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To describe the pattern of blood culture utilization in an academic university hospital setting.
Retrospective cohort study.
A 789-bed tertiary-care university hospital that processes 40,000+blood cultures annually.
We analyzed blood cultures collected from adult inpatients at the Hospital of the University of Pennsylvania between July 1, 2014, and June 30, 2015. Descriptive statistics and regression models were used to analyze patterns of blood culture utilization: frequency of blood cultures, use of repeat cultures following a true-positive culture, and number of sets drawn per day.
In total, 38,939 blood culture sets were drawn during 126,537 patient days (incidence rate, 307.7 sets per 1,000 patient days). The median number of blood culture sets drawn per hospital encounter was 2 (range, 1–76 sets). The median interval between blood cultures was 2 days (range, 1–71 days). Oncology services and cultures with gram-positive cocci were significantly associated with greater odds of having repeat blood cultures drawn the following day. Emergency services had the highest rate of drawing single blood-culture sets (16.9%), while oncology services had the highest frequency of drawing ≥5 blood culture sets within 24 hours (0.91%). Approximately 10% of encounters had at least 1 true-positive culture, and 89.2% of those encounters had repeat blood cultures drawn. The relative risk of a patient having repeat blood cultures was lower for those in emergency, surgery, and oncology services than for those in general medicine.
Ordering practices differed by service and culture results. Analyzing blood culture utilization can contribute to the development of guidelines and benchmarks for appropriate usage.
Introduction: Continued smoking by cancer patients causes adverse cancer treatment outcomes, but few patients receive evidence-based smoking cessation as a standard of care.
Aim: To evaluate practical strategies to promote wide-scale dissemination and implementation of evidence-based tobacco cessation services within state cancer centers.
Methods: A Collaborative Learning Model (CLM) for Quality Improvement was evaluated with three community oncology practices to identify barriers and facilitate practice change to deliver evidence-based smoking cessation treatments to cancer patients using standardized assessments and referrals to statewide smoking cessation resources. Patients were enrolled and tracked through an automated data system and received follow-up cessation support post-enrollment. Monthly quantitative reports and qualitative data gathered through interviews and collaborative learning sessions were used to evaluate meaningful quality improvement changes in each cancer center.
Results: Baseline practice evaluation for the CLM identified the lack of tobacco use documentation, awareness of cessation guidelines, and awareness of services for patients as common barriers. Implementation of a structured assessment and referral process demonstrated that of 1,632 newly registered cancer patients,1,581 (97%) were screened for tobacco use. Among those screened, 283 (18%) were found to be tobacco users. Of identified tobacco users, 207 (73%) were advised to quit. Referral of new patients who reported using tobacco to an evidence-based cessation program increased from 0% at baseline across all three cancer centers to 64% (range = 30%–89%) during the project period.
Conclusions: Implementation of quality improvement learning collaborative models can dramatically improve delivery of guideline-based tobacco cessation treatments to cancer patients.
To determine whether antimicrobial-impregnated textiles decrease the acquisition of pathogens by healthcare provider (HCP) clothing.
We completed a 3-arm randomized controlled trial to test the efficacy of 2 types of antimicrobial-impregnated clothing compared to standard HCP clothing. Cultures were obtained from each nurse participant, the healthcare environment, and patients during each shift. The primary outcome was the change in total contamination on nurse scrubs, measured as the sum of colony-forming units (CFU) of bacteria.
PARTICIPANTS AND SETTING
Nurses working in medical and surgical ICUs in a 936-bed tertiary-care hospital.
Nurse subjects wore standard cotton-polyester surgical scrubs (control), scrubs that contained a complex element compound with a silver-alloy embedded in its fibers (Scrub 1), or scrubs impregnated with an organosilane-based quaternary ammonium and a hydrophobic fluoroacrylate copolymer emulsion (Scrub 2). Nurse participants were blinded to scrub type and randomly participated in all 3 arms during 3 consecutive 12-hour shifts in the intensive care unit.
