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To integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs).
Design, Setting, and Participants
This 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015.
Phase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication.
Overall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3·85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9·06 in phase 1 to 1·65 in phase 4 (relative risk [RR], 0·182; 95% confidence interval [CI], 0·153–0·216; P<·001). New catheters per 1,000 patient days declined from 53·4 in phase 1 to 39·5 in phase 4 (RR, 0·740; 95% CI, 0·730; P<·001), and catheter days per 1,000 patient days decreased from 194·5 in phase 1 to 140·7 in phase 4 (RR, 0·723; 95% CI, 0·719–0·728; P<·001). The reinsertion rate declined from 3·66% in phase 1 to 3·25% in phase 4 (RR, 0·894; 95% CI, 0·834–0·959; P=·0017).
The phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.
The ramus communicans, neural connection between medial and lateral plantar nerves of the horse, was transected to determine the degree to which medial and lateral plantar nerves contribute to the plantar ramus. After 2 months, sections of plantar nerves immediately proximal and distal to the communicating branch were collected and processed for electron microscopy. All examined nerves had undergone Wallerian degeneration and contained regenerating and mature fibers. Layers of the myelin sheath were separated by spaces and vacuoles, indicating demyelination of medial and lateral plantar nerves. Shrunken axons varied in diameter and were surrounded by an irregular axolemma. Shrunken axoplasm of both myelinated and non-myelinated fibers contained ruptured mitochondria and cristae, disintegrating cytoskeleton, and vacuoles of various sizes. The cytoplasm of neurolemmocytes contained various-sized vesicles, ruptured mitochondria within a fragile basal lamina and myelin whorls of multilayered structures indicative of Wallerian degeneration. These ultrastructural changes, found proximal and distal to the ramus in medial and lateral plantar nerves, suggest that axonal flow is bi-directional through the ramus communicans of the pelvic limbs of horses, a previously unreported finding. As well, maturity of nerves proximal and distal to the ramus indicates that all nerve fibers do not pass through the ramus.
Retreat of Mendenhall Glacier nearJuneau, Alaska, U.S.A., has exposed a bedrock ridge spotted with “siltskins”, patchy coatings of calcite-cemented clay-to sandsized lithic grains. Coatings 0.5–20 mm thick occur in two distinct morphologies. Thin, striated siltskins coat mainly stoss faces. Thicker, corrugated siltskins on lee faces consist of parallel micro-ridges elongated downslope. Thin-section analysis shows that siltskins consist of a basal, calcite-rich layer overlain by microlaminated layers of calcite-cemented lithic grains. Scanning electron microscope (SEM) energy-dispersive spectrometer (EDS) analysis of laminae and surfaces shows laterally persistent Ca/Si differences. Isotopic values for δO18 and δO13 ranged from −19.52‰ to −12.74‰ and −6.18‰ to −3.44‰, respectively, consistent with deposition from subglacial waters of varying isotopic composition and with derivation of carbon from inorganic sources. Corrugated siltskins are complex depositional features modified by erosional processes. Parallel micro-ridges spaced 1–10 mm apparently formed as sediment-rich water dripped down lee-slope rock faces. Ice–rock separation, flow energy and the transported sediment controlled the layering and depositional forms. Siltskins probably formed when a subglacial cavity system was active on the rock ridge and provide clues about how microscale hydrologic processes interact with larger-scale subglacial systems.
The establishment of a chronology of Saint John Chrysostom's early life is beset with difficulties arising not from a lack of sources, but from a relative abundance of incomplete accounts, which sometimes contradict one another and which are of uncertain reliability. The fifth chapter of Palladius’ Dialogue is generally considered to be our most valuable source. Yet even in the use of this document some caution is advisable. Palladius knew Chrysostom during the last years of the latter's life; consequently his account of the events in Constantinople is of great value. But what were his sources for the saint's early life? Two in particular have been proposed: Chrysostom himself, and his aunt, the deaconess Sabiniana. Our own experience of human nature should warn us that a man in his late fifties or early sixties does not always remember accurately the details of his youth, and that the testimony of elderly aunts about the early years of their famous nephews is never entirely above question. Moreover, it should be remembered that Palladius’ Dialogue had an apologetic purpose.
It is increasingly essential for medical researchers to be literate in statistics, but the requisite degree of literacy is not the same for every statistical competency in translational research. Statistical competency can range from ‘fundamental’ (necessary for all) to ‘specialized’ (necessary for only some). In this study, we determine the degree to which each competency is fundamental or specialized.
We surveyed members of 4 professional organizations, targeting doctorally trained biostatisticians and epidemiologists who taught statistics to medical research learners in the past 5 years. Respondents rated 24 educational competencies on a 5-point Likert scale anchored by ‘fundamental’ and ‘specialized.’
