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Clusters of Salmonella Enteritidis cases were identified by the Minnesota Department of Health using both pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS) single nucleotide polymorphism analysis from 1 January 2015 through 31 December 2017. The median turnaround time for obtaining WGS results was 11 days longer than for PFGE (12 vs. 1 day). WGS analysis more than doubled the number of clusters compared to PFGE analysis, but reduced the total number of cases included in clusters by 34%. The median cluster size was two cases for WGS compared to four for PFGE, and the median duration of WGS clusters was 27 days shorter than PFGE clusters. While the percentage of PFGE clusters with a confirmed source (46%) was higher than WGS clusters (32%), a higher percentage of cases in clusters that were confirmed as outbreaks reported the vehicle or exposure of interest for WGS (78%) than PFGE (46%). WGS cluster size was a significant predictor of an outbreak source being confirmed. WGS data have enhanced S. Enteritidis cluster investigations in Minnesota by improving the specificity of cluster case definitions and has become an integral part of the S. Enteritidis surveillance process.
Emergency Medical Services (EMS) systems have developed protocols for prehospital activation of the cardiac catheterization laboratory for patients with suspected ST-elevation myocardial infarction (STEMI) to decrease first-medical-contact-to-balloon time (FMC2B). The rate of “false positive” prehospital activations is high. In order to decrease this rate and expedite care for patients with true STEMI, the American Heart Association (AHA; Dallas, Texas USA) developed the Mission Lifeline PreAct STEMI algorithm, which was implemented in Los Angeles County (LAC; California USA) in 2015. The hypothesis of this study was that implementation of the PreAct algorithm would increase the positive predictive value (PPV) of prehospital activation.
This is an observational pre-/post-study of the effect of the implementation of the PreAct algorithm for patients with suspected STEMI transported to one of five STEMI Receiving Centers (SRCs) within the LAC Regional System. The primary outcome was the PPV of cardiac catheterization laboratory activation for percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The secondary outcome was FMC2B.
A total of 1,877 patients were analyzed for the primary outcome in the pre-intervention period and 405 patients in the post-intervention period. There was an overall decrease in cardiac catheterization laboratory activations, from 67% in the pre-intervention period to 49% in the post-intervention period (95% CI for the difference, -14% to -22%). The overall rate of cardiac catheterization declined in post-intervention period as compared the pre-intervention period, from 34% to 30% (95% CI, for the difference -7.6% to 0.4%), but actually increased for subjects who had activation (48% versus 58%; 95% CI, 4.6%-15.0%). Implementation of the PreAct algorithm was associated with an increase in the PPV of activation for PCI or CABG from 37.9% to 48.6%. The overall odds ratio (OR) associated with the intervention was 1.4 (95% CI, 1.1-1.8). The effect of the intervention was to decrease variability between medical centers. There was no associated change in average FMC2B.
The implementation of the PreAct algorithm in the LAC EMS system was associated with an overall increase in the PPV of cardiac catheterization laboratory activation.
Rumen sensors provide specific information to help understand rumen functioning in relation to health disorders and to assist in decision-making for farm management. This review focuses on the use of rumen sensors to measure ruminal pH and discusses variation in pH in both time and location, pH-associated disorders and data analysis methods to summarize and interpret rumen pH data. Discussion on the use of rumen sensors to measure redox potential as an indication of the fermentation processes is also included. Acids may accumulate and reduce ruminal pH if acid removal from the rumen and rumen buffering cannot keep pace with their production. The complexity of the factors involved, combined with the interactions between the rumen and the host that ultimately determine ruminal pH, results in large variation among animals in their pH response to dietary or other changes. Although ruminal pH and pH dynamics only partially explain the typical symptoms of acidosis, it remains a main indicator and may assist to optimize rumen function. Rumen pH sensors allow continuous monitoring of pH and of diurnal variation in pH in individual animals. Substantial drift of non-retrievable rumen pH sensors, and the difficulty to calibrate these sensors, limits their application. Significant within-day variation in ruminal pH is frequently observed, and large distinct differences in pH between locations in the rumen occur. The magnitude of pH differences between locations appears to be diet dependent. Universal application of fixed conversion factors to correct for absolute pH differences between locations should be avoided. Rumen sensors provide high-resolution kinetics of pH and a vast amount of data. Commonly reported pH characteristics include mean and minimum pH, but these do not properly reflect severity of pH depression. The area under the pH × time curve integrates both duration and extent of pH depression. The use of this characteristic, as well as summarizing parameters obtained from fitting equations to cumulative pH data, is recommended to identify pH variation in relation to acidosis. Some rumen sensors can also measure the redox potential. This measurement helps to understand rumen functioning, as the redox potential of rumen fluid directly reflects the microbial intracellular redox balance status and impacts fermentative activity of rumen microorganisms. Taken together, proper assessment and interpretation of data generated by rumen sensors requires consideration of their limitations under various conditions.
