To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Summary: In this paper we build on work investigating the feasibility of human immunodeficiency virus (HIV) testing in emergency departments (EDs), estimating the prevalence of hepatitis B, C and HIV infections among persons attending two inner-London EDs, identifying factors associated with testing positive in an ED. We also undertook molecular characterisation to look at the diversity of the viruses circulating in these individuals, and the presence of clinically significant mutations which impact on treatment and control.
Blood-borne virus (BBV) testing in non-traditional settings is feasible, with emergency departments (ED) potentially effective at reaching vulnerable and underserved populations. We investigated the feasibility of BBV testing within two inner-London EDs. Residual samples from biochemistry for adults (⩾18 years) attending The Royal Free London Hospital (RFLH) or the University College London Hospital (UCLH) ED between January and June 2015 were tested for human immunodeficiency virus (HIV)Ag/Ab, anti-hepatitis C (HCV) and HBsAg. PCR and sequence analysis were conducted on reactive samples. Sero-prevalence among persons attending RFH and UCLH with residual samples (1287 and 1546), respectively, were 1.1% and 1.0% for HBsAg, 1.6% and 2.3% for anti-HCV, 0.9% and 1.6% for HCV RNA, and 1.3% and 2.2% for HIV. For RFH, HBsAg positivity was more likely among persons of black vs. white ethnicity (odds ratio 9.08; 95% confidence interval 2.72–30), with anti-HCV positivity less likely among females (0.15, 95% CI 0.04–0.50). For UCLH, HBsAg positivity was more likely among non-white ethnicity (13.34, 95% CI 2.20–80.86 (Asian); 8.03, 95% CI 1.12–57.61 (black); and 8.11, 95% CI 1.13–58.18 (other/mixed)). Anti-HCV positivity was more likely among 36–55 year olds vs. ⩾56 years (7.69, 95% CI 2.24–26.41), and less likely among females (0.24, 95% CI 0.09–0.65). Persons positive for HIV-markers were more likely to be of black vs. white ethnicity (4.51, 95% CI 1.63–12.45), and less likely to have one ED attendance (0.39, 95% CI 0.17–0.88), or female (0.12, 95% CI 0.04–0.42). These results indicate that BBV-testing in EDs is feasible, providing a basis for further studies to explore provider and patient acceptability, referral into care and cost-effectiveness.
The construct of self-concept lies at the core of the positive psychology revolution. Historically, as one of the cornerstone constructs in the social sciences, the approach to self-concept has been adapted to focus on how healthy individuals can thrive in life. In this chapter we differentiate between the historical unidimensional perspective of self-concept (centered on self-esteem) and the evolving multifaceted models discriminating between different aspects of self (such as specific academic, social, physical, and emotional components).
the definition of self-concept and the reason it is so important;
historical and evolving perspectives of self-concept;
general and domain-specific theoretical models with associated empirical research regarding self-concept, motivation, and performance;
the way different self-concept domains vary as a function of gender and age;
the impact of specific psychological and social traits on self-concept development;
the differentiation between multidimensional perspectives of personality and self-concept;
theoretical models of academic self-concept formation and its relation to achievement;
frame of reference effects in self-concept formation;
a construct-validity approach to self-concept enhancement interventions; and directions for further research.
Introduction: Resource allocation planning (RAP) for emergency medical services (EMS) systems determines optimal resources for patient needs in order to minimize morbidity and mortality. The British Columbia Emergency Health Services developed a new RAP using an evidenced informed methodology, statistical analysis of outcomes and with further clinical input from EMS physicians, paramedics and allied EMS providers. The revised RAP was implemented on a pan provincial basis in fall of 2013. It is unknown how the modifications will affect outcomes of EMS cases. Population-based analysis was used to determine the effect of a comprehensive RAP changes by comparing 24-hour mortality before and after province-wide implementation of the revised RAP. Methods: The primary outcome, 24-hour mortality, was obtained through linked provincial health administrative data. All adult cases with evaluable outcome data were included in the analysis. A pre and post methodology was used to evaluate the effect of post-RAP revision (post-RAP-revision) on 24-hour mortality compared to pre-RAP revision (pre-RAP-revision). Multivariable logistic regression was used to adjust for variations in other significant factors associated with 24-hour mortality. The interrupted time series (ITS) estimated any immediate changes in the level or trend of outcome after the start of the revised RAP implementation (fall of 2013), while simultaneously controlling for pre-existing trends. Results: The cohort is comprised of 562,546 cases (April 2012 March 2015). In the multivariate model, adjusted for age, sex, urban/metro region, season, day hour, and MPDS determinant, the probability of dying within 24 hours of EMS call was 7% lower in the post-RAP-revision cohort (OR=0.936; 95% CI: 0.886 - 0.989; P=0.018). A sub-group analysis of immediately life-threatening cases demonstrated similar effect (OR=0.890; 95% CI: 0.808 - 0.981; P=0.019) Conclusion: Our results demonstrate that a comprehensive, evidence informed reconstruction of a provincial EMS RAP is feasible. Despite considerable change in crew level response and resource allocation, there was significant decrease in 24 hour mortality in a large pan-provincial population based patient cohort.
