. At the services level, Recovery Colleges often develop somewhat separately from their host system, reducing the reach of the college into the host organisation but allowing development of an alternative culture giving experiential learning opportunities to staff around co-production and the role of a peer workforce. At the societal level, partnering with community-based agencies gave other members of the public opportunities for learning alongside people with mental health problems and enabled community agencies to work with people they might not have otherwise. Recovery Colleges also gave opportunities to beneficially impact on community attitudes.
This study is the first to characterise the mechanisms of action and impact of Recovery Colleges on mental health staff, mental health and social care services, and wider society. The findings suggest that a certain distance is needed in the relationship between the Recovery College and its host organisation if a genuine cultural alternative is to be created. Different strategies are needed depending on what level of impact is intended, and this study can inform decision-making about mechanisms to prioritise. Future research into Recovery Colleges should include contextual evaluation of these higher level impacts, and investigate effectiveness and harms.
To determine the prevalence of Clostridium difficile colonization among patients who meet the 2017 IDSA/SHEA C. difficile infection (CDI) Clinical Guideline Update criteria for the preferred patient population for C. difficile testing.
Tertiary-care hospital in St. Louis, Missouri.
Patients whose diarrheal stool samples were submitted to the hospital’s clinical microbiology laboratory for C. difficile testing (toxin EIA) from August 2014 to September 2016.
Electronic and manual chart review were used to determine whether patients tested for C. difficile toxin had clinically significant diarrhea and/or any alternate cause for diarrhea. Toxigenic C. difficile culture was performed on all stool specimens from patients with clinically significant diarrhea and no known alternate cause for their diarrhea.
A total of 8,931 patients with stool specimens submitted were evaluated: 570 stool specimens were EIA positive (+) and 8,361 stool specimens were EIA negative (−). Among the EIA+stool specimens, 107 (19% of total) were deemed eligible for culture. Among the EIA− stool specimens, 515 (6%) were eligible for culture. One EIA+stool specimen (1%) was toxigenic culture negative. Among the EIA− stool specimens that underwent culture, toxigenic C. difficile was isolated from 63 (12%).
Most patients tested for C. difficile do not have clinically significant diarrhea and/or potential alternate causes for diarrhea. The prevalence of toxigenic C. difficile colonization among EIA− patients who met the IDSA/SHEA CDI guideline criteria for preferred patient population for C. difficile testing was 12%.
The predictions of mean-field electrodynamics can now be probed using direct numerical simulations of random flows and magnetic fields. When modelling astrophysical magnetohydrodynamics, it is important to verify that such simulations are in agreement with observations. One of the main challenges in this area is to identify robust quantitative measures to compare structures found in simulations with those inferred from astrophysical observations. A similar challenge is to compare quantitatively results from different simulations. Topological data analysis offers a range of techniques, including the Betti numbers and persistence diagrams, that can be used to facilitate such a comparison. After describing these tools, we first apply them to synthetic random fields and demonstrate that, when the data are standardized in a straightforward manner, some topological measures are insensitive to either large-scale trends or the resolution of the data. Focusing upon one particular astrophysical example, we apply topological data analysis to H i observations of the turbulent interstellar medium (ISM) in the Milky Way and to recent magnetohydrodynamic simulations of the random, strongly compressible ISM. We stress that these topological techniques are generic and could be applied to any complex, multi-dimensional random field.
OBJECTIVES/SPECIFIC AIMS: The advent of Highly Active Antiretroviral Treatments (HAART) has allowed HIV-positive individuals to live longer in recent years. This has resulted in a higher incidence of mortalities occurring in these individuals due to cardiovascular pathologies, as opposed to deaths due to HIV. Even with long-term HAART, persons living with HIV (PLWHIV) still exhibit inflammation, which is associated with deleterious cardiovascular outcomes. PLWHIV on HAART have a higher prevalence of hypertension, which is associated with an increased risk of cardiovascular events. Moreover, chronic inflammation has been shown to be related to the translocation of microbes and endotoxins across the gastrointestinal tract. Such microbial translocation (MT) is increased in individuals with digestive disorders and their associated symptoms (e.g., diarrhea, abdominal pain, and nausea). This study aims to explore the pathologies common to both MT-induced inflammation and cardiovascular symptoms by examining the associations between gastrointestinal symptoms and hypertension in PLWHIV on HAART. METHODS/STUDY POPULATION: The sample included 351 PLWHIV on HAART. Pre-existing de-identified data were analyzed. Sample demographics included 56.98 % African Americans, 41.31% Caucasians, ages 20–66 years (mean age=43.65years), 21% female, 89% male, HIV viral load, CD4 counts. Self-reported data from the Symptom Co-Morbidity Questionnaire and Socio-demographic questionnaire were analyzed with SPSS v.24. RESULTS/ANTICIPATED RESULTS: In total, 86 PLWHIV (24.50%) stated that they have hypertension; 39 subjects (45.3%) reported having diarrhea, 30 subjects (34.8%) reported nausea, and 12 (13.9%) reported constipation and vomiting. Among ethnicities with hypertension and gastrointestinal symptoms, African Americans compared with Caucasians had a higher percentage of diarrhea (28% vs. 17%), nausea (21% vs. 11%), constipation (11% vs. 2%), and vomiting (8% vs. 5%). Women compared with men reported a higher percentage of nausea (28% vs. 24%) and constipation (8% vs. 6%). Men compared with women reported a higher percentage of diarrhea (38% vs. 7%) and vomiting (8% vs. 5%). DISCUSSION/SIGNIFICANCE OF IMPACT: These data support the need for targeted screening to include both blood pressure and associated gastrointestinal symptoms. Further studies supporting these results may assist practitioners to target treatments that may prevent cardiovascular comorbidities.
