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Surgical site infections (SSIs) are common surgical complications that lead to increased costs. Depending on payer type, however, they do not necessarily translate into deficits for every hospital.
We investigated how surgical site infections (SSIs) influence the contribution margin in 2 reimbursement systems based on diagnosis-related groups (DRGs).
This preplanned observational health cost analysis was nested within a Swiss multicenter randomized controlled trial on the timing of preoperative antibiotic prophylaxis in general surgery between February 2013 and August 2015. A simulation of cost and income in the National Health Service (NHS) England reimbursement system was conducted.
Of 5,175 patients initially enrolled, 4,556 had complete cost and income data as well as SSI status available for analysis. SSI occurred in 228 of 4,556 of patients (5%). Patients with SSIs were older, more often male, had higher BMIs, compulsory insurance, longer operations, and more frequent ICU admissions. SSIs led to higher hospital cost and income. The median contribution margin was negative in cases of SSI. In SSI cases, median contribution margin was Swiss francs (CHF) −2045 (IQR, −12,800 to 4,848) versus CHF 895 (IQR, −2,190 to 4,158) in non-SSI cases. Higher ASA class and private insurance were associated with higher contribution margins in SSI cases, and ICU admission led to greater deficits. Private insurance had a strong increasing effect on contribution margin at the 10th, 50th (median), and 90th percentiles of its distribution, leading to overall positive contribution margins for SSIs in Switzerland. The NHS England simulation with 3,893 patients revealed similar but less pronounced effects of SSI on contribution margin.
Depending on payer type, reimbursement systems with DRGs offer only minor financial incentives to the prevention of SSI.
In the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.
We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.
We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = −0.71; 95% confidence interval [CI] −1.01 to −0.41; I2 = 83%; 95% CI 78–88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = −1.02; 95% CI −1.52 to −0.51; I2 = 89%; 95% CI 82–93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = −1.05; 95% CI −1.55 to −0.56; I2 = 87%; 95% CI 79–92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.
Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.
The leaf-eating caterpillar, Opisina arenosella Walker, is the most destructive pest of coconut palm in India and Southeast Asia. The management practices employed against O. arenosella so far have been unsuccessful in many instances in India, due to the pest behaviour and coconut palm phenology. The life cycle, incidence and behaviour of O. arenosella are rather interesting and useful for the intervention of pheromone trapping technique for its management. We conducted the present study with the intention of identifying the female sex pheromone of O. arenosella and testing its efficacy under field conditions. Gas chromatography coupled electroantennographic detection (GC–EAD) and gas chromatography–mass spectrometry (GC–MS) analysis of female pheromone glands extract of one-day-old O. arenosella females confirmed the presence of (Z,Z,Z)-3,6,9-tricosatriene (Z3Z6Z9-23Hy) as the dominant sex pheromone component. The male antennal response to female pheromone gland extract and synthetic Z3Z6Z9-23Hy was recorded using GC–EAD, and the results revealed that antennal response was positive to both the treatments at 0.13 mV and 0.14 mV respectively, compared to control (air), which was 0.016 mV. It was also evident from wind-tunnel experiments that the male moth response was high (80%) with the female gland extract, compared to 60% with synthetic pheromone and 0% for control (air). Male moths caught in the traps with and without lure were assessed in two field sites and recorded 69.26% and 54.25% more moth catches in the traps with the lure. We also observed a similar result in the cage experiment in which male moths caught in the traps with and without lure were 64.50% and 12.40%, respectively. The study also confirmed that 93.20% moths caught in the pheromone-baited traps were male. From the study, it is evident that the presence of (Z,Z,Z)-3,6,9-tricosatriene, which is the sex pheromone compound from the female gland extract of O. arenosella, is an effective attractant in pheromone traps for the male moth under field conditions.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
The flora of Laos remains one of the least known within the Indo-Burma biodiversity hotspot. A floristic inventory was carried out in Phou Hin Poun National Biodiversity Conservation Area, an under-explored area of the Khammouane Limestone. This study provides a list of 27 taxa that are additions to the most recent country checklists. The Ebenaceae, Euphorbiaceae and Myrtaceae are the families with the highest species number. In this list, four species are endemic to Indochina (Cambodia, Laos and Vietnam): Cynometra dongnaiensis Pierre, Jasminum vidalii P.S.Green, Memecylon chevalieri Guillaumin and Pothos gigantipes Buchet ex P.C.Boyce. These results illustrate the paucity of our knowledge of the region surveyed and of the flora of Laos in general.