Introduction: Primary care paramedics (PCPs) have limited options to provide analgesia during transport thus timely pain relief is often significantly delayed. Inhaled nitrous oxide is considered usual care for PCPs, but is limited in effectiveness. Intranasal (IN) ketamine has been shown to provide effective analgesia with no deleterious effects on cardiorespiratory function thus may provide rapid, easily-administered and well-tolerated analgesia in prehospital transports. Methods: This was a randomized double-blind pilot series. Patients with an acute painful condition reporting a pain score of 5 or more on an 11-point verbal numeric rating scale (VNRS) were included. Exclusion criteria were age under 18 years, known intolerance to ketamine, non-traumatic chest pain, altered mental status, pregnancy and nasal occlusion. Patients were randomized to 0.75 mg/kg of IN ketamine or IN saline. All patents received inhaled nitrous oxide. The primary outcome was the proportion of patients experiencing a reduction in VNRS pain score of two points or more (clinically significant pain reduction) at 30 minutes. Secondary outcomes were patient-reported comfort, patient and provider satisfaction, and incidence of adverse events. Results: 40 patients were enrolled, 20 in each group. 80% of IN ketamine patients compared to 60% of placebo patients reported a 2-point reduction in VNRS pain score by 30 minutes. 50% of ketamine vs 25% of placebo patients reported feeling moderately or much better. 85% of ketamine vs 75% of placebo patients reported any improvement in subjective comfort. 80% of ketamine patients reported minor adverse effects compared to 52% of placebo patients. No serious adverse effects were reported. Conclusion: The addition of IN ketamine to usual care with nitrous oxide appears to result in a greater proportion of patients reporting a clinically significant reduction in VNRS pain score and improved subjective comfort, with a greater incidence of minor adverse effects. These findings will be used to power a definitive randomized double-blind trial.
Middens (nests and caches) of Late Pleistocene arctic ground squirrels (Urocitellus parryii) that are preserved in the permafrost of Beringia archive valuable paleoecological data. Arctic ground squirrels selectively include the plant material placed in middens. To account for this selectivity bias, we used a multi-proxy approach that includes ancient DNA (aDNA) and macro- and microfossil analyses. Here, we provide insight into Pleistocene vegetation conditions using macrofossils, pollen, phytoliths and non-pollen palynomorphs, and aDNA collected from one such midden from the Yukon Territory (Canada), which was formed between 30,740 and 30,380 cal yr BP. aDNA confirmed the midden was constructed by U. parryii. We recovered 39 vascular plant and bryophyte genera and 68 fungal genera from the midden samples. Grass and other herbaceous families dominated vegetation assemblages according to all proxies. aDNA data yielded several records of vascular plants that are outside their current biogeographic range, while some of the recovered fungi yielded additional evidence for local occurrence of Picea trees during glacial conditions. We propose that future work on fossil middens should combine the study of macro- and microfossils with aDNA analysis to get the most out of these environmental archives.
Among other items, the Bessel/Struve correspondence reflects the competition between the two astronomers in deriving a value of a stellar parallax significantly differing from zero. This paper summarizes the letters written between 1837 and 1840.
