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To validate a system to detect ventilator associated events (VAEs) autonomously and in real time.
Retrospective review of ventilated patients using a secure informatics platform to identify VAEs (ie, automated surveillance) compared to surveillance by infection control (IC) staff (ie, manual surveillance), including development and validation cohorts.
The Massachusetts General Hospital, a tertiary-care academic health center, during January–March 2015 (development cohort) and January–March 2016 (validation cohort).
Ventilated patients in 4 intensive care units.
The automated process included (1) analysis of physiologic data to detect increases in positive end-expiratory pressure (PEEP) and fraction of inspired oxygen (FiO2); (2) querying the electronic health record (EHR) for leukopenia or leukocytosis and antibiotic initiation data; and (3) retrieval and interpretation of microbiology reports. The cohorts were evaluated as follows: (1) manual surveillance by IC staff with independent chart review; (2) automated surveillance detection of ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and possible VAP (PVAP); (3) senior IC staff adjudicated manual surveillance–automated surveillance discordance. Outcomes included sensitivity, specificity, positive predictive value (PPV), and manual surveillance detection errors. Errors detected during the development cohort resulted in algorithm updates applied to the validation cohort.
In the development cohort, there were 1,325 admissions, 479 ventilated patients, 2,539 ventilator days, and 47 VAEs. In the validation cohort, there were 1,234 admissions, 431 ventilated patients, 2,604 ventilator days, and 56 VAEs. With manual surveillance, in the development cohort, sensitivity was 40%, specificity was 98%, and PPV was 70%. In the validation cohort, sensitivity was 71%, specificity was 98%, and PPV was 87%. With automated surveillance, in the development cohort, sensitivity was 100%, specificity was 100%, and PPV was 100%. In the validation cohort, sensitivity was 85%, specificity was 99%, and PPV was 100%. Manual surveillance detection errors included missed detections, misclassifications, and false detections.
Manual surveillance is vulnerable to human error. Automated surveillance is more accurate and more efficient for VAE surveillance.
Genome assemblies can form the basis of comparative analyses fostering insight into the evolutionary genetics of a parasite's pathogenicity, host–pathogen interactions, environmental constraints and invasion biology; however, the length and complexity of many parasite genomes has hampered the development of well-resolved assemblies. In order to improve Trichinella genome assemblies, the genome of the sylvatic encapsulated species Trichinella murrelli was sequenced using third-generation, long-read technology and, using syntenic comparisons, scaffolded to a reference genome assembly of Trichinella spiralis, markedly improving both. A high-quality draft assembly for T. murrelli was achieved that totalled 63·2 Mbp, half of which was condensed into 26 contigs each longer than 571 000 bp. When compared with previous assemblies for parasites in the genus, ours required 10-fold fewer contigs, which were five times longer, on average. Better assembly across repetitive regions also enabled resolution of 8 Mbp of previously indeterminate sequence. Furthermore, syntenic comparisons identified widespread scaffold misassemblies in the T. spiralis reference genome. The two new assemblies, organized for the first time into three chromosomal scaffolds, will be valuable resources for future studies linking phenotypic traits within each species to their underlying genetic bases.
We aimed to compare the procedural and mid-term performance of a specifically designed self-expanding stent with balloon-expandable stents in patients undergoing hybrid palliation for hypoplastic left heart syndrome and its variants.
The lack of specifically designed stents has led to off-label use of coronary, biliary, or peripheral stents in the neonatal ductus arteriosus. Recently, a self-expanding stent, specifically designed for use in hypoplastic left heart syndrome, has become available.
We carried out a retrospective cohort comparison of 69 neonates who underwent hybrid ductal stenting with balloon-expandable and self-expanding stents from December, 2005 to July, 2014.
