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Surgical site infection (SSI) is a common postprocedure complication that may be prevented by adhering to established recommendations, including administration of preoperative antibiotic prophylaxis. Patients with a β-lactam allergy (BLA) label have an increased risk of SSI. We sought to evaluate the appropriateness of preoperative antibiotic prophylaxis in patients labeled with a BLA compared those without a BLA.
This was a single-center, retrospective, matched cohort study of adult patients who underwent a clean or clean-contaminated knee replacement, abdominal hysterectomy, colorectal surgery, or coronary artery bypass graft (CABG). Patients with a BLA label were matched to patients without a BLA label based on procedure, age, and body mass index (BMI). The primary end point was the rate of appropriate preoperative antibiotic prophylaxis, including antibiotic selection and timing prior to incision.
In total, 260 patients were included. Knee replacement (38%) was the most common procedure, followed by abdominal hysterectomy (25%), colorectal surgery (18%), and CABG (18%). Appropriate preoperative antibiotic prophylaxis was higher among patients without a BLA (76% vs 37%; P < .001). Among patients with a mild-to-moderate reaction or intolerance, 29 (53%) received antibiotics that would have been appropriate only if the patient had had a severe BLA. Patients with a BLA were more likely to have had an antibiotic omitted from the prophylactic regimen (44% vs 4%; P < .001).
Patients with a BLA were more likely to receive inappropriate preoperative antibiotic prophylaxis, attributed to misinterpretation of BLA labels and antibiotic omissions. Optimizing antibiotic prophylaxis among patients with BLAs remains an area of opportunity to prevent SSIs.
Gravitational waves from coalescing neutron stars encode information about nuclear matter at extreme densities, inaccessible by laboratory experiments. The late inspiral is influenced by the presence of tides, which depend on the neutron star equation of state. Neutron star mergers are expected to often produce rapidly rotating remnant neutron stars that emit gravitational waves. These will provide clues to the extremely hot post-merger environment. This signature of nuclear matter in gravitational waves contains most information in the 2–4 kHz frequency band, which is outside of the most sensitive band of current detectors. We present the design concept and science case for a Neutron Star Extreme Matter Observatory (NEMO): a gravitational-wave interferometer optimised to study nuclear physics with merging neutron stars. The concept uses high-circulating laser power, quantum squeezing, and a detector topology specifically designed to achieve the high-frequency sensitivity necessary to probe nuclear matter using gravitational waves. Above 1 kHz, the proposed strain sensitivity is comparable to full third-generation detectors at a fraction of the cost. Such sensitivity changes expected event rates for detection of post-merger remnants from approximately one per few decades with two A+ detectors to a few per year and potentially allow for the first gravitational-wave observations of supernovae, isolated neutron stars, and other exotica.
The radiocarbon (14C) calibration curve so far contains annually resolved data only for a short period of time. With accelerator mass spectrometry (AMS) matching the precision of decay counting, it is now possible to efficiently produce large datasets of annual resolution for calibration purposes using small amounts of wood. The radiocarbon intercomparison on single-year tree-ring samples presented here is the first to investigate specifically possible offsets between AMS laboratories at high precision. The results show that AMS laboratories are capable of measuring samples of Holocene age with an accuracy and precision that is comparable or even goes beyond what is possible with decay counting, even though they require a thousand times less wood. It also shows that not all AMS laboratories always produce results that are consistent with their stated uncertainties. The long-term benefits of studies of this kind are more accurate radiocarbon measurements with, in the future, better quantified uncertainties.
Improved plasticity models require simultaneous experimental local strain and microstructural evolution data. Microscopy tools, such as electron backscatter diffraction (EBSD), that can monitor transformation at the relevant length-scale, are often incompatible with digital image correlation (DIC) techniques required to determine local deformation. In this paper, the viability of forescatter detector (FSD) images as the basis for the DIC study is investigated. Standard FSD and an integrated EBSD/FSD approach (Pattern Region of Interest Analysis System: PRIAS™) are analyzed. Simultaneous strain and microstructure maps are obtained for tensile deformation of Q&P 1180 steel up to ~14% strain. Tests on an undeformed sample that is simply shifted indicate a standard deviation of error in strain of around 0.4% without additional complications from a deformed surface. The method resolves strain bands at ~2 μm spacing but does not provide significant sub-grain strain resolution. Similar resolution was obtained for mechanically polished and electropolished samples, despite electropolished surfaces presenting a smoother, simpler topography. While the resolution of the PRIAS approach depends upon the EBSD step size, the 80 nm step size used provides seemingly similar resolution as 8,000× (22.7 nm) FSD images. Surface feature evolution prevents DIC analysis across large strain steps (>6% strain), but restarting DIC, using an FSD reference image from an interim strain step, allows reasonable DIC across the stress–strain curve. Furthermore, the data are obtained easily and provide complementary information for EBSD analysis.
