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Background: Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies suggest that many of these patients receive low-value interventions. Providing clinicians with their practice reports and peer comparator data or an achievable benchmark of care (audit and feedback) has been shown to be an effective strategy to improve adherence to guidelines. Aim Statement: To decrease low-value care (use of any or all of chest radiographs, viral testing and salbutamol) in infants with bronchiolitis by delivering individual physician reports in addition to Group Facilitated Feedback Sessions (GFFS) to pediatric emergency physicians (PEPs). Measures & Design: Our cohort included 3,883 patients ≤12 months old that presented to two emergency departments with a diagnosis of bronchiolitis from April 1, 2013 to April 30, 2018. Using administrative data we captured baseline characteristics and interventions. Consenting PEPs received two audit and feedback (A&F) reports which included their individual and peer comparator data. Two multi-disciplinary GFFS (including inpatient pediatricians, nurse, learners and respiratory therapists) presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention, and was analyzed using statistical process control charts. Process measures (consent to obtain report, attendance and evaluations from the feedback session) and balancing measures were also captured. Evaluation/Results: 78% of PEPs consented to receive their A&F reports. Patient baseline characteristics were similar in the baseline (n = 3109) and intervention period (n = 774). Following the baseline physician reports and the GFFS, low-value care decreased from 42.6% to 27.1% (absolute difference: -15.5%; 95% confidence interval (CI): -19.8% to -11.2%) and 78.9% to 64.4% (absolute difference: -14.5%; 95% CI: -21.9% to -7.2%) in patients who were not admitted and admitted, respectively. Balancing measures such as ICU admission (absolute difference: -0.6%; 95%CI: -5.7% to 4.4%) and ED revisit within 72 hours (absolute difference: -0.1%; 95% CI: -3.1% to 3.0% non-admitted patients, 1.0%; 95% CI: -1.2% to 3.2% admitted patients) were unchanged. Discussion/Impact: The combination of audit and feedback and a GFFS significantly reduced low-value care for pediatric patients with bronchiolitis by PEP's.
Major depression is a significant problem for people with a traumatic brain injury (TBI) and its treatment remains difficult. A promising approach to treat depression is Mindfulness-based cognitive therapy (MBCT), a relatively new therapeutic approach rooted in mindfulness based stress-reduction (MBSR) and cognitive behavioral therapy (CBT). We conducted this study to examine the effectiveness of MBCT in reducing depression symptoms among people who have a TBI.
Twenty individuals diagnosed with major depression were recruited from a rehabilitation clinic and completed the 8-week MBCT intervention. Instruments used to measure depression symptoms included: BDI-II, PHQ-9, HADS, SF-36 (Mental Health subscale), and SCL-90 (Depression subscale). They were completed at baseline and post-intervention.
All instruments indicated a statistically significant reduction in depression symptoms post-intervention (p < .05). For example, the total mean score on the BDI-II decreased from 25.2 (9.8) at baseline to 18.2 (11.7) post-intervention (p=.001). Using a PHQ threshold of 10, the proportion of participants with a diagnosis of major depression was reduced by 59% at follow-up (p=.012).
Most participants reported reductions in depression symptoms after the intervention such that many would not meet the criteria for a diagnosis of major depression. This intervention may provide an opportunity to address a debilitating aspect of TBI and could be implemented concurrently with more traditional forms of treatment, possibly enhancing their success. The next step will involve the execution of multi-site, randomized controlled trials to fully demonstrate the value of the intervention.
Traumatic brain injuries (TBI) may lead to persistent depression symptoms. We conducted several pilot studies to examine the efficacy of mindfulness-based interventions to deal with this issue; all showed strong effect sizes. The logical next step was to conduct a randomized controlled trial (RCT).
We sought to determine the efficacy of mindfulness-based cognitive therapy for people with depression symptoms post-TBI (MBCT-TBI).
Using a multi-site RCT design, participants (mean age = 47) were randomized to intervention or control arms. Treatment participants received a group-based, 10-week intervention; control participants waited. Outcome measures, administered pre- and post-intervention, and after three months, included: Beck Depression Inventory-II (BDI-II), Patient Health Questionnaire-9 (PHQ-9), and Symptom Checklist-90-Revised (SCL-90-R). The Philadelphia Mindfulness Scale (PHLMS) captured present moment awareness and acceptance.
BDI-II scores decreased from 25.47 to 18.84 in treatment groups while they stayed relatively stable in control groups (respectively 27.13 to 25.00; p = .029). We did not find statistically significant differences on the PHQ-9 and SCL-90R post- treatment. However, after three months, all scores were statistically significantly lower than at baseline (ps < .01). Increases in mindfulness were associated with decreases in BDI-II scores (r = -.401, p = .025).
