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To assess the incidence rate of S. aureus colonization at baseline along with the mupirocin susceptibility (or resistance) rate in patients in a neonatal intensive care unit (NICU) and a pediatric intensive care unit (PICU) in conjunction with the implementation of universal decolonization as the standard of care.
Prospective cohort study.
Children’s Hospital of Michigan (CHM) inpatient intensive care units (ICUs).
Newly admitted pediatric patients to the CHM NICU or PICU aged between 1 day and ≤21 years.
Baseline and follow-up S. aureus screening cultures were obtained before patients underwent universal decolonization with mupirocin 2% antibiotic ointment (intranasal and umbilical) and chlorhexidine baths as standard of care to reduce CLABSI rates.
Baseline S. aureus colonization rates of new admissions to the CHM NICU and PICU were high at 32% and 29%, respectively. Baseline mupirocin susceptibility to any S. aureus growth was 98.4%. All baseline culture isolates whether positive for MRSA or MSSA, with one exception, had minimum inhibitory concentrations (MICs) of ≤0.19 µg/mL. All follow-up study cultures after universal decolonization at 7 days or beyond with any S. aureus growth had mupirocin MICs of ≤0.125 µg/mL.
Baseline S. aureus colonization rates of new admissions to the CHM ICUs were high as was baseline mupirocin susceptibility. Follow-up cultures, albeit limited in number, did not detect increasing mupirocin MICs over 1 year, despite broad mupirocin exposure due to the implementation of universal decolonization.
To determine the impact of a passive, prescriber-directed, electronic best-practice advisory coupled with prescriber education on the rate of antibiotic prescribing for acute, uncomplicated bronchitis in ambulatory adults across a large health system.
This study was a quasi-experiment examining antibiotic prescribing for ambulatory adults with acute bronchitis from January 1, 2016 through December 31, 2018. The intervention was implemented in December 2016 for emergency departments and urgent care clinics followed by ambulatory clinics in September 2017.
Outpatient settings across a health system, including 15 emergency departments, >30 urgent care clinics, and >150 ambulatory clinics.
All adults with a primary diagnosis of acute bronchitis who were seen and discharged from a study site were included.
A passive, prescriber-directed, best-practice advisory for treatment of acute bronchitis in the electronic health record and an optional, online education module regarding acute bronchitis.
The study included 81,975 ambulatory adults with a primary diagnosis of acute bronchitis during the preintervention period (19.8% >65 years of age; 61.9% female) and 89,571 ambulatory adults during the postintervention period (16.5% >65 years of age; 61.1% female). Antibiotic prescribing rates decreased from 60.8% (49,877 of 81,975 patients) preintervention to 51.4% (46,018 of 89,571 patients) postintervention (absolute difference, 9.4%; P < .001). The largest reduction occurred in the emergency departments.
An electronic best practice advisory combined with prescriber education was associated with a statistically significant reduction in antibiotic prescribing for adults with acute bronchitis. Future studies should incorporate patient education and address prescriber-reported barriers to appropriate antibiotic prescribing.
A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.
The “upper pit” at the Lost Chicken placer gold mine in east central Alaska contains fossils that provide information on the flora and insect fauna of interior Alaska just before the onset of global cooling at 2.5 myr. Fossils come from sediments interbedded with the Lost Chicken tephra (dated at 2.9 ± 0.4 myr—early Late Pliocene) and portray the floodplain and valley of a small creek within a region dominated by a coniferous forest richer in genera and species than the present one. Climate was wetter and less continental, and there was probably little or no permafrost. At least one other Pliocene tephra (the Fortymile tephra) occurs at the site and is also associated with plant and insect fossils. Among these fossils are extinct plants and insects like those found at other Tertiary sites in northern Canada and Alaska. The Lost Chicken sequence is the same age as the Beaufort Formation on Meighen Island, more than 1000 km to the north. Like Lost Chicken, Meighen Island sediments contain fossils representing a diverse boreal environment. This shows that the latitudinal climate gradient during early Late Pliocene time was shallower than at present and the boreal forest had a far greater latitudinal span than now.
A wide range of Arthurian material is discussed here, reflecting its diversity, and enduring vitality. Geoffrey of Monmouth's best-selling Historia regum Britannie is discussed in the context of Geoffrey's reception in Wales and the relationship between Latin and Welsh literary culture. Two essays deal with the Middle English Ywain and Gawain: the first offers a comparative study of the Middle English poem alongside Chrétien's Yvain and the Welsh Owein, while the second considers Ywain and Gawain with the Alliterative Morte Arthure in their northern English cultural and political context, the world of the Percys and the Nevilles. It is followed by a discussion of Edward III's recuperation of his abandoned Order of the Round Table, which offers an intriguing explanation for this reversal in the context of Edward's victory over the French at Poitiers. The final essay is a comparison of fifteenth- and twentieth-century portrayals of Camelot in Malory and T.H. White, as both idea and locale, and a centre of hearsay and gossip. The volume is completed with a unique and little-known medieval Greek Arthurian poem, presented in facing-page edition and modern English translation.
