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To update current estimates of non–device-associated pneumonia (ND pneumonia) rates and their frequency relative to ventilator associated pneumonia (VAP), and identify risk factors for ND pneumonia.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. Pneumonia (device associated and non–device associated) were captured through comprehensive, hospital-wide active surveillance using CDC definitions and methodology.
From 2013 to 2017, there were 163,386 hospitalizations (97,485 unique patients) and 771 pneumonia cases (520 ND pneumonia and 191 VAP). The rate of ND pneumonia remained stable, with 4.15 and 4.54 ND pneumonia cases per 10,000 hospitalization days in 2013 and 2017 respectively (P = .65). In 2017, 74% of pneumonia cases were ND pneumonia. Male sex and increasing age we both associated with increased risk of ND pneumonia. Additionally, patients with chronic bronchitis or emphysema (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.40–3.06), congestive heart failure (HR, 1.48; 95% CI, 1.07–2.05), or paralysis (HR, 1.72; 95% CI, 1.09–2.73) were also at increased risk, as were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18–2.00) or in the ICU (HR, 1.49; 95% CI, 1.06–2.09). We did not detect a change in ND pneumonia risk with use of chlorhexidine mouthwash, total parenteral nutrition, all medications of interest, and prior ventilation.
The incidence rate of ND pneumonia did not change from 2013 to 2017, and 3 of 4 nosocomial pneumonia cases were non–device associated. Hospital infection prevention programs should consider expanding the scope of surveillance to include non-ventilated patients. Future research should continue to look for modifiable risk factors and should assess potential prevention strategies.
To update current estimates of non–device-associated urinary tract infection (ND-UTI) rates and their frequency relative to catheter-associated UTIs (CA-UTIs) and to identify risk factors for ND-UTIs.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. UTIs (device and non-device associated) were captured through comprehensive, hospital-wide active surveillance using Centers for Disease Control and Prevention case definitions and methodology.
From 2013 to 2017 there were 163,386 hospitalizations (97,485 unique patients) and 1,273 UTIs (715 ND-UTIs and 558 CA-UTIs). The rate of ND-UTIs remained stable, decreasing slightly from 6.14 to 5.57 ND-UTIs per 10,000 hospitalization days during the study period (P = .15). However, the proportion of UTIs that were non–device related increased from 52% to 72% (P < .0001). Female sex (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.50–2.50) and increasing age were associated with increased ND-UTI risk. Additionally, the following conditions were associated with increased risk: peptic ulcer disease (HR, 2.25; 95% CI, 1.04–4.86), immunosuppression (HR, 1.48; 95% CI, 1.15–1.91), trauma admissions (HR, 1.36; 95% CI, 1.02–1.81), total parenteral nutrition (HR, 1.99; 95% CI, 1.35–2.94) and opioid use (HR, 1.62; 95% CI, 1.10–2.32). Urinary retention (HR, 1.41; 95% CI, 0.96–2.07), suprapubic catheterization (HR, 2.28; 95% CI, 0.88–5.91), and nephrostomy tubes (HR, 2.02; 95% CI, 0.83–4.93) may also increase risk, but estimates were imprecise.
Greater than 70% of UTIs are now non–device associated. Current targeted surveillance practices should be reconsidered in light of this changing landscape. We identified several modifiable risk factors for ND-UTIs, and future research should explore the impact of prevention strategies that target these factors.
Burn patients are particularly vulnerable to infection, and an estimated half of all burn deaths are due to infections. This study explored risk factors for healthcare-associated infections (HAIs) in adult burn patients.
Retrospective cohort study.
Tertiary-care burn center.
Adults (≥18 years old) admitted with burn injury for at least 2 days between 2004 and 2013.
HAIs were determined in real-time by infection preventionists using Centers for Disease Control and Prevention criteria. Multivariable Cox proportional hazards regression was used to estimate the direct effect of each risk factor on time to HAI, with inverse probability of censor weights to address potentially informative censoring. Effect measure modification by burn size was also assessed.
Overall, 4,426 patients met inclusion criteria, and 349 (7.9%) patients had at least 1 HAI within 60 days of admission. Compared to <5% total body surface area (TBSA), patients with 5%–10% TBSA were almost 3 times as likely to acquire an HAI (hazard ratio [HR], 2.92; 95% CI, 1.63–5.23); patients with 10%–20% TBSA were >6 times as likely to acquire an HAI (HR, 6.38; 95% CI, 3.64–11.17); and patients with >20% TBSA were >10 times as likely to acquire an HAI (HR, 10.33; 95% CI, 5.74–18.60). Patients with inhalational injury were 1.5 times as likely to acquire an HAI (HR, 1.61; 95% CI, 1.17–2.22). The effect of inhalational injury (P=.09) appeared to be larger among patients with ≤20% TBSA.
Larger burns and inhalational injury were associated with increased incidence of HAIs. Future research should use these risk factors to identify potential interventions.
