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Background: Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, California (SHIELD OC) was a CDC-funded regional decolonization intervention from April 2017 through July 2019 involving 38 hospitals, nursing homes (NHs), and long-term acute-care hospitals (LTACHs) to reduce MDROs. Decolonization in NH and LTACHs consisted of universal antiseptic bathing with chlorhexidine (CHG) for routine bathing and showering plus nasal iodophor decolonization (Monday through Friday, twice daily every other week). Hospitals used universal CHG in ICUs and provided daily CHG and nasal iodophor to patients in contact precautions. We sought to evaluate whether decolonization reduced hospitalization and associated healthcare costs due to infections among residents of NHs participating in SHIELD compared to nonparticipating NHs. Methods: Medicaid insurer data covering NH residents in Orange County were used to calculate hospitalization rates due to a primary diagnosis of infection (counts per member quarter), hospital bed days/member-quarter, and expenditures/member quarter from the fourth quarter of 2015 to the second quarter of 2019. We used a time-series design and a segmented regression analysis to evaluate changes attributable to the SHIELD OC intervention among participating and nonparticipating NHs. Results: Across the SHIELD OC intervention period, intervention NHs experienced a 44% decrease in hospitalization rates, a 43% decrease in hospital bed days, and a 53% decrease in Medicaid expenditures when comparing the last quarter of the intervention to the baseline period (Fig. 1). These data translated to a significant downward slope, with a reduction of 4% per quarter in hospital admissions due to infection (P < .001), a reduction of 7% per quarter in hospitalization days due to infection (P < .001), and a reduction of 9% per quarter in Medicaid expenditures (P = .019) per NH resident. Conclusions: The universal CHG bathing and nasal decolonization intervention adopted by NHs in the SHIELD OC collaborative resulted in large, meaningful reductions in hospitalization events, hospitalization days, and healthcare expenditures among Medicaid-insured NH residents. The findings led CalOptima, the Medicaid provider in Orange County, California, to launch an NH incentive program that provides dedicated training and covers the cost of CHG and nasal iodophor for OC NHs that enroll.
Disclosures: Gabrielle M. Gussin, University of California, Irvine, Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.
As the IAU heads towards its second century, many changes have simultaneously transformed Astronomy and the human condition world-wide. Amid the amazing recent discoveries of exoplanets, primeval galaxies, and gravitational radiation, the human condition on Earth has become blazingly interconnected, yet beset with ever-increasing problems of over-population, pollution, and never-ending wars. Fossil-fueled global climate change has begun to yield perilous consequences. And the displacement of people from war-torn nations has reached levels not seen since World War II.
Hypertrophic cardiomyopathy has a range of clinical severity in children. Treatment options are limited, mainly on account of small patient size. Disopyramide is a sodium channel blocker with negative inotropic properties that effectively reduces left ventricular outflow tract gradients in adults with hypertrophic cardiomyopathy, but its efficacy in children is uncertain. A retrospective chart review of patients ⩽21 years of age with hypertrophic cardiomyopathy at our institution and treated with disopyramide was performed. Left ventricular outflow tract Doppler gradients before and after disopyramide initiation were compared as the primary outcome measure. Nine patients received disopyramide, with a median age of 5.6 years (range 6 days–12.9 years). The median left ventricular outflow tract Doppler gradient before initiation of disopyramide was 81 mmHg (range 30–132 mmHg); eight patients had post-initiation echocardiograms, in which the median lowest recorded Doppler gradient was 43 mmHg (range 15–100 mmHg), for a median % reduction of 58.2% (p=0.002). With median follow-up of 2.5 years, eight of nine patients were still alive, although disopyramide had been discontinued in six of the nine patients. Reasons for discontinuation included septal myomectomy (four patients), heart transplantation (one patient), and side effects (one patient). Disopyramide was effective for the relief of left ventricular outflow tract obstruction in children with hypertrophic cardiomyopathy, although longer-term data suggest that its efficacy is not sustained. In general, it was well tolerated. Further study in larger patient populations is warranted.
