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Heart failure (HF) has a 2% prevalence in the population and is a major cause of morbidity and mortality. Multiple efforts have been made worldwide to improve quality of care and decrease unplanned readmissions for HF patients, one of which has been the introduction of specialist HF nurses (HFN) in primary health care. The present evidence on the benefits of HFN is contradicting. This study aims to evaluate the impact of a quality improvement intervention, availability of a HFN in Swedish primary care, on hospital readmissions.
Methods:
All patients over the age of 65 with a HF diagnosis and with complete information on availability of a HFN were included in this retrospective register-based study. Using propensity score matching (PSM) techniques, two comparable groups of 128 patients each were created according to the exposure status, availability or no availability of a HFN. The rate of readmission was compared between the groups.
Results:
Using PSM, 256 patients were matched, 128 in the HFN group and 128 in the no-HFN group. A total of 50% and 46.09% of patients in the HFN and no-HFN groups were readmitted, respectively. Mean number of readmissions per patient was 1.19 (SD 0.61) in the HFN group and 1.10 (SD 0.44) in the no-HFN group. Patients in the HFN had 17.6% higher odds of being readmitted during the study period, OR: 1.176 (CI: 0.716–1.932), and 3.8% lower odds of being readmitted within 30 days, OR: 0.962 (CI: 0.528–1.750).
Conclusions:
Availability of a HFN in primary care was not significantly associated with reduced readmissions for the patients included in this study. Further investigations are warranted looking at the impacts of availability and access to a HFN in primary care on readmissions and other patient outcomes.
Double-cropping winter rye cover crops (CC) with soybean in the North Central US could help with the global effort to sustainably intensify agriculture. Studies addressing the management of these systems are limited. Therefore, a field study was conducted from 2017 to 2019 in Central Iowa, US to evaluate winter rye CC biomass production, aboveground N accumulation, estimated economics, estimated within-field energy balance and estimated greenhouse gas (GHG) emissions under three N application rates (0, 60, 120 kg N ha−1) and three planting methods (pre- and post-harvest broadcast and post-harvest drilling). Averaged over N rates, all planting methods resulted in >5.0 Mg ha−1 year−1 rye aboveground biomass dry matter. Averaged over the 2-year study and compared with unfertilized treatments, applying 60 kg N ha−1 produced 1.1 Mg ha−1 more aboveground biomass (6.1 vs 5.0 Mg ha−1), accumulated 30 kg ha−1 more N in aboveground biomass (88 vs 58 kg N ha−1), and led to 20 GJ ha−1 more net energy. Biomass production was not significantly higher with 120 kg N ha−1 compared with the 60 kg N ha−1 rate. Even when accounting for an estimated 0.75 Mg ha−1 of above ground rye biomass left in the field after harvesting, more N was removed than applied at the 60 kg N ha−1 rate. The minimum rye prices over the 2-year study needed for double-cropping winter rye CC to be profitable (breakeven prices) averaged $117 and $104 Mg−1 for the 0 and 60 kg N ha−1 rates, which factors in estimated soybean yield reductions in 2019 compared with local averages but not off-site transportation. GHG emissions were estimated to increase approximately threefold between the unfertilized and 60 kg N ha−1 rates without considering bioenergy offsets. While environmental tradeoffs need further study, results suggest harvesting fertilized rye CC biomass before planting soybean is a promising practice for the North Central US to maximize total crop and net energy production.
To compare strategies for hospital ranking based on colon surgical-site infection (SSI) rate by combining all colon procedures versus stratifying by surgical approach (ie, laparoscopic vs open).
Design:
Retrospective cohort study.
Methods:
We identified SSIs among Medicare beneficiaries undergoing colon surgery from 2009 through 2013 using previously validated methods. We created a risk prediction model for SSI using age, sex, race, comorbidities, surgical approach (laparoscopy vs open), and concomitant colon and noncolon procedures. Adjusted SSI rates were used to rank hospitals. Subanalyses were performed for common colon procedures and procedure types for which there were both open and laparoscopic procedures. We generated ranks using only open and only laparoscopic procedures, overall and for each subanalysis. Rankings were compared using a Spearman correlation coefficient.