MBCT-TBI may alleviate depression symptoms up to three months post-intervention. Greater mindfulness may have contributed to the reduction in depression symptoms although the association does not confirm causality. More work is required to replicate these findings, identify subgroups that may better respond to the intervention, and refine the intervention to maximize its effectiveness.
Better control of highly pathogenic avian influenza (HPAI) outbreaks requires deeper understanding of within-flock virus transmission dynamics. For such fatal diseases, daily mortality provides a proxy for disease incidence. We used the daily mortality data collected during the 2015 H5N2 HPAI outbreak in Minnesota turkey flocks to estimate the within-flock transmission rate parameter (β). The number of birds in Susceptible, Exposed, Infectious and Recovered compartments was inferred from the data and used in a generalised linear mixed model (GLMM) to estimate the parameters. Novel here was the correction of these data for normal mortality before use in the fitting process. We also used mortality threshold to determine HPAI-like mortality to improve the accuracy of estimates from the back-calculation approach. The estimated β was 3.2 (95% confidence interval (CI) 2.3–4.3) per day with a basic reproduction number of 12.8 (95% CI 9.2–17.2). Although flock-level estimates varied, the overall estimate was comparable to those from other studies. Sensitivity analyses demonstrated that the estimated β was highly sensitive to the bird-level latent period, emphasizing the need for its precise estimation. In all, for fatal poultry diseases, the back-calculation approach provides a computationally efficient means to obtain reasonable transmission parameter estimates from mortality data.
We present an age-structured mathematical model of malaria and pneumonia to study the effect of two capacity-building interventions: Integrated Management of Infectious Diseases (IMID) and On-site Support Services (OSS). IMID leads to a reduction in malaria prevalence by more than 2·4% across the [0,5), [5,14) and [14,50) age groups. IMID + OSS reduces it by more than 16·0% across all age groups. IMID decreases pneumonia prevalence by more than 3·0% across all age groups while IMID + OSS decreases it by more than 1·0% across all age groups. The number of malaria and pneumonia deaths is reduced by 7·8% by IMID across all age groups and IMID + OSS decreases this number by 30·5% across all age groups, which translates to saving a life of a child per month. Prevalence of malaria-pneumonia for the [0,5) age group is 0·52% at baseline, and IMID and IMID + OSS reduce it by 6·6% and 23·6%, respectively. There is no change in incidence of malaria or pneumonia disease episodes. The results also indicate that triaging of children contributes more than 50% to the effect of the interventions in reduction of deaths and a range of 14–91% in reduction of disease cases.
The imperfection sensitivity of cylindrical panels under compression loading is shown to be not only reduced but effectively eliminated using stiffness tailoring techniques. Shells are designed with variable angle-tow (VAT) laminae, giving their laminates variable-stiffness properties over the surface co-ordinates. By employing an asymptotic model of the non-linear shell behaviour and a genetic algorithm, the post-buckling stability was maximised with respect to the VAT design variables. Results for optimised straight-fibre and VAT shells are presented in comparison with quasi-isotropic designs. In the straight-fibre case, small improvements in the post-buckling stability are shown to be possible but at the expense of the buckling load. In the VAT case, on the other hand, considerable improvements in the post-buckling stability are obtained and drops in axial stiffness and load associated with buckling are reduced to negligible levels. The improvements are shown to be a result of a benign membrane stress distribution prior to buckling and a localisation of the buckling mode. The asymptotic results are compared with non-linear finite-element analyses and are found to be in good agreement. Potential future multi-objective optimisation studies are discussed.
Background: There are no disease modifying agents for the treatment of Alzheimer’s disease (AD). Pathologically, AD is associated with the misfolding of two peptides: beta-amyloid (plaques) and tau (tangles). Methods: Using large-scale computer simulations, we modelled the misfolding of both beta-amyloid and tau, identifying a common conformational motif (CCM; i.e. an abnormal peptide shape), present in both beta-amyloid and tau, that promotes their misfolding. We screened a library of 11.8 million compounds against this in silico model of protein misfolding, identifying three novel molecular classes of putative therapeutics as anti-protein misfolding agents. We synthesized approximately 400 new chemical entity drug-like molecules in each of these three classes (i.e. 1200 potential drug candidates). These were comprehensively screened in a battery of five in vitro protein oligomerization assays. Selected compounds were next evaluated in the APP/PS1 doubly transgenic mouse model of AD. Results: Two new classes of molecules were identified with the ability to block the oligomerization of both beta-amyloid and tau. These compounds are drug-like with good pharmacokinetic properties and are brain-penetrant. They exhibit excellent efficacy in transgenic mouse models. Conclusion: Computer aided drug design has enabled the discovery of novel drug-like molecules able to inhibit both tau and beta-amyloid misfolding.