The conopid fly Stylogaster neglecta Williston (Diptera: Conopidae) is a parasitoid with no known host. We report this species as the first recorded dipteran parasitoid of Oecanthus nigricornis Walker (Orthoptera: Gryllidae) (black-horned tree crickets). We reared field-collected O. nigricornis juveniles over several months in 2017 and found that larval S. neglecta emerged from them during late July into August. We estimated the incubation period for S. neglecta larvae to be around 30 days based on the length of time it took for them to emerge from the host and pupate (subsequently all hosts died). We documented several cases of multiple parasitism. In 2018, we dissected O. nigricornis sampled from four sites across southern Ontario, Canada and upstate New York, United States of America and found that the percentage of juvenile O. nigricornis parasitised ranged 2–39%. Further sampling will be necessary to determine whether this variation represents consistent population differences or between-year variation in parasitism.
Tobacco smoking is a leading cause of preventable death and disease worldwide. Adults with mental ill-health smoke tobacco at substantially higher rates than other adults, with public health approaches effective in the population overall having less impact on those with mental ill-health. However, less is known about the tobacco smoking behaviours, attitudes and knowledge of young people with mental ill-health, despite this being the peak period of onset for both mental illness and cigarette smoking.
Young people attending a youth mental health centre (providing both primary and specialist care) in Melbourne, Australia were approached by youth peer researchers and asked to complete a survey about smoking behaviours, attitudes and knowledge. We examined smoking and associated attitudes in the sample overall, and as a function of the services accessed.
In total, 114 young people completed the survey, with 56.3% reporting lifetime cigarette smoking, 42.0% smoking in the last 12 months and 28.6% in the past week. Of current regular smokers, 75.0% acknowledged they should quit in the future; however, only 23.5% planned to do so in the next month, with 44.4% confident that they could quit. Participants lacked knowledge about interactions between tobacco smoking, mental and physical health.
Youth presenting for mental ill-health had high rates of cigarette smoking relative to population rates. Presentation at youth mental health services may represent a critical window for early intervention to reduce the lifetime impacts of cigarette smoking in mental ill-health. Interventions to support smoking cessation in this group are urgently needed.
Cannabis is the world's most commonly used illicit substance. Whilst its effects on perception are well documented, little is known about the neural basis of these effects and how they are modulated by two of cannabis sativa's most abundant active ingredients, Delta-9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD).
We used fMRI to assess the effects of THC and CBD on brain activation during a simple visual and auditory stimulation paradigm in healthy volunteers.
Fourteen right handed male subjects were scanned on 3 occasions. Identical 10mg THC, 600mg CBD and placebo capsules were allocated in a balanced double blinded pseudorandomised crossover design.
Ingestion of THC and CBD led to reliable increases in plasma levels of each substance and for THC concomitant increases in anxiety, intoxication and positive psychotic symptoms; CBD and placebo caused no significant symptoms. Visual and auditory stimulation led to robust activations in occipital and temporal cortices respectively under placebo conditions. Administration of THC led to decreased activation in primary sensory cortices relative to placebo whilst CBD led to an increase in activation in right temporal regions during auditory stimulation and right striate cortex activation during visual stimulation. THC mediated reduction of activation in this area during auditory stimulation correlated with a concomitant rise in psychotic symptoms.
These data indicate that the different psychoactive constituents of cannabis have dissociable effects on sensory processing, often in opposite directions
Inner-city youth suffer a high burden of mental illness and seek health care on an episodic basis (McCreary, 2001).
These youth tend to receive limited support services due to a lack of continuity of care as they move from child to adult services. Other barriers include homelessness and substance use.
The Vancouver Inner City Youth Mental Health Program (ICYMHP) is a psychiatry led initiative to provide psychiatric services and further collaboration between inner-city youth agencies providing care to at risk youth.
To introduce and review a collaborative model of care between psychiatric services and community based organizations.
To review the demographics, presentations and outcomes of youth assessed through the ICYMHP.
A chart review of all clients assessed through the program from its inception (November 2007) to May 2009 (18 months).
Results from clients seen between November 2007 and June 2008 indicate an incidence of psychosis of 40% in men and 21% in women. Mood disorders were the primary diagnosis in 18% of men and 29% of women. Active substance misuse is high (71% of men, cannabis as drug of choice; 54% of women, methamphetamine as drug of choice). Length of stay at Covenant House nearly tripled for those under the care of the ICYMH versus the general shelter population, a positive outcome (21 days versus 9).
