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Prevention of Clostridioides difficile infection (CDI) is a national priority and may be facilitated by deployment of the Targeted Assessment for Prevention (TAP) Strategy, a quality improvement framework providing a focused approach to infection prevention. This article describes the process and outcomes of TAP Strategy implementation for CDI prevention in a healthcare system.
Hospital A was identified based on CDI surveillance data indicating an excess burden of infections above the national goal; hospitals B and C participated as part of systemwide deployment. TAP facility assessments were administered to staff to identify infection control gaps and inform CDI prevention interventions. Retrospective analysis was performed using negative-binomial, interrupted time series (ITS) regression to assess overall effect of targeted CDI prevention efforts. Analysis included hospital-onset, laboratory-identified C. difficile event data for 18 months before and after implementation of the TAP facility assessments.
The systemwide monthly CDI rate significantly decreased at the intervention (β2, −44%; P = .017), and the postintervention CDI rate trend showed a sustained decrease (β1 + β3; −12% per month; P = .008). At an individual hospital level, the CDI rate trend significantly decreased in the postintervention period at hospital A only (β1 + β3, −26% per month; P = .003).
This project demonstrates TAP Strategy implementation in a healthcare system, yielding significant decrease in the laboratory-identified C. difficile rate trend in the postintervention period at the system level and in hospital A. This project highlights the potential benefit of directing prevention efforts to facilities with the highest burden of excess infections to more efficiently reduce CDI rates.
Background: Hereditary transthyretin-mediated (hATTR) amyloidosis is a multi-systemic, heterogenous, life-threatening disease. Patisiran resulted in significant improvement in neuropathy and QoL at 18-months compared to placebo, and was generally well-tolerated in the Phase 3 APOLLO study. Methods: Multi-center, OLE study to evaluate the efficacy and safety of long-term patisiran dosing for ≤ 5 years in hATTR amyloidosis patients with polyneuropathy who have completed the APOLLO study (NCT02510261). Endpoints include safety, tolerability and long-term efficacy of patisiran. Measures of clinical benefit are the same endpoints used in APOLLO including changes in mNIS+7 composite neuropathy impairment score and QoL (Norfolk QoL-DN) Results: As of December 2017, 184 of 186 (99%) patients who completed APOLLO and 25 patients from the Ph 2 OLE study enrolled in the Global OLE study. Baseline data for 211(APOLLO/placebo, n=49; APOLLO/patisiran, n=137 and patisiran Ph 2 OLE, n=25) patients included: median age 61 years (26-84); 74% males; 46% V30M. Interim safety data and 12-month efficacy results will be presented. Conclusions: The global OLE study includes a diverse population of hATTR amyloidosis patients. Interim data will include the long-term safety and maintenance of effect in patients continuing on patisiran, as well as the impact of treatment with patisiran on patients previously treated with placebo.
Background: When compared to the general population, researchers have reported elevated rates of mental health issues in the pediatric epilepsy population. These issues have been found to be especially problematic around the time of transition from pediatric to adult care. This is significant because depression and/or anxiety have been found to be directly related to worsened seizure outcomes and quality of life. Despite this, no known Canadian pediatric epilepsy centers have integrated mental health assessment into mainstream practice. Methods: To explore the importance of mental health assessments, we looked at the prevalence rates of both depression and anxiety in 91 adolescents with epilepsy aged 14 to 18 (M=16.3, 51 males, 41 females) enrolled into an epilepsy transition clinic. Results: 58.3% of adolescents showed signs of depression (28.6% mild, 21.4% moderate, 6.0% moderately-severe, 2.4% severe), and 51.8% of adolescents showed signs of anxiety (31.8% mild, 10.6% moderate, 9.4% severe). Remarkably, 54.8% of patients presenting with moderate to severe depression and/or anxiety had not been previously identified Conclusions: These results suggest that in order to ensure the best possible outcomes for patients, mental health assessments should be integrated into the standard model of care for transition-aged adolescents with epilepsy.