Unusual speleothems, associated with hyperalkaline (pH > 12) groundwaters
have formed within a shallow, abandoned railway tunnel at Peak Dale,
Derbyshire, UK. The hyperalkaline groundwaters are produced by the leaching
of a thin layer (<2 m) of old lime-kiln waste on the soil-bedrock surface
above the tunnel by rainwater. This results in a different reaction and
chemical process to that more commonly associated with the formation of
calcium carbonate speleothems from Ca-HCO3-type groundwaters and
degassing of CO2. Stalagmites within the Peak Daletunnel have
grown rapidly (averaging 33 mm y–1), following the closure of the
tunnel 70 years ago. They have an unusual morphology comprising a central
sub-horizontally-laminated column of micro- to nano-crystalline calcium
carbonate encompassed by an outer sub-vertical assymetricripple-laminated
layer. The stalagmites are composed largely of secondary calcite forming
pseudomorphs (<1 mm) that we believe to be predominantly after the 'cold
climate' calcium carbonate polymorph, ikaite (calcium carbonate hexahydrate:
CaCO3·6H2O), withminor volumes of small (<5 μm)
pseudomorphs after vaterite. The tunnel has a near constant temperature of
8–9°C, which is slightly above the previously published crystallization
temperatures for ikaite (<6°C). Analysis of a stalagmite actively growing
at the time ofsampling, and preserved immediately within a dry nitrogen
cryogenic vessel, indicates that following crystallization of ikaite,
decomposition to calcite occurs rapidly, if not instantaneously. We believe
this is the first occurrence of this calcium carbonate polymorph observed
To investigate the feasibility of a national audit of epistaxis management led and delivered by a multi-region trainee collaborative using a web-based interface to capture patient data.
Six trainee collaboratives across England nominated one site each and worked together to carry out this pilot. An encrypted data capture tool was adapted and installed within the infrastructure of a university secure server. Site-lead feedback was assessed through questionnaires.
Sixty-three patients with epistaxis were admitted over a two-week period. Site leads reported an average of 5 minutes to complete questionnaires and described the tool as easy to use. Data quality was high, with little missing data. Site-lead feedback showed high satisfaction ratings for the project (mean, 4.83 out of 5).
This pilot showed that trainee collaboratives can work together to deliver an audit using an encrypted data capture tool cost-effectively, whilst maintaining the highest levels of data quality.
Skin and soft tissue infections (SSTIs) due to Staphylococcus aureus have become increasingly common in the outpatient setting; however, risk factors for differentiating methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) SSTIs are needed to better inform antibiotic treatment decisions. We performed a case-case-control study within 14 primary-care clinics in South Texas from 2007 to 2015. Overall, 325 patients [S. aureus SSTI cases (case group 1, n = 175); MRSA SSTI cases (case group 2, n = 115); MSSA SSTI cases (case group 3, n = 60); uninfected control group (control, n = 150)] were evaluated. Each case group was compared to the control group, and then qualitatively contrasted to identify unique risk factors associated with S. aureus, MRSA, and MSSA SSTIs. Overall, prior SSTIs [adjusted odds ratio (aOR) 7·60, 95% confidence interval (CI) 3·31–17·45], male gender (aOR 1·74, 95% CI 1·06–2·85), and absence of healthcare occupation status (aOR 0·14, 95% CI 0·03–0·68) were independently associated with S. aureus SSTIs. The only unique risk factor for community-associated (CA)-MRSA SSTIs was a high body weight (⩾110 kg) (aOR 2·03, 95% CI 1·01–4·09).
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.
Our knowledge of the universe comes from recording the photon and particle fluxes incident on the Earth from space. We thus require sensitive measurement across the entire energy spectrum, using large telescopes with efficient instrumentation located on superb sites. Technological advances and engineering constraints are nearing the point where we are recording as many photons arriving at a site as is possible. Major advances in the future will come from improving the quality of the site. The ultimate site is, of course, beyond the Earth’s atmosphere, such as on the Moon, but economic limitations prevent our exploiting this avenue to the degree that the scientific community desires. Here we describe an alternative, which offers many of the advantages of space for a fraction of the cost: the Antarctic Plateau.