Background:ATP8A2 mutations have only recently been associated with human disease. We present the clinical features from the largest cohort of patients with this disorder reported to date. Methods: An observational study of 9 unreported and 2 previously reported patients with biallelic ATP8A2 mutations was carried out at multiple centres. Results: The mean age of the cohort was 9.4 years old (range: 2.5-28 yrs). All patients demonstrated developmental delay, severe hypotonia and movement disorders: chorea/choreoathetosis (100%), dystonia (27%) or facial dyskinesia (18%). Hypotonia was apparent at birth (70%) or before 6 months old (100%). Optic atrophy was observed in 75% of patients who had a funduscopic examination. MRI of the brain was normal for most patients with a small proportion showing mild cortical atrophy (30%), delayed myelination (20%) and/or hypoplastic optic nerves (20%). Epilepsy was seen in two older patients. Conclusions:ATP8A2 gene mutations have emerged as a cause of a novel phenotype characterized by developmental delay, severe hypotonia and hyperkinetic movement disorders. Optic atrophy is common and may only become apparent in the first few years of life, necessitating repeat ophthalmologic evaluation. Early recognition of the cardinal features of this condition will facilitate diagnosis of this disorder.
Current policy emphasises the importance of ‘living well’ with dementia, but there has been no comprehensive synthesis of the factors related to quality of life (QoL), subjective well-being or life satisfaction in people with dementia. We examined the available evidence in a systematic review and meta-analysis. We searched electronic databases until 7 January 2016 for observational studies investigating factors associated with QoL, well-being and life satisfaction in people with dementia. Articles had to provide quantitative data and include ⩾75% people with dementia of any type or severity. We included 198 QoL studies taken from 272 articles in the meta-analysis. The analysis focused on 43 factors with sufficient data, relating to 37639 people with dementia. Generally, these factors were significantly associated with QoL, but effect sizes were often small (0.1–0.29) or negligible (<0.09). Factors reflecting relationships, social engagement and functional ability were associated with better QoL. Factors indicative of poorer physical and mental health (including depression and other neuropsychiatric symptoms) and poorer carer well-being were associated with poorer QoL. Longitudinal evidence about predictors of QoL was limited. There was a considerable between-study heterogeneity. The pattern of numerous predominantly small associations with QoL suggests a need to reconsider approaches to understanding and assessing living well with dementia.
To characterize trends in outpatient antibiotic prescriptions in the United States
Retrospective ecological and temporal trend study evaluating outpatient antibiotic prescriptions from 2013 to 2015
National administrative claims data from a pharmacy benefits manager PARTICIPANTS. Prescription pharmacy beneficiaries from Express Scripts Holding Company
Annual and seasonal percent change in antibiotic prescriptions
Approximately 98 million outpatient antibiotic prescriptions were filled by 39 million insurance beneficiaries during the 3-year study period. The most commonly prescribed antibiotics were azithromycin, amoxicillin, amoxicillin/clavulanate, ciprofloxacin, and cephalexin. No significant changes in individual or overall annual antibiotic prescribing rates were found during the study period. Significant seasonal variation was observed, with antibiotics being 42% more likely to be prescribed during February than September (peak-to-trough ratio [PTTR], 1.42; 95% confidence interval [CI], 1.39–1.61). Similar seasonal trends were found for azithromycin (PTTR, 2.46; 95% CI, 2.44–3.47), amoxicillin (PTTR, 1.52; 95% CI, 1.42–1.89), and amoxicillin/clavulanate (PTTR, 1.78; 95% CI, 1.68–2.29).
This study demonstrates that annual national outpatient antibiotic prescribing practices remained unchanged during our study period. Furthermore, seasonal peaks in antibiotics generally used to treat viral upper respiratory tract infections remained unchanged during cold and influenza season. These results suggest that inappropriate prescribing of antibiotics remains widespread, despite the concurrent release of several guideline-based best practices intended to reduce inappropriate antibiotic consumption; however, further research linking national outpatient antibiotic prescriptions to associated medical conditions is needed to confirm these findings.