Background: Growing evidence has that a suggested that mental health strongly influences quality of life (QoL) in adolescents with epilepsy. In addition, research has suggested that these mental health issues are associated with increased seizure burden and worsened health outcomes. Despite this, and the elevated rate of mental health issues in this population, seizure control tends to be the dominant or sole concern for treating physicians. Methods: In order to look at potential predictors of QoL in adolescents we looked at seizure related data, demographic variables, and comorbid conditions in 70 adolescents with epilepsy aged 14 to 18 (M= 16.3l; 37 males, 33 females) enrolled into an epilepsy transition clinic. Results: Regression analysis found that mental health remained a significant and independent predictor of QoL even when other significant seizure related variables were accounted for (t(58)= -3.44, p= .001). Furthermore, when looking at the individual subscales of patient QoL (e.g., memory, social support, stigma), mental health was consistently found to be the strongest correlate. Conclusions: These results demonstrate that in order to ensure the best outcomes for transition-aged adolescents with epilepsy, it is important to not only manage and treat seizures, but also to assess and treat mental health issues.
Hypertension prevalence is on the rise in low- and middle-income countries (LMICs) like South Africa, and migration and its concomitant urbanization are often considered to be associated with this rise. However, relatively little is known about the relationship between blood pressure (BP) and internal migration – a highly prevalent population process in LMICs. This study employed data for a group of 194 adult men and women from an original pilot dataset drawn from the Agincourt Health and Demographic Surveillance System in north-east South Africa conducted in 2012. Migrants in the sample were identified, tracked and interviewed. The relationship between BP and migration distance and the number of months an individual spent away from his/her home village was estimated using robust OLS regression, controlling for a series of socioeconomic, health and behavioural characteristics. It was found that migrants who moved a longer distance and for longer durations had significantly higher systolic and diastolic blood pressures compared with shorter-term migrants and those who remained nearby or in their home village. These associations remained robust and statistically significant when adjusting for measures of socioeconomic conditions, as well as body mass index and the number of meals consumed per day. Migration, both in terms of distance and time away, explained significant variation in the blood pressure of migrants in this typical South African context. The findings suggest the need for further studies of the nutritional and psycho-social factors associated with geographic mobility that may be important to understand rising hypertension levels in LMICs.
Fatigue syndromes (FSs) affect large numbers of individuals, yet evidence from epidemiological studies on adverse outcomes, such as premature death, is limited.
Cohort study involving 385 general practices in England that contributed to the Clinical Practice Research Datalink (CPRD) with linked inpatient Hospital Episode Statistics (HES) and Office for National Statistics (ONS) cause of death information. A total of 10 477 patients aged 15 years and above, diagnosed with a FS during 2000–2014, were individually matched with up to 20 comparator patients without a history of having a FS. Prevalence ratios (PRs) were estimated to compare the FS and comparison cohorts on clinical characteristics. Adjusted hazard ratios (HRs) for subsequent adverse outcomes were estimated from stratified Cox regression models.
Among patients diagnosed with FSs, we found elevated baseline prevalence of: any psychiatric illness (PR 1.77; 95% CI 1.72–1.82), anxiety disorders (PR 1.92; 1.85–1.99), depression (PR 1.89; 1.83–1.96), psychotropic prescriptions (PR 1.68; 1.64–1.72) and comorbid physical illness (PR 1.28; 1.23–1.32). We found no significant differences in risks for: all-cause mortality (HR 0.99; 0.91–1.09), natural death (HR 0.99; 0.90–1.09), unnatural death (HR 1.00; 0.59–1.72) or suicide (HR 1.68; 0.78–3.63). We did, however, observe a significantly elevated non-fatal self-harm risk: HR 1.83; 1.56–2.15.
The absence of elevated premature mortality risk is reassuring. The raised prevalence of mental illness and increased non-fatal self-harm risk indicate a need for enhanced assessment and management of psychopathology associated with fatigue syndromes.