In total, 43 balloon-expandable stents were implanted in 41 neonates and more recently 47 self-expanding stents in 28 neonates. In the balloon-expandable stents group, stent-related complications occurred in nine patients (22%), compared with one patient in the self-expanding stent group (4%). During follow-up, percutaneous re-intervention related to the ductal stent was performed in five patients (17%) in the balloon-expandable stent group and seven patients (28%) in self-expanding stents group.
Hybrid ductal stenting with self-expanding stents produced favourable results when compared with the results obtained with balloon-expandable stents. Immediate additional interventions and follow-up re-interventions were similar in both groups with complications more common in those with balloon-expandable stents.
Theoretical models predict that plant interactions with free-living soil microbes, pathogens and fungal symbionts are regulated by nutrient availability. Working along a steep natural gradient of soil fertility in a Costa Rican tropical dry forest, we examined how soil nutrients affect plant–microbe interactions using two complementary approaches. First, we measured mycorrhizal colonization of roots and soil P availability in 18 permanent plots spanning the soil fertility gradient. We measured root production, root colonization by mycorrhizal fungi, phosphatase activity and Bray P in each of 144 soil cores. Next, in a full-factorial manipulation of soil type and microbial community origin, tree seedlings of Albizia guachapele and Swietenia macrophylla were grown in sterilized high-, intermediate- and low-fertility soils paired with microbial inoculum from each soil type. Seedling growth, biomass allocation and root colonization by mycorrhizas were quantified after 2 mo. In the field, root colonization by mycorrhizal fungi was unrelated to soil phosphorus across a five-fold gradient of P availability. In the shadehouse, inoculation with soil microbes had either neutral or positive effects on plant growth, suggesting that positive effects of mycorrhizal symbionts outweighed negative effects of soil pathogens. The presence of soil microbes had a greater effect on plant biomass than variation in soil nutrient concentrations (although both effects were modest), and plant responses to mycorrhizal inoculation were not dependent on soil nutrients. Taken together, our results emphasize that soil microbial communities can influence plant growth and morphology independently of soil fertility.
We connect known results about diffusion limits of Markov chain Monte Carlo (MCMC) algorithms to the computer science notion of algorithm complexity. Our main result states that any weak limit of a Markov process implies a corresponding complexity bound (in an appropriate metric). We then combine this result with previously-known MCMC diffusion limit results to prove that under appropriate assumptions, the random-walk Metropolis algorithm in d dimensions takes O(d) iterations to converge to stationarity, while the Metropolis-adjusted Langevin algorithm takes O(d1/3) iterations to converge to stationarity.
Photodissociation regions (PDRs) and shocks give rise to conspicuous emission from rotationally and vibrationally excited molecular hydrogen. This line emission has now been studied with ISO and from the ground in great detail. A remarkable discovery has been that toward the Orion outflow and other shock-excited regions, the H2 level populations show a very high excitation component. We suggest that these high-excitation populations may arise from non-thermal pumping processes, such as H2 formation and high-velocity ion-molecule collision in partially dissociative shocks. In PDRs such as NGC 7023 however, formation pumping is always less important than fluorescent pumping.
We furthermore present two HD emission line detections toward Orion Peak 1. This enables the first comparison of the H2 and the HD excitation, which surprisingly turn out to be identical.
To report the International Nosocomial Infection Control Consortium surveillance data from 40 hospitals (20 cities) in India 2004–2013.
Surveillance using US National Healthcare Safety Network’s criteria and definitions, and International Nosocomial Infection Control Consortium methodology.