Results:
In total, 694,813 colon procedures were identified among 508,135 Medicare beneficiaries. The overall SSI rate was 7.6%. The laparoscopic approach was associated with lower SSI risk (OR, 0.5; 95% CI, 0.4–0.5), and higher SSI risk was associated with concomitant abdominal surgeries (OR, 1.4; 95% CI, 1.4–1.5) and higher Elixhauser score (OR, 1.1; 95% CI, 1.0–1.1). Hospital rankings for laparascopic procedures were poorly correlated with rankings for open procedures (r = 0.23).
Conclusions:
Hospital rankings based on total colon procedures fail to account for differences in SSI risk from laparoscopic vs open procedures. Stratifying rankings by surgical approach yields a more equitable comparison of surgical performance.
Current information about the prevalence of various mental health disorders in the general adult population of the Republic of Ireland is lacking. In this study, we examined the prevalence of 12 common mental disorders, the proportion of adults who screened positive for any disorder, the sociodemographic factors associated with meeting criteria for a disorder and the associations between each disorder and history of attempted suicide.
Methods
A non-probability nationally representative sample (N = 1110) of adults living in Ireland completed self-report measures of 12 mental health disorders. Effect sizes were calculated using odds ratios from logistic regression models, and population attributable risk fractions (PAFs) were estimated to quantify the associations between each disorder and attempted suicide.
Results
Prevalence rates ranged from 15.0% (insomnia disorder) to 1.7% (histrionic personality disorder). Overall, 42.5% of the sample met criteria for a mental health disorder, and 11.1% had a lifetime history of attempted suicide. Younger age, being a shift worker and trauma exposure were independently associated with a higher likelihood of having a mental health disorder, while being in university was associated with a lower likelihood of having a disorder. ICD-11 complex posttraumatic stress disorder, borderline personality disorder and insomnia disorder had the highest PAFs for attempted suicide.
Conclusions
Mental health disorder prevalence in Ireland is relatively high compared to international estimates. The findings are discussed in relation to important mental health policy implications.
Background: Aerosol-generating procedures (AGPs) performed on COVID-19–positive patients raise concerns about the dissemination of SARS-CoV-2 via aerosols and droplets. Infectious aerosols and droplets generated by SARS-CoV-2–positive patient AGPs or through direct COVID-19 patient coughing or exhalation could potentially contaminate surfaces, leading to the indirect spread of SARS-CoV-2 via fomites within the emergency department (ED). We sampled surfaces of ED patient rooms occupied by known SARS-CoV-2–positive patients or patients under investigation for COVID-19 and undergoing an AGP to determine the frequency of room contamination with SARS-CoV-2 RNA. Methods: Swabs were collected from 5 room surfaces in the ED following AGPs performed on patients under investigation for COVID-19 or positive for SARS-CoV-2. High- and low-touch surfaces 6 feet (2 m) from the patient (door handle and return vent, respectively) and reusable medical equipment were swabbed. Swabs were tested for SARS-CoV-2 RNA by RT-qPCR; positive samples were cultured in Vero E6 cells. Patient COVID-19 results were confirmed through the electronic medical record. Results: In total, 203 rooms were sampled: 43 SARS-CoV-2–positive patients with an AGP, 44 SARS-CoV-2–positive patients who did not have an AGP, and 116 SARS-CoV-2–negative patients with an AGP, for a total of 1,015 swabs. Overall, SARS-CoV-2 RNA was detected on 36 (3.5%) surfaces from 29 rooms (14.3%) (Table 1). RNA contamination was detected more frequently in rooms occupied by SARS-CoV-2–positive patients who did not have an AGP than rooms occupied by COVID-19 patients (30% vs 14%). SARS-CoV-2 RNA was also detected in rooms occupied by SARS-CoV-2–negative patients undergoing an AGP (9%). SARS-CoV-2 RNA was most frequently detected on air vents (n = 15), bedrails (n = 10), equipment and vital signs monitors (n = 4 each), and door handles (n = 3). One bedrail was positive by culture and confirmed by an RT-qPCR cycle threshold reduction from >40 to 13. Conclusions: We detected SARS-CoV-2 RNA contamination on room surfaces in the ED, regardless of patient AGP or COVID-19 status; however, RNA contamination of room surfaces was most common in rooms occupied by SARS-CoV-2–positive patients who did not have an AGP, which may be attributable to stage of disease and viral shedding. SARS-CoV-2 RNA contamination was also present in rooms where APGs were performed on SARS-CoV-2–negative patients, suggesting carryover from previous patients. SARS-CoV-2 RNA was found most often on room air-return vents, further emphasizing the importance of aerosols in the spread of SARS-CoV-2.