The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting.
A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.
A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.
Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.
Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted.
For the first time, valence electron energy-loss spectroscopy (VEELS) was applied to individual single-crystalline SnO2 nanowires to investigate the dielectric function, band gap, and optical absorption coefficient. The results are compared with data from optical techniques such as spectroscopic ellipsometry and UV-Vis, and theoretical calculations from variations of density functional theory. The data obtained agree well with the standard optical and theoretical techniques. The dielectric function and optical absorption coefficient are given up to 20 eV, which otherwise requires a synchrotron source and large single crystals via optical methods. The energy loss function is given up to 40 eV, which gives a useful comparison to previous theoretical studies in an energy range that cannot be achieved via optical measurements. The comparison gives confidence in the accuracy of this method for exploring spatially-resolved measurements in individual nanoparticles or more complex nanostructures that are otherwise difficult to measure accurately using optical techniques.
Control of glyphosate-resistant (GR) horseweed in soybean with glyphosate (900 g ai ha−1) plus saflufenacil (25 gaiha−1) has been variable. The objective of this research was to determine the effect of GR horseweed height, density, and time of day (TOD) at application on saflufenacil plus glyphosate efficacy in soybean. All experiments were completed six times during a 2 yr period (2014, 2015) in fields previously confirmed with GR horseweed. Applications from 0900 to 2100 hours provided optimal control of GR horseweed 8 WAA. Soybean yield paralleled GR horseweed control with the highest yield of 3000kgha−1 at 1500 hours, and the lowest yield of 2400kgha−1 at 0600 hours. The height and density of GR horseweed at application had minimal effect on saflufenacil efficacy. Saflufenacil provided>99% control of GR horseweed when applied to small plants and low densities; however, control decreased to 95% when>25 cm tall, and to 96% in densities>800 plants m−2 at 6 WAA due to some plant regrowth. TOD of application had a greater influence on GR horseweed control with saflufenacil than height or density. To optimize control of GR horseweed, saflufenacil should be applied during daytime hours to small plants at low densities. Optimizing GR horseweed control minimizes weed seed return and weed interference.
The control of glyphosate-resistant (GR) horseweed (Conyza canadensis) in soybean has been variable with glyphosate plus saflufenacil. The objective of this research was to determine the biologically effective rate (BER) of saflufenacil, saflufenacil mixed with glyphosate, and metribuzin mixed with saflufenacil and glyphosate applied preplant (PP) for the control of GR horseweed in no-till soybean; a study was conducted to determine each of the three treatments. For each study, seven field sites infested with GR horseweed were used over a 2-yr period (2014, 2015). Saflufenacil alone at 25 and 36 g ai ha–1 provided 90 and 95% control of GR Horseweed 8 wk after application, while the BER to achieve 98% control was outside of the treatment range tested. The saflufenacil plus glyphosate (900 g ai ha–1) BER experiment found less saflufenacil was required as 25, 34, and 47 g ha–1 provided 90, 95, and 98% control of GR horseweed respectively. The metribuzin BER experiment found 61, 261, and 572 g ha–1 was required to provide 90, 95 and 98% control of GR horseweed, respectively, mixed with saflufenacil (25 g ha–1) and glyphosate (900 g ha–1). The addition of metribuzin with the recommended rate of saflufenacil (25 g ha–1) plus glyphosate improved control and a second effective herbicide mode of action for the control of GR horseweed. The use of a threeway herbicide mixture can be an effective weed management strategy to control GR horseweed in soybean.