We employ global input–output analysis to quantify amplification of exogenous disturbances in compressible boundary layer flows. Using the spatial structure of the dominant response to time-periodic inputs, we explain the origin of steady reattachment streaks in a hypersonic flow over a compression ramp. Our analysis of the laminar shock–boundary layer interaction reveals that the streaks arise from a preferential amplification of upstream counter-rotating vortical perturbations with a specific spanwise wavelength. These streaks are associated with heat-flux striations at the wall near flow reattachment and they can trigger transition to turbulence. The streak wavelength predicted by our analysis compares favourably with observations from two different hypersonic compression ramp experiments. Furthermore, our analysis of inviscid transport equations demonstrates that base-flow deceleration contributes to the amplification of streamwise velocity and that the baroclinic effects are responsible for the production of streamwise vorticity. Finally, the appearance of the temperature streaks near reattachment is triggered by the growth of streamwise velocity and streamwise vorticity perturbations as well as by the amplification of upstream temperature perturbations by the reattachment shock.
Currently no national guidelines exist for the management of scabies outbreaks in residential or nursing care homes for the elderly in the United Kingdom. In this setting, diagnosis and treatment of scabies outbreaks is often delayed and optimal drug treatment, environmental control measures and even outcome measures are unclear. We undertook a systematic review to establish the efficacy of outbreak management interventions and determine evidence-based recommendations. Four electronic databases were searched for relevant studies, which were assessed using a quality assessment tool drawing on STROBE guidelines to describe the quality of observational data. Nineteen outbreak reports were identified, describing both drug treatment and environmental management measures. The quality of data was poor; none reported all outcome measures and only four described symptom relief measures. We were unable to make definitive evidence-based recommendations. We draw on the results to propose a framework for data collection in future observational studies of scabies outbreaks. While high-quality randomised controlled trials are needed to determine optimal drug treatment, evidence on environmental measures will need augmentation through other literature studies. The quality assessment tool designed is a useful resource for reporting of outcome measures including patient-reported measures in future outbreaks.
Background: Patients presenting to the Emergency Department (ED) with unmet palliative care needs are often admitted to hospital and this can be a pivotal point in their subsequent health care journey. Literature from the United States supports the integration of palliative care resources in the ED and to our knowledge, this has yet to be done in a Canadian setting. Aim Statement: To develop, implement, and evaluate a model to support patients presenting to the ED with unmet palliative care needs. Measures & Design: A pilot project was implemented in one campus of the ED at a tertiary care academic center in Ottawa, Ontario. A palliative care nurse specialist was available for consultation with goals to: a) reduce admission to hospital for patients choosing to have a palliative approach to their care; b) increase coordination between ED and community resources; and c) be a resource for ED staff. Referral criteria were developed after systematic review of the literature and in consultation with palliative and emergency medicine experts. Evaluation/Results: Over the course of the study period (9 months), 50 referrals were made. The primary reason for referral was for increased community supports. Patient outcomes: 10 patients were discharged to hospice/palliative care units from the ED, 38 patients were discharged home. Of those discharged home, 66% had no returns to ED within 30 days. Qualitative feedback collected via pre and post survey has been extremely supportive from ED health care practitioners and community palliative care providers. Discussion/Impact: This ongoing project has led to positive, patient centered outcomes and decreased admission to acute care hospital. Ongoing evaluation will include consideration of Ontario Palliative Care Network quality indicators and cost-analysis to determine impact on health care system.