We collected data from 236,700 ICU patients for 970,713 bed-days
Pooled device-associated healthcare-associated infection rates for adult and pediatric ICUs were 5.1 central line–associated bloodstream infections (CLABSIs)/1,000 central line–days, 9.4 cases of ventilator-associated pneumonia (VAPs)/1,000 mechanical ventilator–days, and 2.1 catheter-associated urinary tract infections/1,000 urinary catheter–days
In neonatal ICUs (NICUs) pooled rates were 36.2 CLABSIs/1,000 central line–days and 1.9 VAPs/1,000 mechanical ventilator–days
Extra length of stay in adult and pediatric ICUs was 9.5 for CLABSI, 9.1 for VAP, and 10.0 for catheter-associated urinary tract infections. Extra length of stay in NICUs was 14.7 for CLABSI and 38.7 for VAP
Crude extra mortality was 16.3% for CLABSI, 22.7% for VAP, and 6.6% for catheter-associated urinary tract infections in adult and pediatric ICUs, and 1.2% for CLABSI and 8.3% for VAP in NICUs
Pooled device use ratios were 0.21 for mechanical ventilator, 0.39 for central line, and 0.53 for urinary catheter in adult and pediatric ICUs; and 0.07 for mechanical ventilator and 0.06 for central line in NICUs.
Despite a lower device use ratio in our ICUs, our device-associated healthcare-associated infection rates are higher than National Healthcare Safety Network, but lower than International Nosocomial Infection Control Consortium Report.
Infect. Control Hosp. Epidemiol. 2016;37(2):172–181
The North American opossum (Didelphis virginiana) is the definitive host for at least three named species of Sarcocystis: Sarcocystis falcatula, Sarcocystis neurona and Sarcocystis speeri. The South American opossums (Didelphis albiventris, Didelphis marsupialis and Didelphis aurita) are definitive hosts for S. falcatula and S. lindsayi. The sporocysts of these Sarcocystis species are similar morphologically. They are also not easily distinguished genetically because of the difficulties of DNA extraction from sporocysts and availability of distinguishing genetic markers. Some of these species can be distinguished by bioassay; S. neurona and S. speeri are infective to gamma interferon gene knockout (KO) mice, but not to budgerigars (Melopsittacus undulatus); whereas S. falcatula and S. lindsayi are infective to budgerigars but not to KO mice. The natural intermediate host of S. speeri is unknown. In the present study, development of sarcocysts of S. speeri in the KO mice is described. Sarcocysts were first seen at 12 days post-inoculation (p.i.), and they became macroscopic (up to 4 mm long) by 25 days p.i. The structure of the sarcocyst wall did not change from the time bradyzoites had formed at 50–220 days p.i. Sarcocysts contained unique villar protrusions, ‘type 38’. The polymerase chain reaction amplifications and sequences analysis of three nuclear loci (18S rRNA, 28S rRNA and ITS1) and two mitochondrial loci (cox1 and cytb) of S. speeri isolate from an Argentinean opossum (D. albiventris) confirmed its membership among species of Sarcocystis and indicated an especially close relationship to another parasite in this genus that employs opossums as its definitive host, S. neurona. These results should be useful in finding natural intermediate host of S. speeri.
This short note investigates convergence of adaptive Markov chain Monte Carlo algorithms, i.e. algorithms which modify the Markov chain update probabilities on the fly. We focus on the containment condition introduced Roberts and Rosenthal (2007). We show that if the containment condition is not
satisfied, then the algorithm will perform very poorly. Specifically, with positive probability, the adaptive algorithm will be asymptotically less efficient then any nonadaptive ergodic MCMC algorithm. We call such algorithms AdapFail, and conclude that they should not be used.
Transmission of pathogens between domestic and wild life animals plays an important role in epidemiology. Feral pig populations are increasing and expanding in the USA, and may constitute a risk to non-biosecure domestic pig facilities by serving as reservoirs for pathogens. We surveyed, for Sarcocystis infection, the myocardium of 1006 feral pigs (Sus scrofa) trapped or hunted in 29 states during the Comprehensive Feral Swine Disease Surveillance Program of the USDA's Animal and Plant Health Inspection Service, Wildlife Services unit during 2012–2014. Sarcocysts were detected in histological sections of 25% (251/1006) of myocardium with an average parasitic load/intensity of infection of 3·03 sarcocysts/section (1·5×0·7 cm), and higher prevalence of myocarditis in severe infections. Microscopic examination of pepsin digests of 147 hearts revealed a higher prevalence of Sarcocystis bradyzoites (49%, 72/147) than when diagnosed by histology. A fragment of Sarcocystis 18S rRNA was amplified and digested with a restriction endonuclease, revealing a pattern consistent with Sarcocystis miescheriana in all 44 selected samples. Sequencing 31 of these 44 isolates confirmed their correspondence to S. miescheriana. Thus, S. miescheriana infection, but not the zoonotic parasite Sarcocystis suihominis, appears to be prevalent and widespread in feral pigs in the USA.