We examined two potentially interacting, connected pathways by which parental supportiveness during early adolescence (ages 1–13) may come to be associated with later African American young adult smoking. The first pathway is between parental supportiveness and young adult stress (age 19), with stress, in turn, predicting increased smoking at age 20. The second pathway is between supportive parenting and tumor necrosis factor (TNF) gene methylation (i.e., TNFm), a proinflammatory epitype, with low levels indicating greater inflammatory potential and forecasting increased risk for smoking in response to young adult stress. In a sample of 382 African American youth residing in rural Georgia, followed from early adolescence (age 10–11) to young adulthood (age 20), supportive parenting indirectly predicted smoking via associations with young adult stress, IE = –0.071, 95% confidence interval [–0.132, –0.010]. In addition, supportive parenting was associated with TNFm measured at age 20 (r = .177, p = .001). Further, lower TNFm was associated with a significantly steeper slope (b = 0.583, p = .003) of increased smoking in response to young adult stress compared to those with higher TNFm (b = 0.155, p = .291), indicating an indirect, amplifying role for supportive parenting via TNFm. The results suggest that supportive parenting in early adolescence may play a role in understanding the emergence of smoking in young adulthood.
In North America, terrestrial records of biodiversity and climate change that span Marine Oxygen Isotope Stage (MIS) 5 are rare. Where found, they provide insight into how the coupling of the ocean–atmosphere system is manifested in biotic and environmental records and how the biosphere responds to climate change. In 2010–2011, construction at Ziegler Reservoir near Snowmass Village, Colorado (USA) revealed a nearly continuous, lacustrine/wetland sedimentary sequence that preserved evidence of past plant communities between ~140 and 55 ka, including all of MIS 5. At an elevation of 2705 m, the Ziegler Reservoir fossil site also contained thousands of well-preserved bones of late Pleistocene megafauna, including mastodons, mammoths, ground sloths, horses, camels, deer, bison, black bear, coyotes, and bighorn sheep. In addition, the site contained more than 26,000 bones from at least 30 species of small animals including salamanders, otters, muskrats, minks, rabbits, beavers, frogs, lizards, snakes, fish, and birds. The combination of macro- and micro-vertebrates, invertebrates, terrestrial and aquatic plant macrofossils, a detailed pollen record, and a robust, directly dated stratigraphic framework shows that high-elevation ecosystems in the Rocky Mountains of Colorado are climatically sensitive and varied dramatically throughout MIS 5.
Ninety plant macrofossil taxa from the Ziegler Reservoir fossil site near Snowmass Village, Colorado, record environmental changes at high elevation (2705 m asl) in the Rocky Mountains during the Last Interglacial Period. Present-day vegetation is aspen forest (Populus tremuloides) intermixed with species of higher (Picea, Abies) and lower (Artemisia, Quercus) elevations. Stratigraphic units 4–13 contain montane forest taxa found near the site today and several species that today generally live at lower elevations within (Abies concolor, Lycopus americanus) and outside Colorado (Najas flexilis). These data suggest near-modern climatic conditions, with slightly warmer summer and winter temperatures. This montane forest period was succeeded by a shorter treeless interval (Unit 14) representing colder and/or drier conditions. In units 15–16, conifer trees reoccur but deciduous and herb taxa are lacking, suggesting a return to warmer conditions, although cooler than during the earlier forest period. Comparison of these inferred paleoclimatic changes with the site's geochronologic framework indicates that the lower interval of sustained warmth correlates with late MIS 6–early 5b (~138–94 ka), the cold interval with MIS 5b (~94–87 ka), and the uppermost cool assemblages with MIS 5a (~87–77 ka).
In two freestanding volumes, Textbook of Neural Repair and Rehabilitation provides comprehensive coverage of the science and practice of neurological rehabilitation. Revised throughout, bringing the book fully up to date, this volume, Medical Neurorehabilitation, can stand alone as a clinical handbook for neurorehabilitation. It covers the practical applications of the basic science principles presented in Volume 1, provides authoritative guidelines on the management of disabling symptoms, and describes comprehensive rehabilitation approaches for the major categories of disabling neurological disorders. New chapters have been added covering genetics in neurorehabilitation, the rehabilitation team and the economics of neurological rehabilitation, and brain stimulation, along with numerous others. Emphasizing the integration of basic and clinical knowledge, this book and its companion are edited and written by leading international authorities. Together they are an essential resource for neuroscientists and provide a foundation of the work of clinical neurorehabilitation professionals.