Introduction: Identification of latent safety threats (LSTs) in the emergency department is an important aspect of quality improvement that can lead to improved patient care. In situ simulation (ISS) takes place in the real clinical environment and multidisciplinary teams can participate in diverse high acuity scenarios to identify LSTs. The purpose of this study is to examine the influence that the profession of the participant (i.e. physician, registered nurse, or respiratory therapist) has on the identification of LSTs during ISS. Methods: Six resuscitation- based adult and pediatric simulated scenarios were developed and delivered to multidisciplinary teams in the Kingston General Hospital ED. Each ISS session consisted of a 10- minute scenario, followed by 3-minutes of individual survey completion and a 7- minute group debrief led by ISS facilitators. An objective assessor recorded LSTs identified during each debrief. Surveys were completed prior to debrief to reduce response bias. Data was collected on participant demographics and perceived LSTs classified in the following categories: medication; equipment; resources and staffing; teamwork and communication; or other. Two reviewers evaluated survey responses and debrief notes to formulate a list of unique LSTs across scenarios and professions. The overall number and type of LSTs from surveys was identified and stratified by health care provider. Results: Thirteen ISS sessions were conducted with a total of 59 participants. Thirty- four unique LSTs (8 medication, 15 equipment, 5 resource, 4 communication, and 2 miscellaneous issues) were identified from surveys and debrief notes. Overall, MDs (n = 12) reported 19 LSTss (n = 41) reported 77 LSTs, and RTs (n = 6) reported 4 LSTs based on individual survey data. The most commonly identified category of LSTs reported by MDs (36.8%) and RTs (75%) was equipment issues while RNs most commonly identified medication issues (36.4%). Participants with □5 years of experience in their profession, on average identified more LSTs in surveys than participants with >5 years experience (1.9 LSTs vs 1.5 LSTs respectively). Conclusion: Nursing staff identified the highest number of LSTs across all categories. There was fairly unanimous identification of major LSTs across professions, however each profession did identify unique perspectives on LSTs in survey responses. ISS programs with the purpose of LST identification would benefit from multidisciplinary participation.
A 2018 workshop on the White Mountain Apache Tribe lands in Arizona examined ways to enhance investigations into cultural property crime (CPC) through applications of rapidly evolving methods from archaeological science. CPC (also looting, graverobbing) refers to unauthorized damage, removal, or trafficking in materials possessing blends of communal, aesthetic, and scientific values. The Fort Apache workshop integrated four generally partitioned domains of CPC expertise: (1) theories of perpetrators’ motivations and methods; (2) recommended practice in sustaining public and community opposition to CPC; (3) tactics and strategies for documenting, investigating, and prosecuting CPC; and (4) forensic sedimentology—uses of biophysical sciences to link sediments from implicated persons and objects to crime scenes. Forensic sedimentology served as the touchstone for dialogues among experts in criminology, archaeological sciences, law enforcement, and heritage stewardship. Field visits to CPC crime scenes and workshop deliberations identified pathways toward integrating CPC theory and practice with forensic sedimentology’s potent battery of analytic methods.
Apatite-type materials AI4AII6(BO4)6X2 have two unique cations sites AI and AII, which can host large mono-, di- tri- and tetra-valent cations. The average cation radii will affect the twist angle and lattice constants. However, there are few reports on the influence of B site substitutions on the twist angle and lattice parameters. It is believed that the lattice constant variation as a function of B site substitutions may not follow the same twist-angle model as proposed for A site. This work reports our results on the crystal chemistry of synthetic apatite Ca10(VxP1−xO4)6F2 obtained through the crystal structure characterization using Rietveld refinement and high-resolution transmission electron microscopy. The quantification of vanadium/phosphorus partitioning in BO4 tetrahedra showed that equilibrium with more than 70% substitution of phosphorous by vanadium was difficult to achieve unless longer annealing (about 1 week at 900 °C) was employed. In comparison with the apatites with different ionic radii at AI and AII sites, Ca10(VxP1−xO4)6F2 apatites with different ionic radii at B site show little twist angle variation for the whole series, which indicates that the dilation of unit cell constants is mainly because of the expansions of BO4 tetrahedra when A site cation is fixed.