A spectrum analyser based on SAW (surface acoustic wave) devices has been developed for Jupiter, solar and pulsar observations. It has an overall frequency range of 100 MHz and a frequency resolution of 30 kHz. A complete spectrum is produced every 80 μs. It is initially being used with a 4000 dipole broadband array in the frequency range 30-130 MHz and for Jupiter observations from 8-38 MHz.
Properties of the microwave emission from HR1099 are examined in an attempt to determine whether the emission arises as gyro-synchrotron radiation from mildly relativistic electrons trapped in magnetic fields above starspots on the active K subgiant component. It is shown that radio curves do not exhibit a systematic variation in phase with the rotation rate, as one might expect for emission from a source situated above a long-lived starspot. However, there is some evidence that the radio flaring occurs at two preferred longitude zones. Whether these zones agree with starspot locations remains to be determined by light curve modelling. What we can say with confidence is that the measured spectral index of the microwave emission does not fit a simple gyro-synchrotron source model, such as that proposed to explain the observed reversal with frequency of the sense of circular polarization.
The effect of laser intensity on characteristics of the plasma ablated from a low-Z (CH) planar target irradiated by a 250 ps, 0.438 µm laser pulse with the intensity of up to 1016 W/cm2 as well as on parameters of the laser-driven shock generated in the target for various scale-lengths of preformed plasma was investigated at the kilojoule Prague Asterix Laser System (PALS) laser facility. Characteristics of the plasma were measured with the use of 3-frame interferometry, ion diagnostics, an X-ray spectrometer, and Kα imaging. Parameters of the shock generated in a Cl doped CH target by the intense 3ω laser pulse were inferred by numerical hydrodynamic simulations from the measurements of craters produced by the shock in the massive Cu target behind the CH layer. It was found that the pressure of the shock generated in the plastic layer is relatively weakly influenced by the preplasma (the pressure drop due to the preplasma presence is ~10–20%) and at the pulse intensity of ~1016 W/cm2 the maximum pressure reaches ~80–90 Mbar. However, an increase in pressure of the shock with the laser intensity is slower than predicted by theory for a planar shock and the maximum pressure achieved in the experiment is by a factor of ~2 lower than predicted by the theory. Both at the preplasma absence and presence, the laser-to-hot electrons energy conversion efficiency is small, ~1% or below, and the influence of hot electrons on the generated shock is expected to be weak.
The 2013 multistate outbreaks contributed to the largest annual number of reported US cases of cyclosporiasis since 1997. In this paper we focus on investigations in Texas. We defined an outbreak-associated case as laboratory-confirmed cyclosporiasis in a person with illness onset between 1 June and 31 August 2013, with no history of international travel in the previous 14 days. Epidemiological, environmental, and traceback investigations were conducted. Of the 631 cases reported in the multistate outbreaks, Texas reported the greatest number of cases, 270 (43%). More than 70 clusters were identified in Texas, four of which were further investigated. One restaurant-associated cluster of 25 case-patients was selected for a case-control study. Consumption of cilantro was most strongly associated with illness on meal date-matched analysis (matched odds ratio 19·8, 95% confidence interval 4·0–∞). All case-patients in the other three clusters investigated also ate cilantro. Traceback investigations converged on three suppliers in Puebla, Mexico. Cilantro was the vehicle of infection in the four clusters investigated; the temporal association of these clusters with the large overall increase in cyclosporiasis cases in Texas suggests cilantro was the vehicle of infection for many other cases. However, the paucity of epidemiological and traceback information does not allow for a conclusive determination; moreover, molecular epidemiological tools for cyclosporiasis that could provide more definitive linkage between case clusters are needed.
Two broad aims drive weed science research: improved management and improved
understanding of weed biology and ecology. In recent years, agricultural
weed research addressing these two aims has effectively split into separate
subdisciplines despite repeated calls for greater integration. Although some
excellent work is being done, agricultural weed research has developed a
very high level of repetitiveness, a preponderance of purely descriptive
studies, and has failed to clearly articulate novel hypotheses linked to
established bodies of ecological and evolutionary theory. In contrast,
invasive plant research attracts a diverse cadre of nonweed scientists using
invasions to explore broader and more integrated biological questions
grounded in theory. We propose that although studies focused on weed
management remain vitally important, agricultural weed research would
benefit from deeper theoretical justification, a broader vision, and
increased collaboration across diverse disciplines. To initiate change in
this direction, we call for more emphasis on interdisciplinary training for
weed scientists, and for focused workshops and working groups to develop
specific areas of research and promote interactions among weed scientists
and with the wider scientific community.