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In March 2017, the New Jersey Department of Health received reports of 3 patients who developed septic arthritis after receiving intra-articular injections for osteoarthritis knee pain at the same private outpatient facility in New Jersey. The risk of septic arthritis resulting from intra-articular injection is low. However, outbreaks of septic arthritis associated with unsafe injection practices in outpatient settings have been reported.
An infection prevention assessment of the implicated facility’s practices was conducted because of the ongoing risk to public health. The assessment included an environmental inspection of the facility, staff interviews, infection prevention practice observations, and a medical record and office document review. A call for cases was disseminated to healthcare providers in New Jersey to identify patients treated at the facility who developed septic arthritis after receiving intra-articular injections.
We identified 41 patients with septic arthritis associated with intra-articular injections. Cultures of synovial fluid or tissue from 15 of these 41 case patients (37%) recovered bacteria consistent with oral flora. The infection prevention assessment of facility practices identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, unsafe injection practices, and poor cleaning and disinfection practices. No additional cases were identified after infection prevention recommendations were implemented by the facility.
Aseptic technique is imperative when handling, preparing, and administering injectable medications to prevent microbial contamination.
This investigation highlights the importance of adhering to infection prevention recommendations. All healthcare personnel who prepare, handle, and administer injectable medications should be trained in infection prevention and safe injection practices.
Internationally, intimate partner violence (IPV) cohorts have demonstrated associations with depression and anxiety. However, this association has not yet been described in a UK population, nor has the association with serious mental illness (SMI).
To explore the relationship between IPV exposure and mental illness in a UK population.
We designed a retrospective cohort study whereby we matched 18 547 women exposed to IPV to 74 188 unexposed women. Outcomes of interest (anxiety, depression and SMI) were identified through clinical codes.
At baseline, 9174 (49.5%) women in the exposed group had some form of mental illness compared with 17 768 (24.0%) in the unexposed group, described as an adjusted odds ratio of 2.62 (95% CI 2.52–2.72). Excluding those with mental illness at baseline, 1254 exposed women (incidence rate 46.62 per 1000 person-years) went on to present with any type of mental illness compared with 3119 unexposed women (incidence rate 14.93 per 1000 person-years), with an aIRR of 2.77 (95% CI 2.58–2.97). Anxiety (aIRR 1.99, 95% CI 1.80–2.20), depression (aIRR 3.05, 95% CI 2.81–3.31) and SMI (aIRR 3.08, 95% CI 2.19–4.32) were all associated with exposure to IPV.
IPV remains a significant public health issue in the UK. We have demonstrated the significant recorded mental health burden associated with IPV in primary care, at both baseline and following exposure. Clinicians must be aware of this association to reduce mental illness diagnostic delay and improve management of psychological outcomes in this group of patients.
Depression is considered to have the highest disability burden of all conditions. Although treatment-resistant depression (TRD) is a key contributor to that burden, there is little understanding of the best treatment approaches for it and specifically the effectiveness of available augmentation approaches.
We conducted a systematic review and meta-analysis to search and quantify the evidence of psychological and pharmacological augmentation interventions for TRD.
Participants with TRD (defined as insufficient response to at least two antidepressants) were randomised to at least one augmentation treatment in the trial. Pre-post analysis assessed treatment effectiveness, providing an effect size (ES) independent of comparator interventions.
Of 28 trials, 3 investigated psychological treatments and 25 examined pharmacological interventions. Pre-post analyses demonstrated N-methyl-d-aspartate-targeting drugs to have the highest ES (ES = 1.48, 95% CI 1.25–1.71). Other than aripiprazole (four studies, ES = 1.33, 95% CI 1.23–1.44) and lithium (three studies, ES = 1.00, 95% CI 0.81–1.20), treatments were each investigated in less than three studies. Overall, pharmacological (ES = 1.19, 95% CI 1.08–1.30) and psychological (ES = 1.43, 95% CI 0.50–2.36) therapies yielded higher ESs than pill placebo (ES = 0.78, 95% CI 0.66–0.91) and psychological control (ES = 0.94, 95% CI 0.36–1.52).