Introduction: Survival for victims of out-of-hospital cardiac arrest (OHCA) is typically 8-12%. Recent evidence has shown that public access automatic external defibrillators (AED) may improve survival. The objectives of this study were to determine whether AEDs improve rates of return of spontaneous circulation (ROSC), overall survival, and favourable neurological survival (FNS) in Canada. Methods: The BC Resuscitation Outcomes Consortium prospectively collected detailed prehospital and hospital data on consecutive non-traumatic OHCAs from 2011-2015 within BC’s four metropolitan areas. We included all EMS-treated adult patients. Data were collected in accordance with recognized Utstein criteria. We described frequencies with counts, means and medians where appropriate, and the Z-test was used to compare population proportions. Results: We examined 7577 OHCAs from 2011-2015. AEDs were deployed on 223 patients in this period (mean age 60.4 yrs [95% CI 45.7-75.1] and 83.9% male; non-AED OHCAs mean age 66.2 yrs [48.4-83.8] and 67.3% male). Seventy seven percent of AED deployments occurred in public locations, 69.1% were witnessed by bystanders and CPR was initiated in 98.7% of these cases. Fifteen percent of non-AED OHCAs occurred in public locations, 38.3% were bystander witnessed, and 45.4% received bystander CPR. AEDs delivered shocks to 61.4% of patients, and EMS crews found an initial shockable rhythm upon scene arrival in 60.5% of AED deployments (22.9% for non-AED cases). AED OHCA patients had higher rates of ROSC at any time (67.2% vs 47.6%; difference of 19.6% [12.9-26.2 p<0.01]), and ROSC at ED arrival (61% vs 35.4%; difference of 25.6% [19.2-32.0 p<0.01]). AED OHCA patients had higher rates of survival to hospital discharge (23.8% vs 8.5%; difference 15.3% [11.5-19.1 p<0.01]). Detailed neurologic outcome data was not available for all patients, yet for those which it was available AED OHCA patients had improved outcomes (modified Rankin score<2) compared to non-AED OHCA patients (9.0% vs 5.4%; difference 3.6% [0.6-6.6 p<0.02]. Conclusion: Automatic external defibrillators markedly improve rates of ROSC at any time, sustained ROSC at ED arrival, survival to hospital discharge, and FNS in Canada. Continued support for public access AED programs is essential to improve patient outcomes.
Introduction: Survival for victims of out-of-hospital cardiac arrest (OHCA) is typically between 8 and 12%. We sought to report the trends in survival in British Columbia (BC) over a 10-year period. Methods: The BC Resuscitation Outcomes Consortium prospectively collected detailed prehospital and hospital data on consecutive non-traumatic OHCAs from 2006 to 2016 within BC’s four metropolitan areas. We included EMS-treated adult patients without DNR orders. To describe baseline characteristics we organized patient characteristics in three time periods: 2006-09, 2010-13, and 2014-16 (first and last periods reported below). The primary and secondary endpoints were survival at hospital discharge and return of spontaneous circulation (ROSC). We tested the significance of year-by-year trends in baseline characteristics, and performed multivariable Poisson regression, using calendar year as an independent variable, to calculate risk-adjusted rates for survival. Results: Between January 1, 2006 and March 31, 2016 there were a total of 26 433 non-traumatic OHCAs, with 15 145 included in this study. There were significant decreases in the proportion with initial shockable cardiac rhythms (28% to 23%) and bystander witnessed arrests (42% to 39%), however significant increases in the proportion with bystander CPR (40% to 49%) and ALS treatment (86% to 97%), and the median chest compression fraction (0.81 to 0.87). There was a significant increase in the median time until termination of resuscitation in those who did not achieve ROSC (27 to 32 minutes), and a significant decrease in the proportion of patients who were transported in absence of ROSC (17% to 6.5%). There was a significant improvement in achieving ROSC (44% to 48%; adjusted rate ratio per year 1.02, 95% CI 1.01 to 1.02) and survival at hospital discharge (10% to 14%; adjusted rate ratio per year 1.05, 95% CI 1.04 to 1.06). Both subgroups of initial shockable (adjusted rate ratio per year 1.04, 95% CI 1.03 to 1.05) and non-shockable (adjusted rate ratio per year 1.08, 95% CI 1.06 to 1.12) cardiac rhythms demonstrated survival improvement. Conclusion: Despite a significant decrease in those with initial shockable rhythms, out-of-hospital cardiac arrest survival in BC’s metropolitan regions increased by approximately 40% over a 10-year period. During this time there were system changes and quality of care improvements as provided by bystanders and professionals.
To evaluate the impact of multidrug-resistant gram-negative rod (MDR-GNR) infections on mortality and healthcare resource utilization in community hospitals.
Two matched case-control analyses.
Six community hospitals participating in the Duke Infection Control Outreach Network from January 1, 2010, through December 31, 2012.
Adult patients admitted to study hospitals during the study period.
Patients with MDR-GNR bloodstream and urinary tract infections were compared with 2 groups: (1) patients with infections due to nonMDR-GNR and (2) control patients representative of the nonpsychiatric, non-obstetric hospitalized population. Four outcomes were assessed: mortality, direct cost of hospitalization, length of stay, and 30-day readmission rates. Multivariable regression models were created to estimate the effect of MDR status on each outcome measure.