In total, 40 nurses were enrolled and completed 3 shifts. Analyses of 2,919 cultures from the environment and 2,185 from HCP clothing showed that scrub type was not associated with a change in HCP clothing contamination (P=.70). Mean difference estimates were 0.118 for the Scrub 1 arm (95% confidence interval [CI], −0.206 to 0.441; P=.48) and 0.009 for the Scrub 2 rm (95% CI, −0.323 to 0.342; P=.96) compared to the control. HCP became newly contaminated with important pathogens during 19 of the 120 shifts (16%).
Antimicrobial-impregnated scrubs were not effective at reducing HCP contamination. However, the environment is an important source of HCP clothing contamination.
Introduction: The emergence of electronic cigarettes (ECs) has become a growing phenomenon that has sharply split opinion among the public health community, physicians, and lawmakers.
Aims: We sought to determine chest physician perceptions regarding ECs.
Methods: We conducted a web-based survey of 18,000 American College of Chest Physician (CHEST) members to determine health care provider experiences with EC users and to characterise provider perceptions regarding ECs.
Results/Findings: There were 994 respondents. Eighty-eight per cent reported that patients had asked their opinion of ECs, and 31% reported EC use among at least 10% of their patients. More disagreed than agreed (41% vs. 21%) that patients could improve their health by switching from tobacco smoking to daily EC use. Respondents were split on whether ECs promote tobacco cessation (32% agree vs. 33% disagree).
Conclusions: Current perceptions of ECs are variable among providers. More than 1/3 of respondents felt that EC's could be used for smoking cessation for smokers who failed prior quit attempts with approved therapies. However, many respondents were not convinced that ECs will reduce harms from tobacco use. There is an urgent need to generate additional high quality scientific data regarding ECs to inform chest physicians, health professionals, and the general public.
We present the first quantitative attempt at reconciling the source and emplacement of granite erratics in Beacon Valley. The erratics are enigmatic because granite does not crop out in the valley and its nearest subaerial exposure is at least 10 km downstream to the east of the valley. Detailed mapping of the valley shows three types of granite erratics, which are not present in equal amounts and do not show spatial patterns. Pb isotopic and elemental compositions of the erratics eliminate the Metschel Tillite as a source and indicate they derive from the Dry Valley plutons. Our limited study tentatively ties the erratics to suites of plutons, but it does not allow a direct tie of the erratics to specific plutons because of i) the geochemical variability of the plutons and ii) the limited number of erratics that were analysed. Published data suggest the erratics provide evidence of wet-based glaciation, which covered the Dry Valleys and much of Antarctica during the mid-Miocene. Our paper also explains the problems associated with the emplacement of these erratics and the age of the massive ice in Beacon Valley.
Introduction: The Medical University of South Carolina (MUSC) hospital implemented an inpatient opt-out smoking-cessation service where smokers received a mandatory smoking-cessation consult and phone follow-up within 1-month post-discharge.
Aim: To examine predictors of patients who opted-out of bedside counselling or follow-up phone calls.
Methods: Eligible adult cigarette smokers admitted to the MUSC hospital were enrolled in the programme. Opting-out of bedside consult or follow-up calls were assessed separately using log-linear modelling where predictors included patient demographics, length of hospitalisation, insurance type, smoking history, and motivation/confidence to quit.
Results: Of the 38,758 admitted patients (February 2014–May 2015), 6,684 reported currently smoking and were automatically referred to bedside-consult. Approximately 26% of smokers made contact with the counselor, most of whom (83%) accepted the consult. Amongst patients eligible for post-discharge follow-up (n = 3485), 49% responded to the calls. Those who opted-out of the bedside-consult were mostly males (RR = 1.29). Those who did not respond to follow-up calls were younger age (RR = 1.33), with Medicaid/no insurance (RR = 1.17), and had not received a bedside consult (RR = 1.32).
Conclusions: An opt-out smoking-cessation programme was feasible and acceptable to most patients and was able to reach 65% of eligible smokers; 17% opted-out of bedside counselling; <1% asked to be removed from further phone calls.
The binary X-ray source GX 1 + 4 was observed during a balloon flight in 1986, November. The source was in a relatively high intensity state. Time analysis of the data shows that the pulsation period was 111.8 ± 1.0 s indicating that one or more episodes of spin-down occurred between 1980 and 1986. Folded pulse profiles are very broad with an indication of a notch at the peak. Evidence has been found for a correlation between hard X-ray intensity and phase of the proposed 304 day orbital period. The time averaged intensity since 1980 is an order of magnitude lower than during the 1970’s. A survey of the post 1980 data shows that several reversals of the period derivative have occurred. Spin-up at the rates typical of the 1970’s has been followed by a dramatic spin-down episode with dP/dt>2.4 × 10−7 s/s.