We consider Markov chain Monte Carlo algorithms which combine Gibbs updates with Metropolis-Hastings updates, resulting in a conditional Metropolis-Hastings sampler (CMH sampler). We develop conditions under which the CMH sampler will be geometrically or uniformly ergodic. We illustrate our results by analysing a CMH sampler used for drawing Bayesian inferences about the entire sample path of a diffusion process, based only upon discrete observations.
In the United States, hypertrophic cardiomyopathy and coronary artery anomalies account for the leading two causes of sudden death in athletes. We present a case of a patient with an anomalous origin of the left main from the right coronary sinus with associated gene-confirmed hypertrophic cardiomyopathy. The patient underwent surgical repair with unroofing of the intramural portion of the left main coronary artery with a good result. We also review the reported cases in the medical literature describing this uncommon association between anomalous coronary artery origin and hypertrophic cardiomyopathy.
Food storage is a crucial adaptation for hunter-gatherers who face seasonal resource shortfalls, but the extra time that hunter-gatherer s must spend accumulating food surpluses has the potential to conflict with the time they need for other activities during seasons of abundance. Since the activities that conflict with storage may be different for women and men, it is important to consider which gender is responsible for storage. We argue that when women perform most storage tasks, the tradeoff between foraging and childcare is likely to shape storage behavior, particularly the decision of which foods to store. Our analysis of storage food preferences among the prehistoric hunter-gatherers of California’s Sierra Nevada suggests that women altered their storage strategy during the late Holocene when the shift to a semi-sedentary settlement system increased the conflict they faced between foraging and providing childcare. The adoption of an acorn-based storage economy during this period allowed women to minimize the time they spent foraging away from their residential bases, so they could better accommodate their childcare needs. This study demonstrates the utility of considering issues beyond the rate of caloric return from foraging to develop more complete models of hunter-gatherer behavior and explanations of the archaeological record.
Eighty-two hospitals of 66 cities in 30 countries (Argentina, Brazil, Colombia, Cuba, Dominican Republic, Egypt, Greece, India, Kosovo, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Poland, Salvador, Saudi Arabia, Serbia, Singapore, Slovakia, Sudan, Thailand, Turkey, Uruguay, and Vietnam) from 4 continents (America, Asia, Africa, and Europe).
Patients undergoing surgical procedures (SPs) from January 2005 to December 2010.
Data were gathered and recorded from patients hospitalized in INICC member hospitals by using the methods and definitions of the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) for SSI. SPs were classified into 31 types according to International Classification of Diseases, Ninth Revision, criteria.
We gathered data from 7,523 SSIs associated with 260,973 SPs. SSI rates were significantly higher for most SPs in INICC hospitals compared with CDC-NHSN data, including the rates of SSI after hip prosthesis (2.6% vs 1.3%; relative risk [RR], 2.06 [95% confidence interval (CI), 1.8–2.4]; P<.001), coronary bypass with chest and donor incision (4.5% vs 2.9%; RR, 1.52 [95% CI, 1.4–1.6]; P<.001); abdominal hysterectomy (2.7% vs 1.6%; RR, 1.66 [95% CI, 1.4–2.0]; P<.001); exploratory abdominal surgery (4.1 % vs 2.0%; RR, 2.05 [95% CI, 1.6–2.6]; P<.001); ventricular shunt, 12.9% vs 5.6% (RR, 2.3 [95% CI, 1.9–2.6]; P<.001), and others.
