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Background: Carbapenem-resistant Enterobacteriaceae (CRE) are endemic in the Chicago region. We assessed the regional impact of a CRE control intervention targeting high-prevalence facilities; that is, long-term acute-care hospitals (LTACHs) and ventilator-capable skilled nursing facilities (vSNFs). Methods: In July 2017, an academic–public health partnership launched a regional CRE prevention bundle: (1) identifying patient CRE status by querying Illinois’ XDRO registry and periodic point-prevalence surveys reported to public health, (2) cohorting or private rooms with contact precautions for CRE patients, (3) combining hand hygiene adherence, monitoring with general infection control education, and guidance by project coordinators and public health, and (4) daily chlorhexidine gluconate (CHG) bathing. Informed by epidemiology and modeling, we targeted LTACHs and vSNFs in a 13-mile radius from the coordinating center. Illinois mandates CRE reporting to the XDRO registry, which can also be manually queried or generate automated alerts to facilitate interfacility communication. The regional intervention promoted increased automation of alerts to hospitals. The prespecified primary outcome was incident clinical CRE culture reported to the XDRO registry in Cook County by month, analyzed by segmented regression modeling. A secondary outcome was colonization prevalence measured by serial point-prevalence surveys for carbapenemase-producing organism colonization in LTACHs and vSNFs. Results: All eligible LTACHs (n = 6) and vSNFs (n = 9) participated in the intervention. One vSNF declined CHG bathing. vSNFs that implemented CHG bathing typically bathed residents 2–3 times per week instead of daily. Overall, there were significant gaps in infection control practices, especially in vSNFs. Also, 75 Illinois hospitals adopted automated alerts (56 during the intervention period). Mean CRE incidence in Cook County decreased from 59.0 cases per month during baseline to 40.6 cases per month during intervention (P < .001). In a segmented regression model, there was an average reduction of 10.56 cases per month during the 24-month intervention period (P = .02) (Fig. 1), and an estimated 253 incident CRE cases were averted. Mean CRE incidence also decreased among the stratum of vSNF/LTACH intervention facilities (P = .03). However, evidence of ongoing CRE transmission, particularly in vSNFs, persisted, and CRE colonization prevalence remained high at intervention facilities (Table 1). Conclusions: A resource-intensive public health regional CRE intervention was implemented that included enhanced interfacility communication and targeted infection prevention. There was a significant decline in incident CRE clinical cases in Cook County, despite high persistent CRE colonization prevalence in intervention facilities. vSNFs, where understaffing or underresourcing were common and lengths of stay range from months to years, had a major prevalence challenge, underscoring the need for aggressive infection control improvements in these facilities.
Funding: The Centers for Disease Control and Prevention (SHEPheRD Contract No. 200-2011-42037)
Disclosures: M.Y.L. has received research support in the form of contributed product from OpGen and Sage Products (now part of Stryker Corporation), and has received an investigator-initiated grant from CareFusion Foundation (now part of BD).
Apolipoprotein E (APOE) E4 is the main genetic risk factor for Alzheimer’s disease (AD). Due to the consistent association, there is interest as to whether E4 influences the risk of other neurodegenerative diseases. Further, there is a constant search for other genetic biomarkers contributing to these phenotypes, such as microtubule-associated protein tau (MAPT) haplotypes. Here, participants from the Ontario Neurodegenerative Disease Research Initiative were genotyped to investigate whether the APOE E4 allele or MAPT H1 haplotype are associated with five neurodegenerative diseases: (1) AD and mild cognitive impairment (MCI), (2) amyotrophic lateral sclerosis, (3) frontotemporal dementia (FTD), (4) Parkinson’s disease, and (5) vascular cognitive impairment.
Genotypes were defined for their respective APOE allele and MAPT haplotype calls for each participant, and logistic regression analyses were performed to identify the associations with the presentations of neurodegenerative diseases.