Inner-city homeless youth suffer from a high burden of mental illness. A collaborative model of care exists to improve health care quality and delivery to this population.
Medication adherence is a matter of relevance for early treatment of psychotic disorder.
To understand pattern of medication adherence in this population and factors influencing.
To understand the antipsychotic adherence pattern in early stages of psychotic disorder and to identify factors that influence.
Natural observation study of 136 patients of first-episode psychosis presenting to Early intervention service in multicultural South London. Data derived from case notes and interviews using standard rating scales for first 18 months.
Only 39% of patients (n=50) were 100% time adherent with antipsychotic medication in the first month (rest were 83%). Patients using illicit substances were less likely 100% adherent (Pearson χ2= 13.1, df=1,p=0.001). Caucasian patients were more likely to be fully adherent in the first month than Ethnic minority patients (Pearson χ2= 7.5, df=1, p=0.009). During the follow-up period about 57% patients had weeks of not taking antipsychotic, mostly after recovery from first episode. Ethnicity (Pearson χ2=4.5, df=1, p=0.05) and experience of extrapyramidal side-effect (Pearson χ2= 5.6, df=1, p=0.02) were associated with this gap. Involvement of a carer in treatment was associated with better (100%) adherence during follow-up (Pearson χ2= 4.9, df=1,p=0.03).
Interventions in early stages of psychosis should focus on therapies involving carers/ families and giving attention to illicit substances use and delivered in way relevant to the local ethnic population. Also antipsychotics chosen carefully, using a lower dose and actively looking for emergence of side-effects.
Current guidelines on management of first-episode mania recommend augmenting with Valproate or other mood-stabilisers if antipsychotic proves ineffective.
To study if timing of starting mood-stabiliser augmentation would influence recovery outcomes in first-episode mania with psychosis.
To study how ‘time to start augmentation’ is related to ‘time to recovery’ and ‘hospital stay’
11 patients with first-episode mania with psychosis (FEM-P) presenting to a specialist early-intervention service in South London, part of naturalistic study of 150 cases of first-episode psychosis. Patients interviewed using the standard rating scales. Other details of treatment obtained from systematic review of case-notes covering 18 months. Operational criteria defined recovery. Correlation and regression analysis carried out to test hypotheses using SPSS-19. Set of predictor variables such as age, DUP, type of antipsychotic, substance misuse used in regression.
All 11 patients started on atypical-antipsychotic (Olanzapine 5, Risperidone 6). 9 patients required augmentation with Valproate, with a mean time of 74 days (s.d.=91) to start augmentation. The mean time to first recovery was 86 days (s.d.=39). Regression analysis with ‘time to recovery’ as dependant variable and ‘time to start augmentation’ as covariate with other predictor variables yielded significant relationship (F=9.2, t=3.1, p=0.02, CI 0.07-0.56). Also time to ‘start augmentation’ showed correlation at trend-level with ‘hospital stay’ (mean= 40, s.d.= 40.3) (Pearson correlation =0.57, p=0.09).
When there is insufficient response with antipsychotic in treatment of FEM-P, augmentation with mood-stabiliser such as Valproate without delay can shorten time to recovery and hospital stay.
Discontinuation of antipsychotic medication occurs in 40-55% of patients following first episode psychosis. It is only recently that the impacts of short periods of nonadherence in first episode psychosis are being understood.
To study the impact of short periods of interruptions in antipsychotic treatment in first episode psychosis.
127 consecutive cases of first episode non-affective psychosis (F20-29 ICD-10) presenting to a specialist first episode psychosis service in South East London. Patients were interviewed at baseline by a researcher using the PANSS and other symptom scales at the start and at 18 months. Clinical notes were analysed using operational criteria set for recovery, exacerbation and relapse. Medication utilisation assessed using patient report and clinical notes to identify interruptions of ≥ 1 month in treatment.
58% (n = 73) patients had a treatment break due to non-adherence in the follow up period. 18 patients had treatment break before first recovery and their time to recovery was significantly prolonged than those without a break (mean 210 days Vs 127 days, t = 2.9, P = 0.01). The odds of relapse was 5.4 for those with treatment break (≥ 1 month) compared to those without break (p = 0.0001, CI 2.1–11). About 40% relapses occurred in first month of treatment break and mean time to relapse was 3 months.
Antipsychotic treatment should be uninterrupted in the early stages of psychosis and periods of even short breaks in treatment carries risk of adverse outcome like longer time to recover and high risk of immediate relapse.