During the summer of 2016, the Hawaii Department of Health responded to the second-largest domestic foodborne hepatitis A virus (HAV) outbreak in the post-vaccine era. The epidemiological investigation included case finding and investigation, sequencing of RNA positive clinical specimens, product trace-back and virologic testing and sequencing of HAV RNA from the product. Additionally, an online survey open to all Hawaii residents was conducted to estimate baseline commercial food consumption. We identified 292 confirmed HAV cases, of whom 11 (4%) were possible secondary cases. Seventy-four (25%) were hospitalised and there were two deaths. Among all cases, 94% reported eating at Oahu or Kauai Island branches of Restaurant Chain A, with 86% of those cases reporting raw scallop consumption. In contrast, a food consumption survey conducted during the outbreak indicated 25% of Oahu residents patronised Restaurant Chain A in the 7 weeks before the survey. Product trace-back revealed a single distributor that supplied scallops imported from the Philippines to Restaurant Chain A. Recovery, amplification and sequence comparison of HAV recovered from scallops revealed viral sequences matching those from case-patients. Removal of product from implicated restaurants and vaccination of those potentially exposed led to the cessation of the outbreak. This outbreak further highlights the need for improved imported food safety.
Background: Unwanted, intrusive thoughts of infant-related harm are a normal, albeit distressing experience for most new mothers. The occurrence of these thoughts can represent a risk factor for the development of obsessive compulsive disorder (OCD). As the early postpartum period represents a time of increased risk for OCD development, the transition to parenthood provides a unique opportunity to better understand OCD development. Aims: The purpose of this study was to assess components of cognitive behavioural conceptualizations of postpartum OCD in relation to new mothers’ thoughts of infant-related harm. Method: English-speaking pregnant women (n = 100) participated. Questionnaires were completed at approximately 36 weeks of gestation, and at 4 and 12 weeks postpartum. An interview to assess postpartum harm thoughts was administered at 4 and 12 weeks postpartum. Questionnaires assessed OC symptoms, OC-related beliefs, fatigue, sleep difficulties and negative mood. Results: Prenatal OC-related beliefs predicted postpartum OC symptoms, as well as harm thought characteristics and behavioural responses to harm thoughts. The severity of behavioural responses to early postpartum harm thoughts did not predict later postpartum OC symptoms, but did predict frequency and time occupation of accidental harm thoughts, and interference in parenting by intentional harm thoughts. Strong relationships between OC symptoms and harm thought characteristics, and concurrent sleep difficulties, negative mood and fatigue were also found. Conclusions: Findings provide support for cognitive behavioural conceptualizations of postpartum OCD and emphasize the importance of maternal sleep, fatigue and negative mood in the relationship between OC-related beliefs and maternal cognitive and behavioural responses to postpartum harm thoughts.
On 27 April 2015, Washington health authorities identified Escherichia coli O157:H7 infections associated with dairy education school field trips held in a barn 20–24 April. Investigation objectives were to determine the magnitude of the outbreak, identify the source of infection, prevent secondary illness transmission and develop recommendations to prevent future outbreaks. Case-finding, hypothesis generating interviews, environmental site visits and a case–control study were conducted. Parents and children were interviewed regarding event activities. Odds ratios (OR) and 95% confidence intervals (CI) were computed. Environmental testing was conducted in the barn; isolates were compared to patient isolates using pulsed-field gel electrophoresis (PFGE). Sixty people were ill, 11 (18%) were hospitalised and six (10%) developed haemolytic uremic syndrome. Ill people ranged in age from <1 year to 47 years (median: 7), and 20 (33%) were female. Twenty-seven case-patients and 88 controls were enrolled in the case–control study. Among first-grade students, handwashing (i.e. soap and water, or hand sanitiser) before lunch was protective (adjusted OR 0.13; 95% CI 0.02–0.88, P = 0.04). Barn samples yielded E. coli O157:H7 with PFGE patterns indistinguishable from patient isolates. This investigation provided epidemiological, laboratory and environmental evidence for a large outbreak of E. coli O157:H7 infections from exposure to a contaminated barn. The investigation highlights the often overlooked risk of infection through exposure to animal environments as well as the importance of handwashing for disease prevention. Increased education and encouragement of infection prevention measures, such as handwashing, can prevent illness.
We investigated the extent to which second-language (L2) learning is influenced by the similarity of grammatical features in one's first language (L1). We used event-related potentials to identify neural signatures of a novel grammatical rule – grammatical gender – in L1 English speakers. Of interest was whether individual differences in L2 proficiency and age of acquisition (AoA) influenced these effects. L2 and native speakers of French read French sentences that were grammatically correct, or contained either a grammatical gender or word order violation. Proficiency and AoA predicted Left Anterior Negativity amplitude, with structure violations driving the proficiency effect and gender violations driving the AoA effect. Proficiency, group, and AoA predicted P600 amplitude for gender violations but not structure violations. Different effects of grammatical gender and structure violations indicate that L2 speakers engage novel grammatical processes differently from L1 speakers and that this varies appreciably based on both AoA and proficiency.