SSI rates were higher for most SPs in INICC hospitals compared with CDC-NHSN data.
To assess the feasibility and effectiveness of the International Nosocomial Infection Control Consortium (INICC) multi-dimensional hand hygiene approach in 19 limited-resource countries and to analyze predictors of poor hand hygiene compliance.
An observational, prospective, cohort, interventional, before-and-after study from April 1999 through December 2011. The study was divided into 2 periods: a 3-month baseline period and a 7-year follow-up period.
Ninety-nine intensive care unit (ICU) members of the INICC in Argentina, Brazil, China, Colombia, Costa Rica, Cuba, El Salvador, Greece, India, Lebanon, Lithuania, Macedonia, Mexico, Pakistan, Panama, Peru, Philippines, Poland, and Turkey.
Healthcare workers at 99 ICU members of the INICC.
A multidimensional hand hygiene approach was used, including (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance, and (6) performance feedback. Observations were made for hand hygiene compliance in each ICU, during randomly selected 30-minute periods.
A total of 149,727 opportunities for hand hygiene were observed. Overall hand hygiene compliance increased from 48.3% to 71.4% (P < .01). Univariate analysis indicated that several variables were significantly associated with poor hand hygiene compliance, including males versus females (63% vs 70%; P<.001), physicians versus nurses (62% vs 72%; P<.001), and adult versus neonatal ICUs (67% vs 81%; P<.001), among others.
Adherence to hand hygiene increased by 48% with the INICC approach. Specific programs directed to improve hand hygiene for variables found to be predictors of poor hand hygiene compliance should be implemented.
We report on the effect of the International Nosocomial Infection Control Consortium's (INICC) multidimensional approach for the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 21 intensive-care units (ICUs), from 14 hospitals in 10 Indian cities. A quasi-experimental study was conducted, which was divided into baseline and intervention periods. During baseline, prospective surveillance of VAP was performed applying the Centers for Disease Control and Prevention/National Healthcare Safety Network definitions and INICC methods. During intervention, our approach in each ICU included a bundle of interventions, education, outcome and process surveillance, and feedback of VAP rates and performance. Crude stratified rates were calculated, and by using random-effects Poisson regression to allow for clustering by ICU, the incidence rate ratio for each time period compared with the 3-month baseline was determined. The VAP rate was 17·43/1000 mechanical ventilator days during baseline, and 10·81 for intervention, showing a 38% VAP rate reduction (relative risk 0·62, 95% confidence interval 0·5–0·78, P = 0·0001).
Extracorporeal cardiopulmonary resuscitation may be defined as the use of extracorporeal membrane oxygenation for the support of patients who do not respond to conventional cardiopulmonary resuscitation. Data from national and international paediatric databases indicate that the use of extracorporeal cardiopulmonary resuscitation is increasing. Guidelines from the American Heart Association suggest that any patient with refractory cardiopulmonary resuscitation and potentially reversible causes of cardiac arrest is a candidate for extracorporeal cardiopulmonary resuscitation. One possible framework for selection of patients for extracorporeal cardiopulmonary resuscitation includes dividing patients on the basis of favourable or unfavourable characteristics. Favourable characteristics include cardiac disease, witnessed event in the intensive care unit, ability to deliver effective cardiopulmonary resuscitation, active patient monitoring present, favourable arterial blood gases, and early institution of extracorporeal membrane oxygenation. Unfavourable characteristics potentially include non-cardiac disease, an unwitnessed cardiac arrest, ineffective cardiopulmonary resuscitation, and severely acidotic arterial blood gases. Considering the significant resources and cost involved in the use of extracorporeal cardiopulmonary resuscitation, its use needs to be critically examined to improve outcomes, assess neurological recovery and quality of life, and help identify populations and other factors that may help guide in the selection of patients for successful extracorporeal cardiopulmonary resuscitation.