No mortality difference was seen in either analysis. Patients with MDR-GNR infections had 2.03 higher odds of 30-day readmission compared with patients with nonMDR-GNR infections (95% CI, 1.04–3.97, P=.04). There was no difference in hospital direct costs between patients with MDR-GNR infections and patients with nonMDR-GNR infections. Hospitalizations for patients with MDR-GNR infections cost $5,320.03 more (95% CI, $2,366.02–$8,274.05, P<.001) and resulted in 3.40 extra hospital days (95% CI, 1.41–5.40, P<.001) than hospitalizations for control patients.
Our study provides novel data regarding the clinical and financial impact of MDR gram-negative bacterial infections in community hospitals. There was no difference in mortality between patients with MDR-GNR infections and patients with nonMDR-GNR infections or control patients.
Increased marine 14C reservoir ages from the surface water of the North Atlantic are documented for the Younger Dryas period. We use terrestrial and marine AMS 14C dates from the time of deposition of the Icelandic Vedde Ash to examine the marine 14C reservoir age. This changed from its modem North Atlantic value of ca. 400 yr to ca. 700 yr during the Younger Dryas climatic event. The increased marine reservoir age has implications for both comparing climatic time series dated by 14C and understanding palaeoceanographic changes that generated the increase.
To describe compliance with the central line (CL) insertion bundle overall and with individual bundle elements in US adult intensive care units (ICUs) and to determine the relationship between bundle compliance and central line–associated bloodstream infection (CLABSI) rates.
National sample of adult ICUs participating in National Healthcare Safety Network (NHSN) surveillance.
Hospitals were surveyed to determine compliance with CL insertion bundle elements in ICUs. Corresponding NHSN ICU CLABSI rates were obtained. Multivariate Poisson regression models were used to assess associations between CL bundle compliance and CLABSI rates, controlling for hospital and ICU characteristics.
A total of 984 adult ICUs in 632 hospitals were included. Most ICUs had CL bundle policies, but only 69% reported excellent compliance (≥95%) with at least 1 element. Lower CLABSI rates were associated with compliance with just 1 element (incidence rate ratio [IRR] 0.77; 95% confidence interval [CI], 0.64–0.92); however, ≥95% compliance with all 5 elements was associated with the greatest reduction (IRR, 0.67; 95% CI, 0.59–0.77). There was no association between CLABSI rates and simply having a written CL bundle policy nor with bundle compliance <75%. Additionally, better-resourced infection prevention departments were associated with lower CLABSI rates.
Our findings demonstrate the impact of transferring infection prevention interventions to the real-world setting. Compliance with the entire bundle was most effective, although excellent compliance with even 1 bundle element was associated with lower CLABSI rates. The variability in compliance across ICUs suggests that, at the national level, there is still room for improvement in CLABSI reduction.
The Amsterdam glacial basin was a major sedimentary sink from late Saalian until late Eemian (Picea zone, E6) times. The basin’s exemplary record makes it a potential reference area for the last interglacial stage. The cored Amsterdam-Terminal borehole was drilled in 1997 to provide a record throughout the Eemian interglacial. Integrated facies analysis has resulted in a detailed reconstruction of the sedimentary history.
After the Saalian ice mass had disappeared from the area, a large, deep lake had come into being, fed by the Rhine river. At the end of the glacial, the lake became smaller because it was cut off from the river-water supply, and eventually only a number of shallow pools remained in the Amsterdam basin. During the early Eemian (Betula zone, El), a seepage lake existed at the site. The lake deepened under the influence of a steadily rising sea level and finally evolved into a silled lagoon (late Quercus zone, E3). Initially, the lagoon water had fairly stable stratification, but as the sea level continued to rise the sill lost its significance, the lagoon becoming well mixed by the middle of the Corylus/Taxus zone (E4b). The phase of free exchange with the open sea ended in the early Carpinus zone (E5), when barriers developed in the sill area causing the lagoon to become stratified again. During the Late Eemian (late E5), a more dynamic system developed. The sandy barriers that had obstructed exchange with the open sea were no longer effective, and a tidally-influenced coastal lagoon formed.
The Eemian sedimentary history shown in the Amsterdam-Terminal borehole is intimately connected with the sea-level history. Because the site includes both a high-resolution pollen signal and a record of sea-level change, it has potential for correlation on various scales. Palaeomagnetic results show that the sediments predate the Blake Event, which confirms that this reversal excursion is relatively young. The U/Th age of the uppermost part of the Eemian sequence is 118.2±6.3 ka.
Besides the link of the HIPPARCOS reference frame to extragalactic objects via radio stars or by the HST, also photographic astrometry is able to calibrate the HIPPARCOS proper motions with regard to an inertial system. Numerical simulations have shown that even with a very small number of well-distributed link fields (3 to 5) the photographic method is competitive with other techniques.