University and college students are vulnerable to developing depressive symptoms. People in low-income countries are disproportionately impacted by mental health problems, yet few studies examine routes to accessing clinical services. Examining motivation and barriers toward seeking clinical mental health services in university students in Bangladesh is important.
Method
Using a cross-sectional survey (n = 350), we assess the relationship between the constructs of autonomy, relatedness, and competency toward using clinical mental health practices (i.e. using professional resources, taking medication) with (1) positive views, (2) perceived need, and (3) use of clinical mental health services among Bangladeshi university students.
Results
Results showed that the perceived need for mental health support was the predictor of the largest magnitude (aOR = 4.99, p = 0.005) for using clinical services. Having a positive view of clinical services was predictive of clinical service use (aOR = 2.87, p = 0.033); however, that association became insignificant (p = 0.054) when adjusting for the perceived need for mental health care. Of the SDT constructs, social influences were predictive of perceiving a need for mental health support, and mental health knowledge was predictive (aOR = 1.10, p = 0.001) of having a positive view of clinical mental health care.
Conclusion
Our findings show that knowledge of mental health is associated with positive views of mental health services, and that higher levels of stress and the presence of people with mental health problems are associated with the perception of a need for mental health care, which is ultimately responsible for using the services.
OBJECTIVES/GOALS: Using the covariate-rich Veteran Health Administration data, estimate the association between Proton Pump Inhibitor (PPI) use and severe COVID-19, rigorously adjusting for confounding using propensity score (PS)-weighting. METHODS/STUDY POPULATION: We assembled a national retrospective cohort of United States veterans who tested positive for SARS-CoV-2, with information on 33 covariates including comorbidity diagnoses, lab values, and medications. Current outpatient PPI use was compared to non-use (two or more fills and pills on hand at admission vs no PPI prescription fill in prior year). The primary composite outcome was mechanical ventilation use or death within 60 days; the secondary composite outcome included ICU admission. PS-weighting mimicked a 1:1 matching cohort, allowing inclusion of all patients while achieving good covariate balance. The weighted cohort was analyzed using logistic regression. RESULTS/ANTICIPATED RESULTS: Our analytic cohort included 97,674 veterans with SARS-CoV-2 testing, of whom 14,958 (15.3%) tested positive (6,262 [41.9%] current PPI-users, 8,696 [58.1%] non-users). After weighting, all covariates were well-balanced with standardized mean differences less than a threshold of 0.1. Prior to PS-weighting (no covariate adjustment), we observed higher odds of the primary (9.3% vs 7.5%; OR 1.27, 95% CI 1.13-1.43) and secondary (25.8% vs 21.4%; OR 1.27, 95% CI 1.18-1.37) outcomes among PPI users vs non-users. After PS-weighting, PPI use vs non-use was not associated with the primary (8.2% vs 8.0%; OR 1.03, 95% CI 0.91-1.16) or secondary (23.4% vs 22.9%;OR 1.03, 95% CI 0.95-1.12) outcomes. DISCUSSION/SIGNIFICANCE: The associations between PPI use and severe COVID-19 outcomes that have been previously reported may be due to limitations in the covariates available for adjustment. With respect to COVID-19, our robust PS-weighted analysis provides patients and providers with further evidence for PPI safety.
Optimizing needleless connector hub disinfection practice is a key strategy in central-line–associated bloodstream infection (CLABSI) prevention. In this mixed-methods evaluation, 3 products with varying scrub times were tested for experimental disinfection followed by a qualitative nursing assessment of each.
Methods:
Needleless connectors were inoculated with varying concentrations of Staphylococcus epidermidis, Pseudomonas aeruginosa, and Staphylococcus aureus followed by disinfection with a 70% isopropyl alcohol (IPA) wipe (a 15-second scrub time and a 15-second dry time), a 70% IPA cap (a 10-second scrub time and a 5-second dry time), or a 3.15% chlorhexidine gluconate with 70% IPA (CHG/IPA) wipe (a 5-second scrub time and a 5-second dry time). Cultures of needleless connectors were obtained after disinfection to quantify bacterial reduction. This was followed by surveying a convenience sample of nursing staff with intensive care unit assignments at an academic tertiary hospital on use of each product.