Our work confirmed the association of the E4 allele with a dose-dependent increased presentation of AD, and an association between the E4 allele alone and MCI; however, the other four diseases were not associated with E4. Further, the APOE E2 allele was associated with decreased presentation of both AD and MCI. No associations were identified between MAPT haplotype and the neurodegenerative disease cohorts; but following subtyping of the FTD cohort, the H1 haplotype was significantly associated with progressive supranuclear palsy.
This is the first study to concurrently analyze the association of APOE isoforms and MAPT haplotypes with five neurodegenerative diseases using consistent enrollment criteria and broad phenotypic analysis.
The Yellow Chat Epthianura crocea is comprised of three disjunct subspecies. Subspecies E. c. macgregori (Capricorn Yellow Chat) is listed as Critically Endangered under the EPBC Act and has a distribution that also appears to be disjunct, with a limited geographic area of less than 7,000 ha. Some populations are threatened by rapid industrial development, and it is important for conservation of the subspecies to determine the extent to which the putative populations are connected. We used 14 microsatellite markers to measure genetic diversity and to determine the extent of gene flow between two disjunct populations at the northern and southern extremes of the subspecies’ range. No significant differences in genetic diversity (number of alleles and heterozygosity) were observed, but clear population structuring was apparent, with obvious differentiation between the northern and southern populations. The most likely explanation for reduced gene flow between the two populations is either the development of a geographic barrier as a consequence of shrinkage of the marine plains associated with the rise in sea levels following the last glacial maxima, or reduced connectivity across the largely unsuitable pasture and forest habitat that now separates the two populations, exacerbated by declining population size and fewer potential emigrants. Regardless of the mechanism, restricted gene flow between these two populations has important consequences for their ongoing conservation. The relative isolation of the smaller southern groups (the Fitzroy River delta and Curtis Island) from the much larger northern group (both sides of the Broad Sound) makes the southern population more vulnerable to local extinction. Conservation efforts should focus on nature refuge agreements with land owners agreeing to maintain favourable grazing management practices in perpetuity, particularly in the northern area where most chats occur. Supplemental exchanges of individuals from northern and southern populations should be explored as a way of increasing genetic diversity and reducing inbreeding.
The average population size of Capricorn Yellow Chat Epthianura crocea macgregori was estimated at 251 +/-31 (SE) by repeated surveys over seven years (2004–2010) using consistent search effort at known occupied sites. Because the survey period coincided with a mixture of dry and wet years (drought from 2004 to 2007 followed by flood rainfall in early 2008 and 2010), it is particularly valuable as a preliminary benchmark upon which to base management decisions. Most of the population (74.5%) was in the Broad Sound area in the north, with lower numbers in the Fitzroy River delta area in the south (22%) and at Curtis Island (3.5%). Sites on Torilla Plain in Broad Sound accounted for two-thirds of the estimated population, making it a priority for conservation efforts. Depending on habitat configuration, some Capricorn Yellow Chats showed a seasonal pattern of habitat use, moving from flooded breeding habitats as they dried to refuge sites such as salt fields or upper marine plains in the dry season; distances moved being < 10 km. Standard surveys from Torilla Plain showed that the chat count during a sequence of above-average rainfall years was almost double that of the average for drought years: 162 +/-28 (2008–2015) compared with 85 +/-15 (2004–2007) respectively. Low population size, large annual fluctuations in population with prior rainfall, rapid declines in low rainfall years, a fragmented distribution and almost half the population concentrated at one site point to a subspecies vulnerable to chance events. Increased climatic extremes predicted by climate change such as higher temperatures, evaporation rates, extended droughts and more intense rainfall events add to its vulnerability.
Increasingly, ambulance services offer alternatives to transfer to the emergency department (ED), when this is better for patients. The introduction of electronic health records (EHR) in ambulance services is encouraged by national policy across the United Kingdom (UK) but roll-out has been variable and complex.