Background: This study examined mortality due to multiple sclerosis (MS) in Canada, 1975-2009 to determine whether there has been a change in age at death relative to the general population and decrease in MS mortality rates. Methods: Mortality rates/100,000 population for MS and all causes were calculated using data derived from Statistics Canada, age-standardized to the 2006 population. Results: The average annual Canadian MS mortality rate, 1975-2009 was 1.23/100,000. Five-year rates for 1975-79, 1980-84, 1985-89, 1990-94, 1995-99, 2000-04, 2005-09 were: 1.16, 0.94, 1.01, 1.16, 1.30, 1.43, 1.33. Trend analysis showed mortality rates over the entire 35 years were stable (average annual percent change of less than one percent). The average annual 1975-2009 rates for females and males were 1.45 and 0.99. Five-year female rates were always higher than males. Regardless of gender, there was a decrease in MS mortality rates in the 0-39 age group and increases in the 60-69, 70-79, and 80+ groups over time. In contrast, there were decreases in all-cause mortality rates across each age group. The highest MS mortality rates for 1975-2009 were consistently in the 50-59 and 60-69 groups for both genders, while the highest all-cause mortality rates were in the 80+ group. Conclusions: Changes in the age distribution of MS mortality rates indicate a shift to later age at death, possibly due to improved health care. However MS patients remain disadvantaged relative to the general population and changes in age at death are not reflected in decreased mortality rates.
Background: Our study examined whether there are differences in MS mortality rates across regions of Canada, which might suggest differences in environment or health care practice that influence outcome. Methods: Statistics Canada data on deaths due to MS and populations at risk, 1975-2009, were derived from the Research Data Centre, University of Alberta. Mortality rates and 95% confidence intervals (CIs) were calculated per 100,000 population for the Atlantic Provinces, Quebec, Ontario and Western Provinces (including Northwest Territories, Yukon, Nunavut), age-standardized to the 2006 population. Results: The average annual MS mortality rates for 1975-2009 per 100,000 population (CIs) were: Atlantic Provinces 1.09 (0.43,1.74); Quebec 1.30 (0.89,1.71); Ontario 1.08 (0.77,1.38); Western Provinces 1.39 (0.99,1.78). Female mortality rates were consistently higher than male rates but there were no differences in the female:male mortality rate ratios across regions. Trend analysis showed that rates were stable over the 35 year time span in 3 regions with non-significant average annual per cent increases/decreases of: Atlantic Provinces –0.43%; Quebec +0.12%; and Western Provinces +0.27%. Only Ontario showed a slight but significant increase of +0.81% (p<0.05). Conclusions: MS mortality rates are similar across the Canadian regions, suggesting that patients are not disadvantaged in terms of mortality by their place of residence.
Cover crops represent a potentially important biological filter during weed community assembly in agroecosystems. This filtering could be considered directional if different cover-crop species result in weed communities with predictably different species composition. We examined the following four questions related to the potential filtering effects of cover crops in a field experiment involving five cover crops grown in monoculture and mixture: (1) Do cover crops differ in their effect on weed community composition? (2) Is competition more intense between cover crops and weeds that are in the same family or functional group? (3) Is competition more intense across weed functional types in a cover-crop mixture compared with cover crops grown in monocultures? (4) Within a cover-crop mixture, is a higher seeding rate associated with more effective biotic filtering of the weed community? We found some evidence that cover crops differentially filtered weed communities and that at least some of these filtering effects were due to differential biomass production across cover-crop species. Monocultures of buckwheat and sorghum–sudangrass reduced the number of weed species relative to the no-cover-crop control by an average of 36 and 59% (buckwheat) and 25 and 40% (sorghum–sudangrass) in 2011 and 2012, respectively. We found little evidence that competition intensity was dependent upon the family or functional classification of the cover crop or weeds, or that cover-crop mixtures were stronger assembly filters than the most effective monocultures. Although our results do not suggest that annual cover crops exert strong directional filtering during weed community assembly, our methodological framework for detecting such effects could be applied to similar future studies that incorporate a greater number of cover-crop species and are conducted under a greater range of cover-cropping conditions.