Lymphopenia is common in adults who have had a Fontan operation although its aetiology and clinical implications remain unknown. Previous work suggests an association between lymphopenia and both liver disease and splenomegaly. The objective of this study was to assess the prevalence of lymphopenia in adults with a Fontan circulation and evaluate its associations with risk factors and clinical outcomes. Using a retrospective cohort study design, we studied 73 adult Fontan patients (age 25.0 ± 8.4 years) who had a complete blood count and abdominal imaging performed. Patients with protein-losing enteropathy were excluded. Clinical data were extracted from hospital records. The mean white blood cell count was 6580 ± 220/ml with a mean lymphocyte count of 1223 ± 508/ml. Lymphopenia, defined as lymphocyte count <1000/ml, was present in 23 (32%) patients. Patients with lymphopenia had a lower total white blood cell count (5556 ± 2517 versus 7136 ± 1924/ml, p = 0.009) and a lower platelet count (162 ± 69 versus 208 ± 69 k/ml, p = 0.008). Lymphopenia was also associated with findings of portal hypertension, including splenomegaly (36 versus 14%, p = 0.04), varices (22 versus 6%, p = 0.04), and ascites (39 versus 14%, p = 0.02). Lymphopenia did not correlate with any cardiac imaging, haemodynamic or exercise testing variables. In conclusion, lymphopenia is common in adult Fontan patients and is associated with markers of portal hypertension. Larger studies are needed to better define the relationship between lymphopenia and clinical outcomes.
Mental disorders are increasingly common among adults in both the developed and developing world and are predicted by the WHO to be the leading cause of disease burden by 2030. Many common physical conditions are more common among people who also have a common mental disorder. This scoping review aims to examine the current literature about the prevention, identification and treatment of physical problems among people with pre-existing mental health disorders in primary care in Europe.
The scoping review framework comprised a five-stage process developed by Arksey & O’Malley (2005). The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Both quantitative and qualitative studies were included, with no restriction on study design.
The initial search identified 299 studies, with a further 28 added from the hand-search (total n = 327) of which 19 were considered relevant to the review research question and included for full analysis. Depression was the mental health condition most commonly studied (nine studies), followed by depression and anxiety (seven studies), with three studies examining any mental disorder. Eleven studies examined the effects of various interventions to address physical and mental comorbidity, with the most commonly studied intervention being collaborative care.
With just 19 studies meeting our criteria for inclusion, there is clearly a paucity of research in this area. Further research is essential in order to understand the pathophysiological mechanisms underlying the association between mental disorders and chronic conditions.
Implantation of bone-anchored hearing devices is performed to improve hearing in patients with chronic suppurative otitis media who cannot wear a conventional hearing aid. The surgical procedure can be safely performed in children aged over five years.
A 15-year-old patient with bilateral chronic suppurative otitis media and conductive hearing loss underwent the procedure to implant a bone-anchored hearing device but was found to have skull thickness of less than 2.5 mm and the procedure was abandoned. A computed tomography scan of the skull was undertaken and a three-dimensional template was reconstructed to identify appropriate thickness of the skull to implant the abutment during a second procedure.
Bone-anchored hearing devices can be implanted by prior imaging and using a template to identify the area of appropriate skull thickness to implant the abutment safely.
Patients diagnosed with glioblastoma (GBM) are treated with surgery followed by fractionated radiotherapy with concurrent and adjuvant temozolomide. Patients are monitored with serial magnetic resonance imaging (MRI). However, treatment-related changes frequently mimic disease progression. We reviewed a series of patients undergoing surgery for presumed first-recurrence GBM, where pathology reports were available for tissue diagnosis, in order to better understand factors associated with a diagnosis of treatment-related changes on final pathology.
Patient records at a single institution between 2005 and 2015 were retrospectively reviewed. Pathology reports were reviewed to determine diagnosis of recurrent GBM or treatment effect. Survival analysis was performed interrogating overall survival (OS) and progression-free survival (PFS). Correlation with radiation treatment plans was also examined.
One-hundred-twenty-three patients were identified. One-hundred-sixteen patients (94%) underwent resection and seven underwent biopsy. Treatment-related changes were reported in 20 cases (16%). These patients had longer median OS and PFS from the time of recurrence than patients with true disease progression. However, there was no significant difference in OS from the time of initial diagnosis. Treatment effect was associated with surgery within 90 days of completing radiation. In patients receiving radiation at our institution (n = 53), larger radiation target volume and a higher maximum dose were associated with treatment effect.
Treatment effect was associated with surgery nearer to completion of radiation, a larger radiation target volume, and a higher maximum point dose. Treatment effect was associated with longer PFS and OS from the time of recurrence, but not from the time of initial diagnosis.