The Commensal Real-time Australian Square Kilometre Array Pathfinder Fast Transients survey is the first extensive astronomical survey using phased array feeds. Since January 2017, it has been searching for fast radio bursts in fly’s eye mode. Here, we present a calculation of the sensitivity and total exposure of the survey that detected the first 20 of these bursts, using the pulsars B1641-45 and B0833-45 as calibrators. The beamshape, antenna-dependent system noise, and the effects of radio-frequency interference and fluctuations during commissioning are quantified. Effective survey exposures and sensitivities are calculated as a function of the source counts distribution. Statistical ‘stat’ and systematics ‘sys’ effects are treated separately. The implied fast radio burst rate is significantly lower than the 37 sky−1 day−1 calculated using nominal exposures and sensitivities for this same sample by Shannon et al. (2018). At the Euclidean (best-fit) power-law index of −1.5 (−2.2), the rate is
(sys) ± 3.6 (stat) sky−1 day−1 (
(sys) ± 2.8 (stat) sky−1 day−1) above a threshold of 56.6 ± 6.6(sys) Jy ms (40.4 ± 1.2(sys) Jy ms). This strongly suggests that these calculations be performed for other FRB-hunting experiments, allowing meaningful comparisons to be made between them.
In the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.
We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.
We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = −0.71; 95% confidence interval [CI] −1.01 to −0.41; I2 = 83%; 95% CI 78–88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = −1.02; 95% CI −1.52 to −0.51; I2 = 89%; 95% CI 82–93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = −1.05; 95% CI −1.55 to −0.56; I2 = 87%; 95% CI 79–92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.
Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.
The GaLactic and Extragalactic All-sky Murchison Widefield Array survey is a radio continuum survey at 72–231 MHz of the whole sky south of declination +30º, carried out with the Murchison Widefield Array. In this paper, we derive source counts from the GaLactic and Extragalactic All-sky Murchison data at 200, 154, 118, and 88 MHz, to a flux density limit of 50, 80, 120, and 290 mJy respectively, correcting for ionospheric smearing, incompleteness and source blending. These counts are more accurate than other counts in the literature at similar frequencies as a result of the large area of sky covered and this survey’s sensitivity to extended emission missed by other surveys. At S154 MHz > 0.5 Jy, there is no evidence of flattening in the average spectral index (α ≈ −0.8 where S ∝ vα) towards the lower frequencies. We demonstrate that the Square Kilometre Array Design Study model by Wilman et al. significantly underpredicts the observed 154-MHz GaLactic and Extragalactic All-sky Murchison counts, particularly at the bright end. Using deeper Low-Frequency Array counts and the Square Kilometre Array Design Study model, we find that sidelobe confusion dominates the thermal noise and classical confusion at v ≳ 100 MHz due to both the limited CLEANing depth and the undeconvolved sources outside the field-of-view. We show that we can approach the theoretical noise limit using a more efficient and automated CLEAN algorithm.
In Norway, incidence of sporadic domestically acquired salmonellosis is low, and most frequently due to Salmonalla Typhimurium. We investigated the risk factors for sporadic Salmonella infections in Norway to improve control and prevention measures. Surveillance data for all Salmonella infections from 2000 to 2015 were analysed for seasonality and proportion associated with domestic reservoirs, hedgehogs and wild birds. A prospective case–control study was conducted from 2010 to 2012 by recruiting cases from the Norwegian Surveillance System for Communicable Diseases and controls from the Norwegian Population Registry (389 cases and 1500 controls). Univariable analyses using logistic regression were conducted and a multivariable model was developed using regularised/penalised logistic regression. In univariable analysis, eating snow, dirt, sand or playing in a sandbox (aOR 4.14; CI 2.15–7.97) was associated with salmonellosis. This was also the only exposure significantly associated with illness in the multivariable model. Since 2004, 34.2% (n = 354) of S. Typhimuirum cases had an MLVA profile linked to a domestic reservoir. A seasonal trend with a peak in August for all Salmonella types and in February for S. Typhimurium was observed. Indirect exposure to domestic reservoirs remains a source of salmonellosis in Norway, particularly for children. Information to the public about avoiding environmental exposure should be strengthened and initiatives to combat salmonellosis in the food chain should be reinforced.
To determine if voluntary policies on supermarket checkout foods are associated with a difference in the healthfulness of foods displayed at, or near, supermarket checkout areas.
Cross-sectional survey of foods at, or near, supermarket checkouts categorised as less healthy or not according to the Food Standards Agency’s Nutrient Profiling Model.
One city in Eastern England (population about 125 000).
All stores in nine supermarket groups open for business in June–July 2017 in the study city. Supermarket checkout food policies were categorised as clear and consistent, vague or inconsistent, or none.