Ventilator-associated pneumonia (VAP) is a frequent complication of severe burn injury. Comparing the current ventilator-associated event-possible VAP definition to the pre-2013 VAP definition, we identified considerably fewer VAP cases in our burn ICU. The new definition does not capture many VAP cases that would have been reported using the pre-2013 definition.
We human beings are social animals, and our social nature is in part revealed through our emotions and their expression: by expressing an emotion, we communicate to others something about our attitudes towards them or towards our circumstances more broadly. Yet standard accounts of the emotional expressions tend to consider a relatively narrow range of relatively simple cases, ignoring more complex cases such as expressions of the reactive attitudes – emotions like gratitude and resentment, approbation and guilt – that are central to our ordinary interpersonal relationships. Indeed, as I shall argue, thinking about what is required in these more complex cases can shed light on how we ought to understand the simpler cases.
One aspect of our social nature as human beings is that we share not only our things and our actions but also our cares and values. Emotions are, we might expect, important for valuing in general, both for our attunement to value and even for things being valuable to us in the first place (Helm 2001). In the case of joint values– those values we share jointly with others as members of some group – we might expect emotions to play an even more central role. For to have a joint value together with others in a group, it is not enough simply that each member of the group in fact has that value; rather, the coincidence of these individual values must be non-accidental in that each values something because we do, where (other things being equal) one would in some sense be failing as a member of the group if one did not value it. Consequently, there must be some means by which such joint values are instituted among all members of the group, and this is plausibly where emotions come in: in addition to enabling us to attend and respond to values generally, we might expect emotional expressions to play an important role in communicating these values to our fellow members and thereby reinforcing the shared sense of value – and shared sense of community – joint values seem to require. My aim here is to explore that role and thereby to argue for a distinctive account of emotional expression, which I shall call the commitment account.
Objectives: Evaluate the association between pediatric sleep-disordered breathing (SDB) and executive functioning. Methods: We searched multiple electronic databases for peer-reviewed journal articles related to pediatric SDB and executive functioning. We included studies that assessed SDB via polysomnography, included objective or questionnaire measures of executive function, and had an age-matched control group. Fourteen articles met inclusion criteria with a total sample of 1697 children ages 5 to 17 years (M=9.81 years; SD=0.34). We calculated an overall effect size for each of the five executive domains (vigilance, inhibition, working memory, shifting, and generativity) as well as effect sizes according to SDB severity: mild, moderate, severe. We also calculated effect sizes separately for objective and subjective questionnaires of executive functioning. Results: We found a medium effect size (−0.427) for just one of five executive function domains on objective neuropsychological measures (generativity). In contrast, effect sizes on all three executive domains measured via questionnaire data were significant, with effect sizes ranging from medium (−0.64) to large (−1.06). We found no difference between executive domains by severity of SDB. Conclusions: This meta-analysis of executive function separated into five domains in pediatric SDB suggested lower performance in generativity on objective neuropsychological measures. There were no differences associated with SDB severity. Questionnaire data suggested dysfunction across the three executive domains measured (inhibition, working memory, shifting). Overall, limited evidence suggested poorer performance in executive function in children with SDB according to objective testing, and subjective ratings of executive function suggested additional worsened performance. (JINS, 2016, 22, 839–850)
Takotsubo cardiomyopathy has been associated with the use of catecholamines; however, its development after the use of nebulised adrenaline for the management of acute airway obstruction has not previously been described.
A 66-year-old man with squamous cell carcinoma of the larynx, with tumour–node–metastasis staging of T3N2cM0, confirmed by biopsy and computed tomography, presented to the emergency department with acute airway obstruction. He was treated twice with nebulised adrenaline and intravenous dexamethasone. After a period of 24 hours, cardiac rhythm changes were noted on telemetry. A 12-lead electrocardiogram showed widespread T-wave inversion and QT prolongation suggestive of an acute coronary syndrome. Coronary angiography demonstrated no coronary artery disease, but left ventricular angiography showed marked apical ballooning and apical wall akinesia consistent with a diagnosis of takotsubo cardiomyopathy.
Takotsubo cardiomyopathy can mimic true ischaemic heart disease and the diagnosis requires a high index of suspicion in patients managed with nebulised adrenaline.
A description is given of a radar facility operating in New Zealand which measures the atmospheric trajectories and hence heliocentric orbits of earth-impacting meteoroids having radiants with declinations +5° < δ < −30° down to a limiting radar meteor magnitude of +13 (corresponding to particle sizes of ~100 μm, masses ~10−6 g). The data handling capacity of the facility permits recording, orbit reduction and efficient presentation of orbital data using graphical packages to be carried out on a routine basis. The daily yield is ~1500 individual orbits with >3×105 secured to date; this is greater than the number determined in all previous meteoroid orbit surveys combined and forms a major southern hemisphere database for dynamical studies of the solar system meteoroid population.