Background: Increased cerebral perfusion pressure (CPP)>70 mmHg has been associated with acute respiratory distress syndrome (ARDS) after traumatic brain injury (TBI). Since this reported association, significant changes in ventilation strategies and fluid management have been accepted as routine critical care. Recently, individualized perfusion targets using autoregulation monitoring suggest CPP titration>70 mmHg. Given these clinical advances, the association between ARDS and increased CPP requires further delineation. Objective: To determine the association between ARDS and increased CPP after TBI. Methods: We conducted a single-center historical cohort study investigating the association of increased CPP and ARDS after TBI. We collected demographic data and physiologic data for CPP, intracranial pressure, mechanical ventilation, cumulative fluid balance and delta/driving pressure (ΔP). We collected outcomes measures pertaining to duration of ventilation, intensive care unit admission length, hospitalization length and 6-month neurological outcome. Results: In total, 113 patients with severe TBI and multimodal neuromonitoring were included. In total, 16 patients (14%) developed ARDS according to the Berlin definition. There was no difference in the mean CPP during the first 7 days of admission between patients who developed ARDS (74 mmHg SD 18 vs. 73 mmHg SD 18, p=0.86) versus those who did not. Patients who developed ARDS had a higher ΔP (15 mmHg  vs. 12 mmHg , p=0.016) and lower lung compliance (35 ml/cmH2O  vs. 49 ml/cmH2O , p=0.024) versus those who did not. Conclusion: We did not observe an association between increased CPP and ARDS. Patients with ARDS had higher ΔP and lower lung compliance.
Paratuberculosis (Johne’s disease) is a chronic invariably fatal enteritis of cattle caused by the bacterium Mycobacterium avium subspecies paratuberculosis and has recently been isolated from wild rabbits. One potential route of transmission of M.a.paratuberculosis from rabbits to cattle is the ingestion of rabbit excreta contaminating pasture. Here we (1) determine the prevalence and level of infection in rabbits and their excreta (2) quantify the level of rabbit faeces contaminating cattle pastures and (3) determine the impact of rabbit faeces on cattle grazing behaviour.
The average yearly net ablation rate on permanently ice-covered Lake Fryxell, Victoria Land, Antarctica, is 30 to 40 cm. This figure was calculated by a novel method utilizing a record of ablation which is incorporated in the ice cover of the lake. These values are higher than those measured on Ross Island 80 km. to the east; the difference in ablation rates for the two areas is attributed to the prevalence of katabatic winds in the climate of Taylor Valley. The Lake Fryxell ablation figure is applied to nearby Canada and Commonwealth Glaciers in the calculation of their ice budgets.
Hip and knee arthroplasty infections are associated with considerable healthcare costs. The merits of reducing the postoperative surveillance period from 1 year to 90 days have been debated.
To report the first pan-Canadian hip and knee periprosthetic joint infection (PJI) rates and to describe the implications of a shorter (90-day) postoperative surveillance period.
Prospective surveillance for infection following hip and knee arthroplasty was conducted by hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) using standard surveillance definitions.
Overall hip and knee PJI rates were 1.64 and 1.52 per 100 procedures, respectively. Deep incisional and organ-space hip and knee PJI rates were 0.96 and 0.71, respectively. In total, 93% of hip PJIs and 92% of knee PJIs were identified within 90 days, with a median time to detection of 21 days. However, 11%–16% of deep incisional and organ-space infections were not detected within 90 days. This rate was reduced to 3%–4% at 180 days post procedure. Anaerobic and polymicrobial infections had the shortest median time from procedure to detection (17 and 18 days, respectively) compared with infections due to other microorganisms, including Staphylococcus aureus.
PJI rates were similar to those reported elsewhere, although differences in national surveillance systems limit direct comparisons. Our results suggest that a postoperative surveillance period of 90 days will detect the majority of PJIs; however, up to 16% of deep incisional and organ-space infections may be missed. Extending the surveillance period to 180 days could allow for a better estimate of disease burden.