Results:
All products reduced overall bacterial burden when compared to sterile water controls, however the IPA and CHG/IPA wipes were superior to the IPA caps when product efficacy was compared. Nursing staff noted improved compliance with CHG/IPA wipes compared with the IPA wipes and the IPA caps, with many preferring the lesser scrub and dry times required for disinfection.
Conclusion:
Achieving adequate bacterial disinfection of needleless connectors while maximizing healthcare staff compliance with scrub and dry times may be best achieved with a combination CHG/IPA wipe.
Moderate rotation and moderate horizontal confinement similarly enhance the heat transport in Rayleigh–Bénard convection (RBC). Here, we systematically investigate how these two types of flow stabilization together affect the heat transport. We conduct direct numerical simulations of confined-rotating RBC in a cylindrical set-up at Prandtl number $\textit {Pr}=4.38$, and various Rayleigh numbers $2\times 10^{8}\leqslant {\textit {Ra}}\leqslant 7\times 10^{9}$. Within the parameter space of rotation (given as inverse Rossby number $0\leqslant {\textit {Ro}}^{-1}\leqslant 40$) and confinement (given as height-to-diameter aspect ratio $2\leqslant \varGamma ^{-1}\leqslant 32$), we observe three heat transport maxima. At lower $ {\textit {Ra}}$, the combination of rotation and confinement can achieve larger heat transport than either rotation or confinement individually, whereas at higher $ {\textit {Ra}}$, confinement alone is most effective in enhancing the heat transport. Further, we identify two effects enhancing the heat transport: (i) the ratio of kinetic and thermal boundary layer thicknesses controlling the efficiency of Ekman pumping, and (ii) the formation of a stable domain-spanning flow for an efficient vertical transport of the heat through the bulk. Their interfering efficiencies generate the multiple heat transport maxima.
Bayesian optimization (BO) has been a successful approach to optimize expensive functions whose prior knowledge can be specified by means of a probabilistic model. Due to their expressiveness and tractable closed-form predictive distributions, Gaussian process (GP) surrogate models have been the default go-to choice when deriving BO frameworks. However, as nonparametric models, GPs offer very little in terms of interpretability and informative power when applied to model complex physical phenomena in scientific applications. In addition, the Gaussian assumption also limits the applicability of GPs to problems where the variables of interest may highly deviate from Gaussianity. In this article, we investigate an alternative modeling framework for BO which makes use of sequential Monte Carlo (SMC) to perform Bayesian inference with parametric models. We propose a BO algorithm to take advantage of SMC’s flexible posterior representations and provide methods to compensate for bias in the approximations and reduce particle degeneracy. Experimental results on simulated engineering applications in detecting water leaks and contaminant source localization are presented showing performance improvements over GP-based BO approaches.
The purpose of this study was to assess impact of different volumes of exercise as well as cumulative moderate to vigorous physical activity (MVPA) on energy intake (EI) and diet quality, as assessed by the Healthy Eating Index-2010(HEI-2010), across a 12-month weight maintenance intervention. Participants were asked to attend group behavioural sessions, eat a diet designed for weight maintenance and exercise either 150, 225 or 300 min/week. Dietary intake was assessed by 3-d food records, and MVPA was assessed by accelerometry. Two hundred and twenty-four participants (42·5 years of age, 82 % female) provided valid dietary data for at least one time point. There was no evidence of group differences in EI, total HEI-2010 score or any of the HEI-2010 component scores (all P > 0·05). After adjusting for age, sex, time, group and group-by-time interactions, there was an effect of cumulative MVPA on EI (1·08, P = 0·04), total HEI-2010 scores (–0·02, P = 0·003), Na (–0·006, P = 0·002) and empty energy scores (–0·007, P = 0·004. There was evidence of a small relationship between cumulative daily EI and weight (β: 0·00187, 95 % CI 0·001, P = 0·003). However, there was no evidence for a relationship between HEI total score (β: −0·006, 95 % CI 0·07, 0·06) or component scores (all P > 0·05) and change in weight across time. The results of this study suggest that increased cumulative MVPA is associated with clinically insignificant increases in EI and decreases in HEI.