Eggs oviposited by Ascaridia galli females in artificial media are commonly used as a source of infective material. We investigated the rate of egg production by cultured mature females (n = 223), and changes in egg viability under different storage and incubation conditions. Eggs recovered after 1, 2 or 3 days of culture were subjected to either (1) storage in water at 4°C (1, 4 or 8 weeks) followed by incubation in 0.1 N H2SO4 at 26°C (2, 4 or 6 weeks); or (2) prolonged storage at 4°C (up to 14 weeks). Egg development and viability was assessed by morphology coupled with a viability dye exclusion test of hatched larvae. Of the 6,044 eggs recovered per mature female 49.2, 38.5 and 12.3% were recovered on days 1, 2 and 3 of worm incubation respectively with similar initial viability (≥99%) between days. Eggs recovered on different days had only minor differences in viability after storage. The prolonged storage period at 4°C significantly affected both viability and embryonation ability resulting in decline in viability of 5.7–6.2% per week. A smaller but significant decline in egg (2.0%) and hatched larval (1.4%) viability per week of incubation at 26°C was also observed. We conclude that storage and incubation conditions, not the day of egg recovery, are the main factors affecting A. galli egg viability. Our findings indicate that under aerobic conditions storage at 26°C may be preferable to 4°C whereas other studies indicate that under anaerobic conditions storage at 4°C is preferable.
Advancements in computer technology have enabled three-dimensional (3D) reconstruction, data-stitching, and manipulation of 3D data obtained on X-ray imaging systems such as micro-computed tomography (μ-CT). Likewise, intuitive evaluation of these 3D datasets can be enhanced by recent advances in virtual reality (VR) hardware and software. Additionally, the generation, viewing, and manipulation of 3D X-ray diffraction datasets, such as pole figures employed for texture analysis, can also benefit from these advanced visualization techniques. We present newly-developed protocols for porting 3D data (as TIFF-stacks) into a Unity gaming software platform so that data may be toured, manipulated, and evaluated within a more-intuitive VR environment through the use of game-like controls and 3D headsets. We demonstrate this capability by rendering μ-CT data of a polymer dogbone test bar at various stages of in situ mechanical strain. An additional experiment is presented showing 3D XRD data collected on an aluminum test block with vias. These 3D XRD data for texture analysis (χ, ϕ, 2θ dimensions) enables the viewer to visually inspect 3D pole figures and detect the presence or absence of in-plane residual macrostrain. These two examples serve to illustrate the benefits of this new methodology for multidimensional analysis.
Percutaneous tunneled drainage catheter (PTDC) placement is a palliative alternative to serial paracenteses in patients with end-stage cancer and refractory ascites. The impact of PTDC on quality of life (QoL) and long-term outcomes has not been prospectively described. The objective was to evaluate changes in QoL after PTDC.
Eligible adult patients with end-stage cancer undergoing PTDC placement for refractory ascites completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and McGill Quality of Life instruments before PTDC placement and at 2 to 7 days and 2 to 4 weeks after PTDC. Catheter function, complications, and laboratory values were assessed. Analysis of QoL data was evaluated with a stratified Wilcoxon signed-rank test.
Fifty patients enrolled. Survey completion ranged from 65% to 100% (median 88%) across timepoints. All patients had a Tenckhoff catheter, with 98% technical success. Median survival after PTDC was 38 days (95% confidence interval = 32, 57 days). European Organization for Research and Treatment of Cancer scores showed improvement in global QoL (p = 0.03) at 1 week postprocedure (PP). Significant symptom improvement was reported for fatigue, nausea/vomiting, pain, dyspnea, insomnia, and appetite at 1 week PP and was sustained at 3 weeks PP for dyspnea (p < 0.01), insomnia (p < 0.01), and appetite loss (p = 0.03). McGill Quality of Life demonstrated overall QoL improvement at 1 (p = 0.03) and 3 weeks (p = 0.04) PP. Decline in sodium and albumin values pre- and post-PTDC slowed significantly (albumin slope –0.43 to –0.26, p = 0.055; sodium slope –2.50 to 1.31, p = 0.04). Creatinine values increased at an accelerated pace post-PTDC (0.040 to 0.21, p < 0.01). Thirty-eight catheter-related complications occurred in 24 of 45 patients (53%).
Significance of results
QoL and symptoms improved after PTDC placement for refractory ascites in patients with end-stage malignancy. Decline in sodium and albumin values slowed postplacement. This study supports the use of a PTDC for palliation of refractory ascites in cancer patients.