Electronic Records in Ambulances (ERA) is a two-year study which aims to investigate and describe the opportunities and challenges of implementing EHR and associated technology in ambulances to support a safe and effective shift to out of hospital care, including the implications for workforce in terms of training, role and clinical decision-making skills.
Our study includes a scoping review of relevant issues and a baseline assessment of progress in all UK ambulance services in implementing EHR. These will inform four in-depth case studies of services at different stages of implementation, assessing current usage, and examining context.
The scoping review identified themes including: there are many perceived potential benefits of EHR, such as improved safety and remote diagnostics, but as yet little evidence of them; technical challenges to implementation may inhibit uptake and lead to increased workload in the short term; staff implementing EHR may do so selectively or devise workarounds; and EHR may be perceived as a tool of staff surveillance.
Our scoping review identified some complex issues around the implementation of EHR and the relevant challenges, opportunities and workforce implications. These will help to inform our fieldwork and subsequent data analysis in the case study sites, to begin early in 2017. Lessons learned from the experience of implementing EHR so far should inform future development of information technology in ambulance services, and help service providers to understand how best to maximize the opportunities offered by EHR to redesign care.
Because individuals develop dementia as a manifestation of neurodegenerative or neurovascular disorder, there is a need to develop reliable approaches to their identification. We are undertaking an observational study (Ontario Neurodegenerative Disease Research Initiative [ONDRI]) that includes genomics, neuroimaging, and assessments of cognition as well as language, speech, gait, retinal imaging, and eye tracking. Disorders studied include Alzheimer’s disease, amyotrophic lateral sclerosis, frontotemporal dementia, Parkinson’s disease, and vascular cognitive impairment. Data from ONDRI will be collected into the Brain-CODE database to facilitate correlative analysis. ONDRI will provide a repertoire of endophenotyped individuals that will be a unique, publicly available resource.
Dementia is a common neurological condition affecting many older individuals that leads to a loss of independence, diminished quality of life, premature mortality, caregiver burden and high levels of healthcare utilization and cost. This is an updated systematic review and meta-analysis of the worldwide prevalence and incidence of dementia.
The MEDLINE and EMBASE databases were searched for relevant studies published between 2000 (1985 for Canadian papers) and July of 2012. Papers selected for full-text review were included in the systematic review if they provided an original population-based estimate for the incidence and/or prevalence of dementia. The reference lists of included articles were also searched for additional studies. Two individuals independently performed abstract and full-text review, data extraction, and quality assessment of the papers. Random-effects models and/or meta-regression were used to generate pooled estimates by age, sex, setting (i.e., community, institution, both), diagnostic criteria utilized, location (i.e., continent) and year of data collection.
Of 16,066 abstracts screened, 707 articles were selected for full-text review. A total of 160 studies met the inclusion criteria. Among individuals 60 and over residing in the community, the pooled point and annual period prevalence estimates of dementia were 48.62 (CI95%: 41.98-56.32) and 69.07 (CI95%: 52.36-91.11) per 1000 persons, respectively. The respective pooled incidence rate (same age and setting) was 17.18 (CI95%: 13.90-21.23) per 1000 person-years, while the annual incidence proportion was 52.85 (CI95%: 33.08-84.42) per 1,000 persons. Increasing participant age was associated with a higher dementia prevalence and incidence. Annual period prevalence was higher in North America than in South America, Europe and Asia (in order of decreasing period prevalence) and higher in institutional compared to community and combined settings. Sex, diagnostic criteria (except for incidence proportion) and year of data collection were not associated with statistically significant different estimates of prevalence or incidence, though estimates were consistently higher for females than males.
Dementia is a common neurological condition in older individuals. Significant gaps in knowledge about its epidemiology were identified, particularly with regard to the incidence of dementia in low- and middle-income countries. Accurate estimates of prevalence and incidence of dementia are needed to plan for the health and social services that will be required to deal with an aging population.