There were 112 responses. Nineteen of 24 competencies were fundamental. The competencies considered most fundamental were assessing sources of bias and variation (95%), recognizing one’s own limits with regard to statistics (93%), identifying the strengths, and limitations of study designs (93%). The least endorsed items were meta-analysis (34%) and stopping rules (18%).
We have identified the statistical competencies needed by all medical researchers. These competencies should be considered when designing statistical curricula for medical researchers and should inform which topics are taught in graduate programs and evidence-based medicine courses where learners need to read and understand the medical research literature.
Mass-casualty (MASCAL) events are known to occur in the combat setting. There are very limited data at this time from the Joint Theater (Iraq and Afghanistan) wars specific to MASCAL events. The purpose of this report was to provide preliminary data for the development of prehospital planning and guidelines.
Cases were identified using the Department of Defense (DoD; Virginia USA) Trauma Registry (DoDTR) and the Prehospital Trauma Registry (PHTR). These cases were identified as part of a research study evaluating Tactical Combat Casualty Care (TCCC) guidelines. Cases that were designated as or associated with denoted MASCAL events were included.
Fifty subjects were identified during the course of this project. Explosives were the most common cause of injuries. There was a wide range of vital signs. Tourniquet placement and pressure dressings were the most common interventions, followed by analgesia administration. Oral transmucosal fentanyl citrate (OTFC) was the most common parenteral analgesic drug administered. Most were evacuated as “routine.” Follow-up data were available for 36 of the subjects and 97% were discharged alive.
The most common prehospital interventions were tourniquet and pressure dressing hemorrhage control, along with pain medication administration. Larger data sets are needed to guide development of MASCAL in-theater clinical practice guidelines.
SchauerSG, AprilMD, SimonE, MaddryJK, CarterR III, DelorenzoRA. Prehospital Interventions During Mass-Casualty Events in Afghanistan: A Case Analysis. Prehosp Disaster Med. 2017;32(4):465–468.
Gurga Chiya and Tepe Marani are small, adjacent mounds located close to the town of Halabja in the southern part of the Shahrizor Plain, one of the most fertile regions of Iraqi Kurdistan. Survey and excavation at these previously unexplored sites is beginning to produce evidence for human settlement spanning the sixth to the fourth millennia, c. 5600–3300 cal. b.c. In Mesopotamian chronology this corresponds to the Late Neolithic through to Chalcolithic periods; the Halaf, Ubaid, and Uruk phases of conventional culture history. In Iraqi Kurdistan, documentation of these periods—which witnessed many important transformations in prehistoric village life—is currently very thin. Here we offer a preliminary report on the emerging results from the Shahrizor Plain, with a particular focus on the description of material culture (ceramic and lithic assemblages), in order to establish a benchmark for further research. We also provide a detailed report on botanical remains and accompanying radiocarbon dates, which allow us to place this new evidence in a wider comparative framework. A further, brief account is given of Late Bronze Age material culture from the upper layers at Gurga Chiya. We conclude with observations on the significance of the Shahrizor Plain for wider research into the later prehistory of the Middle East, and the importance of preserving and investigating its archaeological record.
The voluminous writings of St. John Chrysostom reflect the influence of the important movements and controversies of the fourth century: the spread of monasticism, the final conflict between Christianity and paganism, and the struggle between Nicene orthodoxy and Arianism, which came to an end, at least in the Eastern Empire, with Theodosius the Great and the first Council of Constantinople in 381. Each of these Christian groups — monks, Arians, and Nicene orthodox — had, as George Huntston Williams has clearly shown, its own distinctive attitude towards the imperial state.
During the twentieth century scholarly attention has turned increasingly to Severian of Gabala with new attributions, editions, and commentaries. Many researchers have contributed to this dramatic growth, but three in particular have been in the forefront: J. Zellinger with his Genesishomilien and Studien, H. D. Altendorf with his Untersuchungen, and S. J. Voicu with his many contributions culminating in his magisterial article on Severian in the Dictionnaire de spiritualité, We have reached the point where an index to Severian's scriptural references may be of considerable help to researchers in identifying homilies referred to in other homilies, in determining the authorship of homilies that might be attributed to Severian, and in gaining a better general understanding of Severian's thought and the tradition in which he worked.
The Greek church of southern Italy and Sicily commemorated the temptation of Jesus on the first Sunday of Lent. Homiliaries for the liturgical year presented one or both of two homilies attributed to John Chrysostom, ‘΄ Hλι ος μὲ ν(PG 61, 683–88) and ‘Eξλθεν ò κύριος (CPG 4906). The former is now known to be a composite homily drawn from three homilies of Nestorius edited by Nau. The latter, as will be maintained later, is by Severian of Gabala.