Major depressive disorder (MDD) is moderately heritable, however genome-wide association studies (GWAS) for MDD, as well as for related continuous outcomes, have not shown consistent results. Attempts to elucidate the genetic basis of MDD may be hindered by heterogeneity in diagnosis. The Center for Epidemiological Studies Depression (CES-D) scale provides a widely used tool for measuring depressive symptoms clustered in four different domains which can be combined together into a total score but also can be analysed as separate symptom domains.
We performed a meta-analysis of GWAS of the CES-D symptom clusters. We recruited 12 cohorts with the 20- or 10-item CES-D scale (32 528 persons).
One single nucleotide polymorphism (SNP), rs713224, located near the brain-expressed melatonin receptor (MTNR1A) gene, was associated with the somatic complaints domain of depression symptoms, with borderline genome-wide significance (pdiscovery = 3.82 × 10−8). The SNP was analysed in an additional five cohorts comprising the replication sample (6813 persons). However, the association was not consistent among the replication sample (pdiscovery+replication = 1.10 × 10−6) with evidence of heterogeneity.
Despite the effort to harmonize the phenotypes across cohorts and participants, our study is still underpowered to detect consistent association for depression, even by means of symptom classification. On the contrary, the SNP-based heritability and co-heritability estimation results suggest that a very minor part of the variation could be captured by GWAS, explaining the reason of sparse findings.
The aim of this study was to compare patterns of cognitive decline in older Latinos and non-Latinos. At annual intervals for a mean of 5.7 years, older Latino (n=104) and non-Latino (n=104) persons of equivalent age, education, and race completed a battery of 17 cognitive tests from which previously established composite measures of episodic memory, semantic memory, working memory, perceptual speed, and visuospatial ability were derived. In analyses adjusted for age, sex, and education, performance declined over time in each cognitive domain, but there were no ethnic group differences in initial level of function or annual rate of decline. There was evidence of retest learning following the baseline evaluation, but neither the magnitude nor duration of the effect was related to Latino ethnicity, and eliminating the first two evaluations, during which much of retest learning occurred, did not affect ethnic group comparisons. Compared to the non-Latino group, the Latino group had more diabetes (38.5% vs. 25.0; χ2=4.4; p=.037), fewer histories of smoking (24.0% vs. 39.4%, χ2=5.7; p=.017), and lower childhood household socioeconomic level (−0.410 vs. −0.045, t[185.0]=3.1; p=.002), but controlling for these factors did not affect results. Trajectories of cognitive aging in different abilities are similar in Latino and non-Latino individuals of equivalent age, education, and race. (JINS, 2016, 22, 58–65)
The island of Cyprus was a major producer of copper and stood at the heart of east Mediterranean trade networks during the Late Bronze Age. It may also have been the source of the Red Lustrous Wheelmade Ware that has been found in mortuary contexts in Egypt and the Levant, and in Hittite temple assemblages in Anatolia. Neutron Activation Analysis (NAA) has enabled the source area of this special ceramic to be located in a geologically highly localised and geochemically distinctive area of western Cyprus. This discovery offers a new perspective on the spatial organisation of Cypriot economies in the production and exchange of elite goods around the eastern Mediterranean at this time.
A comprehensive examination of the European public sphere must consider Europeanization from below, of, and by civil society. As Jürgen Habermas argues, civil society has a key role to play in a democratic public sphere: civil society actors at the periphery of the formal political arena have the potential to bring new groups of citizens into the political debate and to highlight problems that may become central to the agenda (Habermas 1996c). If this potential were undermined, it would seriously exacerbate the democratic deficit in the European Union (EU) (Habermas 2006c). This chapter takes stock of the European public sphere with a focus on organized civil society and civil-society actors’ digital communication beyond the mass media.
Earlier studies have found that civil society is weakly represented in the European public sphere, leading to concerns about the lack of broad public engagement or citizen-level political contention. When the capacity of the (national) mass media to employ Europeanized frames and attend to transnational issues or actors is analyzed, the picture that emerges is an issue-driven European sphere in which a few issues or claim makers may reach different national media using similar frames during common periods. However, there is little civil society in this picture: claims are overwhelmingly made by elites who communicate to largely passive audiences. For example, when the European financial crisis erupted in 2010, national papers across the EU were filled with similar pronouncements from various officials, including national leaders such as German Chancellor Angela Merkel and EU officials such as the head of the European Central Bank. Civil society tends to be sketched in terms of voters in Greece or demonstrators in Spain, with few concrete authoritative claims attached. Beyond demonstrations and elections, there is little in the way of media characterizations of broader public engagement with the crisis and other policy issues that cut across both EU and national-governance processes. The question is whether civil society engagement in European public spheres is weak in itself or whether it is simply not captured in these analyses of mass-media content. We suggest that part of the answer may be the latter possibility. To analyze civil society dimensions of European public spheres, it makes sense to look beyond the mass media to the increasingly common alternative forms of public communication that civil society actors utilize.