A new protocol for the quantitative determination of zeolite-group mineral compositions by electron probe microanalysis (wavelength-dispersive spectrometry) under ambient conditions, is presented. The method overcomes the most serious challenges for this mineral group, including new confidence in the fundamentally important Si-Al ratio. Development tests were undertaken on a set of natural zeolite candidate reference samples, representing the compositional extremes of Na, K, Cs, Mg, Ca, Sr and Ba zeolites, to demonstrate and assess the extent of beam interaction effects on each oxide component for each mineral. These tests highlight the variability and impact of component mobility due to beam interaction, and show that it can be minimized with recommended operating conditions of 15 kV, 2 nA, a defocused, 20 μm spot size, and element prioritizing with the spectrometer configuration. The protocol represents a pragmatic solution that works, but provides scope for additional optimization where required. Vital to the determination of high-quality results is the attention to careful preparations and the employment of strict criteria for data reduction and quality control, including the monitoring and removal of non-zeolitic contaminants from the data (mainly Fe and clay phases). Essential quality criteria include the zeolite-specific parameters of R value (Si/(Si + Al + Fe3+), the 'E%' charge-balance calculation, and the weight percent of non-hydrous total oxides. When these criteria are applied in conjunction with the recommended analytical operating conditions, excellent inter-batch reproducibility is demonstrated. Application of the method to zeolites with complex solid-solution compositions is effective, enabling more precise geochemical discrimination for occurrence-composition studies. Phase validation for the reference set was conducted satisfactorily with the use of X-ray diffraction and laser-ablation inductively-coupled plasma mass spectroscopy.
There has been enormous progress during the last few years in the determination of three-dimensional biological structures by single particle electron cryomicroscopy (cryoEM), allowing maps to be obtained with higher resolution and from fewer images than required previously. This is due principally to the introduction of a new type of direct electron detector that has 2- to 3-fold higher detective quantum efficiency than available previously, and to the improvement of the computational algorithms for image processing. In spite of the great strides that have been made, quantitative analysis shows that there are still significant gains to be made provided that the problems associated with image degradation can be solved, possibly by minimising beam-induced specimen movement and charge build up during imaging. If this can be achieved, it should be possible to obtain near atomic resolution structures of smaller single particles, using fewer images and resolving more conformational states than at present, thus realising the full potential of the method. The recent popularity of cryoEM for molecular structure determination also highlights the need for lower cost microscopes, so we encourage development of an inexpensive, 100 keV electron cryomicroscope with a high-brightness field emission gun to make the method accessible to individual groups or institutions that cannot afford the investment and running costs of a state-of-the-art 300 keV installation. A key requisite for successful high-resolution structure determination by cryoEM includes interpretation of images and optimising the biochemistry and grid preparation to obtain nicely distributed macromolecules of interest. We thus include in this review a gallery of cryoEM micrographs that shows illustrative examples of single particle images of large and small macromolecular complexes.
To conduct a full economic evaluation assessing the costs and consequences related to probiotic use for the primary prevention of Clostridium difficile–associated diarrhea (CDAD).
Cost-effectiveness analysis using decision analytic modeling.
A cost-effectiveness analysis was used to evaluate the risk of CDAD and the costs of receiving oral probiotics versus not over a time horizon of 30 days. The target population modeled was all adult inpatients receiving any therapeutic course of antibiotics from a publicly funded healthcare system perspective. Effectiveness estimates were based on a recent systematic review of probiotics for the primary prevention of CDAD. Additional estimates came from local data and the literature. Sensitivity analyses were conducted to assess how plausible changes in variables impacted the results.
Treatment with oral probiotics led to direct costs of CDN $24 per course of treatment per patient. On average, patients treated with oral probiotics had a lower overall cost compared with usual care (CDN $327 vs $845). The risk of CDAD was reduced from 5.5% in those not receiving oral probiotics to 2% in those receiving oral probiotics. These results were robust to plausible variation in all estimates.
Oral probiotics as a preventive strategy for CDAD resulted in a lower risk of CDAD as well as cost-savings. The cost-savings may be greater in other healthcare systems that experience a higher incidence and cost associated with CDAD.
Whispering gallery modes (WGMs) have been widely studied over the past 20 years for various applications, including biological sensing. While the WGM-based sensing approaches reported in the literature have shown tremendous performance down to single molecule detection, at present such sensing technologies are not yet mature and still have significant practical constraints that limit their use in real-world applications. Our work has focused on developing a practical, yet effective, WGM-based sensing platform capable of being used as a dip sensor for in-vivo biosensing by combining WGM fluorescent microresonators with silica Microstructured Optical Fibers (MOFs).
We recently demonstrated that a suspended core MOF with a dye-doped polymer microresonator supporting WGMs positioned onto the tip of the fiber, can be used as a dip sensor. In this architecture the resonator is anchored to one of the MOF air holes, in contact with the fiber core, enabling a significant portion of the evanescent field from the fiber to overlap with the sphere and hence excite the fluorescent WGMs. This architecture allows for remote excitation and collection of the WGMs. The fiber also permits easy manipulation of the microresonator for dip sensing applications, and hence alleviates the need for a complex microfluidic interface. More importantly, it allows for an increase in both the excitation and collection efficiency compared to free space coupling, and also improves the Q factor.
In this paper we present our recent results on microstructured fiber tip WGM-based sensors and show that this sensing platform can be used in clinical diagnostics, for detecting various clinically relevant biomarkers in complex clinical samples.