We know the events of only five or six years in the life of Severian of Gabala, from A.D. 398 or 399 to 404. We are told that Severian was Syrian by birth and spoke Greek with a Syriac accent. His brother bishop and friend Antiochus of Ptolemais went to Constantinople, probably very soon after Chrysostom's episcopal consecration on 15 December 397 or 26 February 398, and earned a great deal of money preaching. Severian decided to follow his friend's example and went to the imperial capital in 398 or 399 to make his fortune. He was well received by Chrysostom; his preaching was evidently a great success, and he became known to many in high office as well as to the emperor Arcadius and the empress Eudoxia.
The British Archaeological Expedition to Kuwait was formed in the spring of 1998 as the result of a visit to Kuwait by Harriet Crawford in November 1997. This visit took place at the invitation of the Director of the National Museum, Dr Fahad al Wohaibi. Several possible projects were discussed and permission was later granted by the Secretary-General of the National Council for Culture, Arts and Letters for a preliminary survey by the Expedition, to be carried out jointly with a team from the National Museum of Kuwait, of the area known as as-Sabiyah at the north end of Kuwait bay (Fig. 1). The area had already been the subject of a preliminary study by Dr Fahad, who had identified one well-preserved site (H3) with both painted and plain Ubaid pottery on the surface. It was also agreed that the team should undertake exploratory work at this site. Dr Fahad's generosity in inviting a British team to work with him in the area was matched only by the kindness with which the Expedition was received in Kuwait. The achievements of the first season are due in large measure to the support offered to us by our colleagues in the National Museum and in the National Council for Culture, Arts and Letters.
The objectives of the first season, which lasted for five weeks in October and November 1998, were as follows: to begin a detailed archaeological survey of the Jazirat Dubaij, a promontory within the Sabiyah area; to conduct a preliminary examination of the geomorphology of the area in order to establish the configuration of the shoreline at a period contemporary with the Ubaid-related site now known as H3; to contour this site; to undertake a surface collection of artefacts at H3; to confirm the presence of structures at the site and to establish the depth of deposit present. All these objectives were achieved.
A third season of excavation by the joint Kuwaiti-British team took place at the Ubaid-related site of H3 in northern Kuwait during the spring of 2001. Permission to excavate was again granted by Dr al Rumayhi, Secretary General of the National Council for Culture, Arts and Letters, to whom we are most grateful. The work was only possible because of the generosity of a number of funding bodies: the NCCAL in Kuwait; the British School of Archaeology in Iraq; the Institute of Archaeology, University College London; the Charlotte Bonham-Carter Charitable Trust; the Central Research fund of London University; the Society for Arabian Studies; and, above all, Kuwait Shell, our industrial sponsor. The success of the season was due to their generosity and to the dedication and skill of all members of the two teams.
Objectives this year included the continuation of work in the multi-cellular building in Area A identified in the second season, and the uncovering of the building visible on the surface in the adjacent Area C. The multi-cellular building proved to be structurally complex and had an unexpected depth of deposit in its chambers. These deposits proved to be extremely rich in finds which will greatly enhance our understanding of the site when analyses are completed. In Area C, the new building was defined and excavated to its base although its relationship with the adjacent building(s) in Area A remains to be defined. Limited work was also carried out in the previously excavated military dug-out, or foxhole, Area F, where work was completed. Two teams worked in Area A which was subdivided this season into an east and a west sector, while a third team investigated Area C.
The fourth season of excavations at H3 at the north end of Kuwait bay took place in the spring of 2002. It is a great pleasure to express again our thanks to all those people who made it possible to continue our work at this important sixth/fifth millennium site with its mix of Arabian Gulf and Mesopotamian traits. Major financial support again came from the National Council for Culture Arts and Letters, together with Kuwait Shell without whose continuing support we would be unable to work. We are equally indebted to our colleagues at the National Museum of Kuwait and especially to Mr Shehab Abdul Hamid Shehab, Director of the Department of Antiquities and Museums, and to Mr Sultan al Darwish and his field team. Our own staff worked magnificently under conditions which were sometimes far from ideal. Without the hard work and skill of members of both the teams we would have achieved little and we thank them all. The major objectives for the 2002 season were as follows:
– to complete the plan of the major complex of rooms in Area A
– to establish the stratigraphic relationship between Areas A and C
– to establish the relationship between the buildings in Area A and the fire pit horizon in Area F (the Foxhole)
– to explore a new area, Area G, to the north of the main complex.
The stratigraphic relationships were successfully established and the plan of an additional building in Area G can now be added to the map of the site. Once again, however, it was found that the limits of the Area A complex in the east lie outside the excavated area, although the development of the structure (s) through time is now much clearer.