Despite being used widely in clinical practice, the evidence for augmentation treatments in TRD is sparse. Although pre-post meta-analyses are limited by the absence of direct comparison, this work finds promising evidence across treatment modalities.
Declaration of interest
In the past 3 years, A.H.Y. received honoraria for speaking from AstraZeneca, Lundbeck, Eli Lilly and Sunovion; honoraria for consulting from Allergan, Livanova and Lundbeck, Sunovion and Janssen; and research grant support from Janssen. In the past 3 years, A.J.C. received honoraria for speaking from AstraZeneca and Lundbeck; honoraria for consulting with Allergan, Janssen, Livanova, Lundbeck and Sandoz; support for conference attendance from Janssen; and research grant support from Lundbeck. B.B. has recently been (soon to be) on the speakers/advisory board for Hexal, Lilly, Lundbeck, Mundipharma, Pfizer, and Servier. No other conflicts of interest.
The Taipan galaxy survey (hereafter simply ‘Taipan’) is a multi-object spectroscopic survey starting in 2017 that will cover 2π steradians over the southern sky (δ ≲ 10°, |b| ≳ 10°), and obtain optical spectra for about two million galaxies out to z < 0.4. Taipan will use the newly refurbished 1.2-m UK Schmidt Telescope at Siding Spring Observatory with the new TAIPAN instrument, which includes an innovative ‘Starbugs’ positioning system capable of rapidly and simultaneously deploying up to 150 spectroscopic fibres (and up to 300 with a proposed upgrade) over the 6° diameter focal plane, and a purpose-built spectrograph operating in the range from 370 to 870 nm with resolving power R ≳ 2000. The main scientific goals of Taipan are (i) to measure the distance scale of the Universe (primarily governed by the local expansion rate, H0) to 1% precision, and the growth rate of structure to 5%; (ii) to make the most extensive map yet constructed of the total mass distribution and motions in the local Universe, using peculiar velocities based on improved Fundamental Plane distances, which will enable sensitive tests of gravitational physics; and (iii) to deliver a legacy sample of low-redshift galaxies as a unique laboratory for studying galaxy evolution as a function of dark matter halo and stellar mass and environment. The final survey, which will be completed within 5 yrs, will consist of a complete magnitude-limited sample (i ⩽ 17) of about 1.2 × 106 galaxies supplemented by an extension to higher redshifts and fainter magnitudes (i ⩽ 18.1) of a luminous red galaxy sample of about 0.8 × 106 galaxies. Observations and data processing will be carried out remotely and in a fully automated way, using a purpose-built automated ‘virtual observer’ software and an automated data reduction pipeline. The Taipan survey is deliberately designed to maximise its legacy value by complementing and enhancing current and planned surveys of the southern sky at wavelengths from the optical to the radio; it will become the primary redshift and optical spectroscopic reference catalogue for the local extragalactic Universe in the southern sky for the coming decade.
Driving in persons with dementia poses risks that must be counterbalanced with the importance of the care for autonomy and mobility. Physicians often find substantial challenges in the assessment and reporting of driving safety for persons with dementia. This paper describes a driving in dementia decision tool (DD-DT) developed to aid physicians in deciding when to report older drivers with either mild dementia or mild cognitive impairment to local transportation administrators.
A multi-faceted, computerized decision support tool was developed, using a systematic literature and guideline review, expert opinion from an earlier Delphi study, as well as qualitative interviews and focus groups with physicians, caregivers of former drivers with dementia, and transportation administrators. The tool integrates inputs from the physician-user about the patient's clinical and driving history as well as cognitive findings, and it produces a recommendation for reporting to transportation administrators. This recommendation is translated into a customized reporting form for the transportation authority, if applicable, and additional resources are provided for the patient and caregiver.
An innovative approach was needed to develop the DD-DT. The literature and guideline review confirmed the algorithm derived from the earlier Delphi study, and barriers identified in the qualitative research were incorporated into the design of the tool.