Field experiments were conducted to evaluate the integration of cover crops and POST herbicides to control glyphosate-resistant Palmer amaranth in cotton. The winter-annual grasses accumulated the greatest amount of biomass and provided the most Palmer amaranth control. The estimates for the logistic regression would indicate that 1540 kg ha−1 would delay Palmer amaranth emerging and growing to 10 cm by an estimated 16.5 days. The Palmer amaranth that emerged in the cereal rye and wheat cover crop treatments took a longer time to reach 10 cm compared to the hairy vetch and crimson clover treatments. POST herbicides were needed for adequate control of Palmer amaranth. The glufosinate-based weed control system provided greater control (75% vs 31%) of Palmer amaranth than did the glyphosate system. These results indicate that a POST only herbicide weed management system did not provide sufficient control of Palmer amaranth, even when used in conjunction with cover crops that produced a moderate level of biomass. Therefore, future recommendations for GR Palmer amaranth control will include integrating cover crops with PRE herbicides, overlaying residual herbicides in-season, timely POST herbicide applications, and hand weeding in order to achieve season-long control of this pest.
The Dark Energy Survey is undertaking an observational programme imaging 1/4 of the southern hemisphere sky with unprecedented photometric accuracy. In the process of observing millions of faint stars and galaxies to constrain the parameters of the dark energy equation of state, the Dark Energy Survey will obtain pre-discovery images of the regions surrounding an estimated 100 gamma-ray bursts over 5 yr. Once gamma-ray bursts are detected by, e.g., the Swift satellite, the DES data will be extremely useful for follow-up observations by the transient astronomy community. We describe a recently-commissioned suite of software that listens continuously for automated notices of gamma-ray burst activity, collates information from archival DES data, and disseminates relevant data products back to the community in near-real-time. Of particular importance are the opportunities that non-public DES data provide for relative photometry of the optical counterparts of gamma-ray bursts, as well as for identifying key characteristics (e.g., photometric redshifts) of potential gamma-ray burst host galaxies. We provide the functional details of the DESAlert software, and its data products, and we show sample results from the application of DESAlert to numerous previously detected gamma-ray bursts, including the possible identification of several heretofore unknown gamma-ray burst hosts.
The government publishes 3 different public report surgical site infection (SSI) metrics, all called standardized infection ratios (SIRs), that impact perceived hospital quality. We conducted a non-random cross-sectional observational pilot study of 20 California hospitals that voluntarily submitted colon surgery and SSI data. Discordant SIR values, leading to contradictory conclusions, occurred in 35% of these hospitals.
Commonly thought of as a disease of poverty and overcrowding in resource-poor settings globally, scabies is also an important public health issue in residential care facilities for the elderly (RCFE) in high-income countries such as the UK. We compared and contrasted current local Health Protection Team (HPT) guidelines for the management of scabies outbreaks in RCFE throughout England. We performed content analysis on 20 guidelines, and used this to create a quantitative report of their variation in key dimensions. Although the guidelines were generally consistent on issues such as the treatment protocols for individual patients, there was substantial variation in their recommendations regarding the prophylactic treatment of contacts, infection control measures and the roles and responsibilities of individual stakeholders. Most guidelines did not adequately address the logistical challenges associated with mass treatment in this setting. We conclude that the heterogeneous nature of the guidelines reviewed is an argument in favour of national guidelines being produced.
Dialysis is the process by which an artificial kidney device removes waste and excess water from a patient. An outstanding problem with dialysis is that the body has a remarkable immune function where proteins and antigens mark foreign objects as possible threats despite the biocompatibility of the material. Upon adhesion to polymeric materials used currently in dialysis, proteins are lost. In this study, polytetrafluoroethylene (PTFE) is investigated as a potential replacement material for dialysis tubing because of its unreactive nature. The focus is to determine if PTFE will prove a viable material in minimizing protein adhesion and further reducing antibody loss of the patient. Protein loss as a function of filtration time was measured. PVC and PTFE materials were investigated following the same battery of testing where the protein concentrations in the blood were characterized using UV Visible spectrophotometry. Results demonstrate a loss of nearly 12 percent of blood proteins to the PVC material over the course of a typical dialysis treatment. Conversely, the protein loss due to adhesion to PTFE was less than two percent.