The heritage of classical antiquity and in particular the status of the great Latin authors vacillated throughout the centuries, both during and since ancient times themselves: not only did particular authors rise and fall in favour, but there were even periods when the very study of the great classics went into eclipse. Interest in the Latin classics and particularly the study of the ancient Latin authors dwindled in Italy during the sixth, seventh, and eighth centuries, and it was mainly in the ninth century that a significant revival of the ancient literary curriculum based on a study of classical authors was launched.
The apogee of classical studies in medieval Italy was reached in the twelfth century. According to Otto of Freising (c.1114–58), the Lombards in the first half of the twelfth century retained ‘the elegance of the Latin language’, and Roffredo da Benevento (c.1170–c.1243) referred to the flourishing state of Latin literary study in Arezzo at the turn of the thirteenth century. A striking literary text written in twelfth-century Italy is Henry of Settimello's (fl. c.1190) famous Elegy, the most significant piece of classicizing Latin poetry composed in Italy before Lovato Lovati (1241–1309) and the emergence of Paduan humanism. It shows the direct influence of Ovid's poetry of exile and echoes of Virgil and Horace are evident; there are numerous references to the classical world, while biblical allusions are rare, and Henry's Stoic philosophy was possibly stimulated by Seneca. Henry was drawn to the classicizing French Latin poets of the twelfth century, such as Walter of Châtillon (1135–1204), Alan of Lille (1116–1202), and Matthew of Vendôme (second half of twelfth century), whose verse techniques and stylistic eccentricities he appropriated.
The clearest direct evidence of the trend is the survival of classical Latin authors used as schoolbooks. In a survey published in 2001, it was possible to identify forty-one Italian manuscript texts of classical authors used as schoolbooks and produced in Italy during the twelfth century and now housed in Florentine libraries, but of course they do not all originate from Florence or even Tuscany. The strong presence of Latin classical authors in twelfth-century Italy, as revealed by the Florentine census, was further confirmed by a continuing survey outside Florence. In 2006 a subsequent publication identified 127 Italian-copied manuscripts of classical Latin authors produced or used as schoolbooks in twelfth-century Italy and now housed outside Florence.
Florentine society was highly literate in the later Middle Ages. Writing at the end of the 1330s, Giovanni Villani (c.1275–1348) provided the following statistics of children attending school in the city of Florence: ‘We find that there are eight to ten thousand boys and girls at reading school; between a thousand and twelve hundred boys at six abacus schools; and five hundred and fifty to six hundred learning grammar and logic in four large schools.’ According to one interpretation, this estimate suggests that the male schooling rate in Florence was between 67 to 83 per cent. The accuracy of Villani's figures has been doubted, but in fact they tally with the picture of literacy disclosed by the Florentine tax records (catasto) of 1427.
Mass literacy, as suggested by Villani and confirmed by the Florentine catasto, was the product of a highly developed education system and syllabus. In later medieval Florence there were three types of schools for pre-university education. The first step was basic reading, taught in elementary schools by teachers normally called doctores puerorum (teachers of boys); this skill was always acquired through the medium of the Latin language. For pupils who continued in formal education, the next stage was the continued study of Latin at a grammar school (grammar was a synonym for Latin, and was normally used in that sense by Dante). An alternative syllabus focused on elementary arithmetic, known as abaco or abbaco, involving not the instrument for calculation now known as the abacus (by the beginning of the thirteenth century, abacus was a synonym for arithmetic), but rather consisting of a course, beginning with elementary arithmetic and culminating in basic commercial knowledge; the abacus was taught entirely in the vernacular. The first abacus teachers began to appear in Florence and Tuscany in the late 1270s; there is no evidence, however, that Dante attended an abacus school, and so this form of education will not be further considered here. Writing was taught after elementary reading by doctores puerorum, grammar masters, and abacus teachers.
Elementary reading and writing
The first textbooks were usually called tabula or carta, salterium, and donatus. Tabula or carta was a sheet of parchment or paper that began with the alphabet and concluded with syllables to sound out; it was fixed on a wooden board and took its name either from the parchment or paper (carta) or from the board (tabula).