Elizabeth Archibald is Professor of English Studies at Durham University, and Principal of St Cuthbert's Society; David F. Johnson is Professor of English at Florida State University, Tallahassee.
Contributors: Christopher Berard, Louis J. Boyle, Thomas H. Crofts, Ralph Hanna, Georgia Lynn Henley, Erich Poppe
This volume of Arthurian Literature ranges from the reception of Geoffrey of Monmouth in Wales to the Camelot of T. H. White. Georgia Henley discusses Latin literary culture in medieval Wales, evaluating the intellectual and literary context in which Geoffrey of Monmouth's seminal Historia regum Britanniae was received. She makes the case for discarding the binary distinction of ‘Welsh vs Latin’ in favour of a view of medieval Wales as a multilingual culture in which Latin and Welsh existed side-by-side and the classical tradition had a significant influence on Welsh literature.
We are pleased to be able to publish a revised version of Prof. Erich Poppe's 2016 O'Donnell Lecture in Celtic Studies, in which he shines a bright comparative light (in terms of both plot and lexis) on Chrétien's Ivain, the Middle English Ywain and Gawain and the Middle Welsh Owein, otherwise known as Chwedyl Iarlles y Ffynnawn (The Tale of the Lady of the Well / Countess of the Spring). In his reading of these poems, Poppe effectively demonstrates Peter Clemoes’ axiom that to read ‘Medieval Welsh literature alongside that of Middle English’ is to recognize how great a debt English literature owes to the Celtic tradition for its Arthurian inspirations.
Christopher Berard returns to the subject of Edward III's abandoned Order of the Round Table to argue that, while Edward's ‘un-Arthurian’ tactics at Crécy made his association with the legendary king problematic, his victory at Poitiers and the capture of the flower of French knighthood – and of Jean II of France himself – rendered that association apt once more. Portraying himself as an Arthurian ‘King of Kings’ enabled Edward to negotiate a treaty with, and seek ransom for, the French king without undermining his own claim to that throne.
Ralph Hanna considers Ywain and Gawain and the Alliterative Morte Arthure in the cultural and political context of the turbulent history of the borders and of two great northern families, the Percys and the Nevilles. In spite of the popular image of the ‘uncouth / violent North’, he argues that northern romances diverge from the popular insular pattern of usurpation, exile and return, focusing instead on more domestic themes and on ‘the failure of mere martial prowess to offer meaningful achievement’. He sees Ywain and Gawain as a response to criticism of romance in texts such as Cursor mundi, stressing the importance of both time and ‘trowth’.
Despite the many important uses (and potential abuses) of focus groups in survey design, the CV literature presents few guidelines to aid moderators in their interaction with focus group participants. This paper draws on the theory and practice of ethnographic interviewing to introduce general guidelines that can improve focus groups as an aid to CV research. The proposed guidelines illustrate types of questions that should reduce speculation and moderator-introduced bias in focus group responses, and improve the correspondence between focus group responses and actual behavior. The paper illustrates these ethnographic guidelines through a CV application concerning watershed resources.
To examine the use of vitamin D supplements during infancy among the participants in an international infant feeding trial.
Information about vitamin D supplementation was collected through a validated FFQ at the age of 2 weeks and monthly between the ages of 1 month and 6 months.
Infants (n 2159) with a biological family member affected by type 1 diabetes and with increased human leucocyte antigen-conferred susceptibility to type 1 diabetes from twelve European countries, the USA, Canada and Australia.
Daily use of vitamin D supplements was common during the first 6 months of life in Northern and Central Europe (>80 % of the infants), with somewhat lower rates observed in Southern Europe (>60 %). In Canada, vitamin D supplementation was more common among exclusively breast-fed than other infants (e.g. 71 % v. 44 % at 6 months of age). Less than 2 % of infants in the USA and Australia received any vitamin D supplementation. Higher gestational age, older maternal age and longer maternal education were study-wide associated with greater use of vitamin D supplements.
Most of the infants received vitamin D supplements during the first 6 months of life in the European countries, whereas in Canada only half and in the USA and Australia very few were given supplementation.