In thirty-three stores, 11 434 checkout food exposures were recorded, of which 8010 (70·1 %) were less healthy; and 2558 foods in areas near checkouts, of which 1769 (69·2 %) were less healthy. After adjusting for a marker of store size, the odds of a checkout food exposure being ‘less healthy’ was lower in stores with vague or inconsistent checkout policies (OR=0·63; 95 % CI 0·49, 0·80) and in stores with clear and consistent checkout policies (OR=0·33; 95 % CI 0·24, 0·45), compared with no policy. There was no difference in the odds of foods near, but not at, checkouts being less healthy according to checkout food policy.
Supermarket checkout food policies were associated with lower odds of checkout foods but not foods near, but not at, checkouts being less healthy. Further research is required to explore impacts on purchasing and consumption.
To examine perspectives on food access among low-income families participating in a cost-offset community-supported agriculture (CO-CSA) programme.
Farm Fresh Foods for Healthy Kids (F3HK) is a multicentre randomized intervention trial assessing the effect of CO-CSA on dietary intake and quality among children from low-income families. Focus groups were conducted at the end of the first CO-CSA season. Participants were interviewed about programme experiences, framed by five dimensions of food access: availability, accessibility, affordability, acceptability and accommodation. Transcribed data were coded on these dimensions plus emergent themes.
Nine communities in the US states of New York, North Carolina, Washington and Vermont.
Fifty-three F3HK adults with children.
CSA models were structured by partner farms. Produce quantity was abundant; however, availability was enhanced for participants who were able to select their own produce items. Flexible CSA pick-up times and locations made produce pick-up more accessible. Despite being affordable to most, payment timing was a barrier for some. Unfamiliar foods and quick spoilage hindered acceptability through challenging meal planning, despite accommodations that included preparation advice.
Although CO-CSA may facilitate increased access to fruits and vegetables for low-income families, perceptions of positive diet change may be limited by the ability to incorporate share pick-up into regular travel patterns and meal planning. Food waste concerns may be particularly acute for families with constrained resources. Future research should examine whether CO-CSA with flexible logistics and produce self-selection are sustainable for low-income families and CSA farms.
The article reviews the relevance and methodological utility of welfare regime typologies for the study of professional sense-making in social work with families. Focus groups were carried out with social workers in European and Latin American countries representing four different policy regimes. A case vignette was used to elicit social workers’ descriptions of how welfare policy may influence how they understand their work task and the notion of family. The research team identified methodological challenges of general relevance in similar policy-practice studies. There were paradoxes in terms of homogeneity on the regime level vs. heterogeneity within and between national services. Pitfalls appeared in the selection of regime-typical cases, language/cultural barriers, and in deciding organisational level. The article shows that welfare typologies have potentialities in that they may provide a helpful analytical basis for theoretical and practical reasoning in which syntheses between policy and practice can be explored, discussed and challenged.
Globally, the prevalence of tuberculosis (TB) disease is higher in males. This study examined the effect of sex and age on Mycobacterium tuberculosis (Mtb) infection. Demographic and exposure data were collected on household contacts of sputum smear-positive pulmonary TB patients in Brazil. Contacts with tuberculin skin test induration ⩾10 mm at baseline or 12 weeks were considered Mtb infected. The study enrolled 917 household contacts from 160 households; 508 (55.4%) were female, median age was 21.0 years (range 0.30–87.0) and 609 (66.4%) had Mtb infection. The proportion infected increased with age from 63.3% in girls <5 years to 75.4% in women ⩾40 years and from 44.9% in boys <5 years to 73.6% in men ⩾40 years. Multivariable modelling showed the odds of infection increased between age 5 and 14 years among female contacts (OR 1.5 per 5-year age increase; 95% CI 1.1–2.2; P = 0.02) and between ages 0–4 and 15–39 years among male contacts (OR 2.7, 95% CI 0.83–8.9 and 1.1, 95% CI 0.99–1.3 per 5-year age increase; P = 0.10, 0.07, respectively). The study suggests that the age at which Mtb infection increases most is different in females compared with males. Studies are needed to explore whether these findings are due to differences in host susceptibility, exposure outside the household or other factors.