It is important to measure the temperature of magnetic nanoparticles during hyperthermia therapy to develop safe practices. We theoretically demonstrate a method for measuring the temperature of magnetic nanoparticles using induction coils and nanoparticle magnetization harmonics. A geometrically decoupled sensing coil is described that enhances the sensitivity to small amounts of iron and also could possibly be used to eliminate sensing challenges created by the high-powered hyperthermia drive field.
Recent developments on the use of the piezoelectric effect in ZnO nanorod-based p-n junctions for energy harvesting applications are presented. Two types of junctions are used. The first is a hybrid p-n device combining the semiconducting polymer poly(3,4-ethylene-dioxythiophene) poly(styrenesulfonate) (PEDOT:PSS) with ZnO nanorods. The second type of junction is an all-inorganic junction between n-type ZnO nanorods and p-type CuSCN. It is shown that both these diodes can be produced on flexible plastic substrates, which generate a voltage output when bent. The voltage output of the ZnO/PEDOT:PSS diodes are measured across a range of resistive loads while bending to find a maximum power point of 12 μWcm-2 at 4 kΩ. It is shown that a voltage output is also generated when this structure is vibrated acoustically. The ZnO/CuSCN diode is sensitized to sunlight with a Ru-based dye to form a photovoltaic device. It is shown that the device efficiency can be increased by application of acoustic vibrations. This is attributed to the electric field generated by the piezoelectric effect in ZnO affecting the charge-carrier recombination at the ZnO surface.
We report an outbreak associated with a dinner cruise on Lake Michigan. This took place on the same day as heavy rainfall, which resulted in 42·4 billion liters of rainwater and storm runoff containing highly diluted sewage being released into the lake. Of 72 cruise participants, 41 (57%) reported gastroenteritis. Stool specimens were positive for Shigella sonnei (n=3), Giardia (n=3), and Cryptosporidium (n=2). Ice consumption was associated with illness (risk ratio 2·2, P=0·011). S. sonnei was isolated from a swab obtained from the one of the boat's ice bins. Environmental inspection revealed conditions and equipment that could have contributed to lake water contaminating the hose used to load potable water onto the boat. Knowledge of water holding and distribution systems on boats, and of potential risks associated with flooding and the release of diluted sewage into large bodies of water, is crucial for public health guidance regarding recreational cruises.
We report the discovery in the Greenland ice sheet of a discrete layer of free nanodiamonds (NDs) in very high abundances, implying most likely either an unprecedented influx of extraterrestrial (ET) material or a cosmic impact event that occurred after the last glacial episode. From that layer, we extracted n-diamonds and hexagonal diamonds (lonsdaleite), an accepted ET impact indicator, at abundances of up to about 5×106 times background levels in adjacent younger and older ice. The NDs in the concentrated layer are rounded, suggesting they most likely formed during a cosmic impact through some process similar to carbon-vapor deposition or high-explosive detonation. This morphology has not been reported previously in cosmic material, but has been observed in terrestrial impact material. This is the first highly enriched, discrete layer of NDs observed in glacial ice anywhere, and its presence indicates that ice caps are important archives of ET events of varying magnitudes. Using a preliminary ice chronology based on oxygen isotopes and dust stratigraphy, the ND-rich layer appears to be coeval with ND abundance peaks reported at numerous North American sites in a sedimentary layer, the Younger Dryas boundary layer (YDB), dating to 12.9 ± 0.1 ka. However, more investigation is needed to confirm this association.
West Nile virus (WNV) was probably introduced in southern and northern Mexico from the USA in two independent events. Since then, WNV activity has been reported in several Mexican states bordering the USA and the Gulf of Mexico, but disease manifestations seen there in humans and equids are quite different to those observed in the USA. We have analysed WNV seroprevalence in asymptomatic, unvaccinated equids from two Mexican states where no data had been previously recorded. WNV IgG antibodies were detected in 31·6% (91/288) of equine sera from Chiapas and Puebla states (53·3% and 8·0%, respectively). Analysis by plaque reduction neutralization test (PRNT) showed good specificity (99·4%) and sensitivity (84·9%) with the ELISA results. Further analyses to detect antibodies against three different flaviviruses (WNV, St Louis encephalitis virus, Ilheus virus) by haemagglutination inhibition (HI) tests on a subset of 138 samples showed that 53% of the 83 HI-positive samples showed specific reaction to WNV. These data suggest continuous expansion of WNV through Mexico.