Cathars have long been regarded as posing the most organised challenge to orthodox Catholicism in the medieval West, even as a "counter-Church" to orthodoxy in southern France and northern Italy. Their beliefs, understood to be inspired by Balkan dualism, are often seen as the most radical among medieval heresies. However, recent work has fiercely challenged this paradigm, arguing instead that "Catharism" was a construct of its persecutors, mis-named and mis-represented by generations of subsequent scholarship, and its supposedly radical views were a fantastical projection of the fears of orthodox commentators. This volume brings together a wide range of views from some of the most distinguished international scholars in the field, in order to address the debate directly while also opening up new areas for research. Focussing on dualism and anti-materialist beliefs in southern France, Italy and the Balkans, it considers a number of crucial issues. These include: what constitutes popular belief; how (and to what extent) societies of the past were based on the persecution of dissidents; and whether heresy can be seen as an invention of orthodoxy. At the same time, the essays shed new light on some key aspects of the political, cultural, religious and economic relationships between the Balkans and more western regions of Europe in the Middle Ages.
Antonio Sennis isSenior Lecturer in Medieval History at University College London Contributors: John H. Arnold, Peter Biller, Caterina Bruschi, David d'Avray, Jörg Feuchter, Bernard Hamilton, Robert I. Moore, MarkGregory Pegg, Rebecca Rist, Lucy Sackville, Antonio Sennis, Claire Taylor, Julien Théry-Astruc, Yuri Stoyanov
The shift to inclusive education within Australia has resulted in increasing numbers of students with autism spectrum disorders (ASD) being placed in mainstream educational settings. This move has created new demands on teachers who are not necessarily trained to meet the challenge. Therefore, the present study aimed to develop an understanding of how 12 Western Australian primary school (K–7) teachers adapted to the challenge of having a student with ASD in their mainstream classroom. Using an interpretivist framework, data from semistructured interviews revealed that teachers perceived a need to first recognise and accept the challenges associated with having a student with ASD in their mainstream classroom before they could move to accessing avenues of support. The implications of this finding are discussed.
This study was initiated to investigate the structural response of the bessbeetle to determine potential advantageous ramifications and effects on the optimization of synthetic composite materials. The result of the micromechanics sensitivity study of various parameters are presented. Variables such as fiber size and shape, fiber volume fraction, ratio of modulus of elasticity of fiber over matrix, are changed one variable at a time, and the response quantities such as stress and tranverse modulus are presented.
Individuals with repetitive or impulsive aggression in the absence of
other disorders may be diagnosed with intermittent explosive disorder
according to DSM–IV, but no such diagnostic category exists in ICD–10.
Mood stabilisers are often used off-license for the treatment of
aggression associated with a variety of psychiatric conditions, but their
efficacy in these and in idiopathic aggression is not known.
To summarise and evaluate the evidence for the efficacy of mood
stabilisers (anticonvulsants/lithium) in the treatment of impulsive or
repetitive aggression in adults.
A meta-analysis of randomised controlled trials that compared a mood
stabiliser with placebo in adults without intellectual disability,
organic brain disorder or psychotic illness, identified as exhibiting
repetitive or impulsive aggression.
Ten eligible trials (489 participants) were identified A pooled analysis
showed an overall significant reduction in the frequency/severity of
aggressive behaviour (standardised mean difference (SMD) =–1.02, 95% CI
−1.54 to −0.50), although heterogeneity was high (I2 = 84.7%). When analysed by drug type, significant effects
were found in the pooled analysis of three phenytoin trials (SMD =–1.34,
95% CI −2.16 to −0.52), one lithium trial (SMD =–0.81, 95% CI −1.35 to
−0.28), and two oxcarbazepine/carbamazepine trials (SMD =–1.20, 95% CI
−1.83 to −0.56). However, when the results of only those studies that had
a low risk of bias were pooled (347 participants), there was no
significant reduction in aggression (SMD =–0.28, 95% CI −0.73 to 0.17,
I2 = 71.4%).
There is evidence that mood stabilisers as a group are significantly
better than placebo in reducing aggressive behaviour, but not all mood
stabilisers appear to share this effect. There is evidence of efficacy
for carbamazepine/oxcarbazepine, phenytoin and lithium. Many studies,
however, were at risk of bias and so further randomised controlled trials