There is evidence that the COVID-19 pandemic has negatively affected mental health, but most studies have been conducted in the general population.
Aims
To identify factors associated with mental health during the COVID-19 pandemic in individuals with pre-existing mental illness.
Method
Participants (N = 2869, 78% women, ages 18–94 years) from a UK cohort (the National Centre for Mental Health) with a history of mental illness completed a cross-sectional online survey in June to August 2020. Mental health assessments were the GAD-7 (anxiety), PHQ-9 (depression) and WHO-5 (well-being) questionnaires, and a self-report question on whether their mental health had changed during the pandemic. Regressions examined associations between mental health outcomes and hypothesised risk factors. Secondary analyses examined associations between specific mental health diagnoses and mental health.
Results
A total of 60% of participants reported that mental health had worsened during the pandemic. Younger age, difficulty accessing mental health services, low income, income affected by COVID-19, worry about COVID-19, reduced sleep and increased alcohol/drug use were associated with increased depression and anxiety symptoms and reduced well-being. Feeling socially supported by friends/family/services was associated with better mental health and well-being. Participants with a history of anxiety, depression, post-traumatic stress disorder or eating disorder were more likely to report that mental health had worsened during the pandemic than individuals without a history of these diagnoses.
Conclusions
We identified factors associated with worse mental health during the COVID-19 pandemic in individuals with pre-existing mental illness, in addition to specific groups potentially at elevated risk of poor mental health during the pandemic.
As conquest accelerated, the French military commanders rewarded Mademba’s loyalty by appointing him to the political bureau and awarding him with appointments to the Legion of Honor, even as he continued to direct the work on telegraph construction. Mademba led African auxiliaries in military engagements to assist the French military and led auxiliaries in quashing African resistance to French conquest. With the capture of Segu in 1890, Colonel Archinard instituted his model of a revived African kingdom in the form of a protectorate through the appointment of Mari Jara as ruler of Segu. Within a few weeks, the French executed Mari Jara, which resulted in another wave of African rebellions. Archinard revised his model of indirect rule to appoint only trusted and loyal Africans to rulership positions, regardless of their legitimate claims to those positions. In 1890, he appointed Bojan as ruler of Segu and in 1891, he appointed Mademba ruler of the États of Sansanding and Dependencies, a new kingdom that had not existed before.
As the investigation into the allegations of Mademba’s abuses of power and criminal acts deepened and as the scandals in France and in the Soudan reverberated throughout the French government, it became clear that no thorough investigation into Mademba could take place as long as he remained in his kingdom. Mademba was ordered to leave his kingdom and report to the capital of the colony, where he was placed under house arrest. This chapter investigates the three nested investigations into the allegations of Mademba’s abuses of power. The investigations by the district commander and the inspector-general concluded that Mademba had indeed abused his power and had acted criminally in the course of his official duties. The third investigation, ordered by the governor-general and the lieutenant-governor to assess the validity of two previous investigations, uncovered biases in the evidence and provided the senior leadership with the means to discredit the two other investigations. Despite the Minister of Colonies’ reluctance, the governor-general exonerated Mademba and released him from house arrest to return to his kingdom. The governor-general, however, appointed a European clerk from the Native Affairs Department to serve as Resident in Sinsani and to surveil Mademba’s rule more closely.
Mademba marched into his new kingdom at the head of a large entourage of his followers, prisoners of war, and their wives. Upon his arrival in his new kingdom, Mademba demanded that chiefs and notables submit to him, although the town of Sinsani and its region had never had rulers of their own. Mademba’s actions during the first year of his rule exacerbated old rivalries and resulted in a widespread revolt, which formed part of a wider set of revolts against French colonial conquest and rule throughout the Middle Niger Valley. The French attributed the revolts to Islamic conspiracies, which displaced attention from their own colonial policies. The French eventually suppressed the revolts and rescued Mademba from the siege of Sinsani. Archinard removed Bojan from the rulership of Segu, but he retained his commitment to indirect rule by appointing Aguibu as ruler of Bandiagara and reasserting Mademba as ruler of a somewhat reduced kingdom in Sinsani. The Ministry of Marine in Paris intervened to restrain continued military actions and incessant budget overruns by appointing a civilian governor in 1893.