White OLEDs (WOLEDTMs) fabricated using energy efficient phosphorescent OLED (PHOLEDTM) technology open up exciting new ways to develop efficient white lighting. WOLEDs have the potential to transform the lighting industry. In this presentation, phosphorescent WOLEDs with high conductivity transport layers will be discussed. White light can be generated by partial energy transfer from blue to green and red. Single WOLED stacks are demonstrated that match the Energy Star® lighting color criteria for 2700K and 3000K with high efficiency (˜80 lm/W) and high color rendering indices (˜80). Both devices had operational lifetimes (LT70%) over 30,000 hours measured from an initial luminance of 1,000 cd/m2. Different techniques to improve optical outcoupling will also be discussed.
Improved management of mental illness and substance misuse comorbidity is a National Health Service priority, but little is known about its prevalence and current management.
To measure the prevalence of comorbidity among patients of community mental health teams (CMHTs) and substance misuse services, and to assess the potential for joint management.
Cross-sectional prevalence survey in four urban UK centres.
Of CMHT patients, 44% (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use; 75% (95% CI 68.2-80.2) of drug service and 85% of alcohol service patients (95% CI 74.2-931) had a past-year psychiatric disorder. Most comorbidity patients appear ineligible for cross-referral between services. Large proportions are not identified by services and receive no specialist intervention.
Comorbidity is highly prevalent in CMHT, drug and alcohol treatment populations, but may be difficult to manage by cross-referral psychiatric and substance misuse services as currently configured and resourced.
Photoluminescence (PL) spectra of interband transitions in GaInNAs/GaAs single quantum wells grown by metalorganic chemical vapor deposition technique on semi-insulating GaAs substrates were measured at 77 K for several samples grown with different In composition and dimethylhydrazine (DMH)/III ratios. The results show that the PL intensity increases as the In mole fraction is increased from 0 to 25%, but the PL intensity is degraded for samples with an In mole fraction of 30% or higher. The peak position energies of the PL spectra were investigated as a function of the DMH/III ratio. Thermal annealing effect induced a blue-shift in the PL spectra peak position energy in samples grown with high DMH/III ratio.
Short-wavelength vertical cavity surface emitting lasers (VCSELS) are typically important for high-density optical memory and optical imaging systems. An AlGaN/GaN multiquantum well (MQW) VCSEL was designed for operation at wavelength of 364 nm. The design process consisted of careful selection of materials and optimization of the parameters for distributed Bragg reflector (DBR) stacks, active region, and calculation of the threshold current density, external quantum efficiency, and threshold carrier concentration. InGaN/AlGaN material system was selected for constructing DBR stacks in order to minimize power dissipation and to achieve high reflectivity. A reflectivity of 99% was calculated for 33 pairs in the bottom DBR stack and 97% was calculated for 30 pairs in the top DBR stack. An external quantum efficiency of 85% has been achieved through parametric optimization. Results were comparable to that of the similar structures based on the review of recent literatures.
The evolution of sheet resistance (Rs) of p-type conductive GaAs(1-x)Nx epilayers (x = 0.6%, 1.4%, and 2.3%) exposed to MeV 1H+, 7Li+, 12C+, and 16O+ ions and the stability of the formed electrical isolation during post-irradiation annealing were investigated. Results show that the threshold dose (Dth) to convert a conductive layer to highly resistive one close-to-linearly depends on original free carrier concentration and inversely depends on the number of irradiation-generated atomic displacements, and is independent of the nitrogen content in GaAsN layers. Increasing beam flux of 12C+ results in a lower Dth, whereas 1H+ beam flux does not affect it, showing the influence of collision cascade density. Results also show that irrespectively of the ion mass, the stability of electrical isolation formed in GaAsN is dependent on the ratio of the concentration of irradiation-created carrier traps to Dth. The electrical isolation can be preserved up to 550°C when the accumulated dose (D) is greater than 3.3 Dth.
We have investigated, theoretically and experimentally, the reduced and optical bandgap shift of Si-doped AlXGa1-XAs alloys as a function of both the Al composition and the Si concentration. The calculations were carried out within a framework of the many particle random phase approximation with the Hubbard local-field correction, considering electron populations in the conduction minima located at the Γ, X and L-points of the Brillouin zone. The experimental data have been obtained by means of photoluminescence spectroscopy. The theoretical predictions are found to be in good agreement with the experimental results.