To describe the epidemiology of complex surgical site infection (SSI) following commonly performed surgical procedures in community hospitals and to characterize trends of SSI prevalence rates over time for MRSA and other common pathogens
We prospectively collected SSI data at 29 community hospitals in the southeastern United States from 2008 through 2012. We determined the overall prevalence rates of SSI for commonly performed procedures during this 5-year study period. For each year of the study, we then calculated prevalence rates of SSI stratified by causative organism. We created log-binomial regression models to analyze trends of SSI prevalence over time for all pathogens combined and specifically for MRSA.
A total of 3,988 complex SSIs occurred following 532,694 procedures (prevalence rate, 0.7 infections per 100 procedures). SSIs occurred most frequently after small bowel surgery, peripheral vascular bypass surgery, and colon surgery. Staphylococcus aureus was the most common pathogen. The prevalence rate of SSI decreased from 0.76 infections per 100 procedures in 2008 to 0.69 infections per 100 procedures in 2012 (prevalence rate ratio [PRR], 0.90; 95% confidence interval [CI], 0.82–1.00). A more substantial decrease in MRSA SSI (PRR, 0.69; 95% CI, 0.54–0.89) was largely responsible for this overall trend.
The prevalence of MRSA SSI decreased from 2008 to 2012 in our network of community hospitals. This decrease in MRSA SSI prevalence led to an overall decrease in SSI prevalence over the study period.
To determine whether daily chlorhexidine gluconate (CHG) bathing of intensive care unit (ICU) patients leads to a decrease in hospital-acquired infections (HAIs), particularly infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).
Interrupted time series analysis.
The study included 33 community hospitals participating in the Duke Infection Control Outreach Network from January 2008 through December 2013.
All ICU patients at study hospitals during the study period.
Of the 33 hospitals, 17 hospitals implemented CHG bathing during the study period, and 16 hospitals that did not perform CHG bathing served as controls. Primary pre-specified outcomes included ICU central-line–associated bloodstream infections (CLABSIs), primary bloodstream infections (BSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTIs). MRSA and VRE HAIs were also evaluated.
Chlorhexidine gluconate (CHG) bathing was associated with a significant downward trend in incidence rates of ICU CLABSI (incidence rate ratio [IRR], 0.96; 95% confidence interval [CI], 0.93–0.99), ICU primary BSI (IRR, 0.96; 95% CI, 0.94–0.99), VRE CLABSIs (IRR, 0.97; 95% CI, 0.97–0.98), and all combined VRE infections (IRR, 0.96; 95% CI, 0.93–1.00). No significant trend in MRSA infection incidence rates was identified prior to or following the implementation of CHG bathing.
In this multicenter, real-world analysis of the impact of CHG bathing, hospitals that implemented CHG bathing attained a decrease in ICU CLABSIs, ICU primary BSIs, and VRE CLABSIs. CHG bathing did not affect rates of specific or overall infections due to MRSA. Our findings support daily CHG bathing of ICU patients.
To determine the association (1) between shorter operative duration and surgical site infection (SSI) and (2) between surgeon median operative duration and SSI risk among first-time hip and knee arthroplasties.
Retrospective cohort study
A total of 43 community hospitals located in the southeastern United States.
Adults who developed SSIs according to National Healthcare Safety Network criteria within 365 days of first-time knee or hip arthroplasties performed between January 1, 2008 and December 31, 2012.
Log-binomial regression models estimated the association (1) between operative duration and SSI outcome and (2) between surgeon median operative duration and SSI outcome. Hip and knee arthroplasties were evaluated in separate models. Each model was adjusted for American Society of Anesthesiology score and patient age.
A total of 25,531 hip arthroplasties and 42,187 knee arthroplasties were included in the study. The risk of SSI in knee arthroplasties with an operative duration shorter than the 25th percentile was 0.40 times the risk of SSI in knee arthroplasties with an operative duration between the 25th and 75th percentile (risk ratio [RR], 0.40; 95% confidence interval [CI], 0.38–0.56; P<.01). Short operative duration did not demonstrate significant association with SSI for hip arthroplasties (RR, 1.04; 95% CI, 0.79–1.37; P=.36). Knee arthroplasty surgeons with shorter median operative durations had a lower risk of SSI than surgeons with typical median operative durations (RR, 0.52; 95% CI, 0.43–0.64; P<.01).
Short operative durations were not associated with a higher SSI risk for knee or hip arthroplasty procedures in our analysis.
Infect. Control Hosp. Epidemiol. 2015;36(12):1431–1436