Elastic engineering strain has been regarded as a low-cost and continuously variable manner for altering the physical and chemical properties of materials, and it becomes even more important at low-dimensionality because at micro/nanoscale, materials/structures can usually bear exceptionally high elastic strains before failure. The elastic strain effects are therefore greatly magnified in micro/nanoscale structures and should be of great potential in the design of novel functional devices. The purpose of this overview is to present a summary of our recently progress in the energy band engineering of elastically bent ZnO micro/nanowires. First, we present the electronic and mechanical coupling effect in bent ZnO nanowires. Second, we summary the bending strain gradient effect on the near-band-edge (NBE) emission photon energy of bent ZnO micro/nanowires. Third, we show that the strain can induce exciton fine-structure splitting and shift in ZnO microwires. Our recent progresses illustrate that the electronic band structure of ZnO micro/nanowires can be dramatically tuned by elastic strain engineering, and point to potential future applications based on the elastic strain engineering of ZnO micro/nanowires.
The accumulation of boron within the porous nickel ferrite (NiFe2O4, NFO) deposits on nuclear fuel rods is a major technological problem with important safety and economical implications. In this work, first-principles results are combined with experimental thermochemical data to analyze the energetics of vacancy formation in NFO and the possibility of B incorporation into the structure of NFO. Under solid-solid equilibrium conditions, the calculations suggest that vacancy formation and B incorporation into the NFO structure is energetically unfavorable, the main limiting factors being the narrow stability domain of NFO and the precipitation of B2O3, Fe3BO5, and Ni3B2O6 as secondary phases. Assuming solid-liquid equilibrium between NFO and the surrounding aqueous solution saturated with respect to NFO, the calculations predict that in operating PWR environment, Ni vacancies are likely to form. Under these conditions the possibility of B incorporation at the Ni vacancy sites cannot be excluded.
The formation of misfit dislocations is an important issue for the performance of heteroepitaxial micro- and optoelectronic devices. We analyze three approaches that quantify the stability of misfit dislocations in axial-heteroepitaxial nanowires with respect to applicability and predictions of critical nanowire dimensions. The “nanoheteroepitaxy” approach of Zubia and Hersee proves suitable for determination of strain partitioning in the presence of an elastic mismatch. Concerning the critical thickness and diameter however the descriptions of Ertekin et al. and Glas respectively yield more reliable results, owing to the consideration of the total coherent and dislocation related energies plus the residual strain energy. In contrast to the model of Ertekin et al., which refers to infinitely long nanowires, the other two mentioned approaches allow predictions of the critical thickness of mismatched deposits on the nanowire axial face.
The advance in Electron Backscatter Diffraction known as High Resolution EBSD has permitted the strain tensor components and neighbour disorientation measurements to be mapped at resolutions better than 2 parts in 10000. Following earlier research into this technique which was focused on verifying the sensitivity and accuracy of the measurements, recent studies have involved investigations on semiconductor and metallic polycrystalline materials. In particular observations of localized regions where residual strains exceeded the macroscopic yield stress have been thoroughly investigated to eliminate experimental error as a possible explanation. No such cause was found. Strain measurements on polycrystalline steels in uniaxial tension and during thermal stress relieving thermal treatment have also been carried out. Maps of the strain distribution during elastic loading and early stages of plastic flow showed hot spots of high strain as in the static tests but overall the measured elastic strain was equal to the applied strain.
The Whillans Ice Stream Subglacial Access Research Drilling (WISSARD) project will test the overarching hypothesis that an active hydrological system exists beneath a West Antarctic ice stream that exerts a major control on ice dynamics, and the metabolic and phylogenetic diversity of the microbial community in subglacial water and sediment. WISSARD will explore Subglacial Lake Whillans (SLW, unofficial name) and its outflow toward the grounding line where it is thought to enter the Ross Ice Shelf seawater cavity. Introducing microbial contamination to the subglacial environment during drilling operations could compromise environmental stewardship and the science objectives of the project, consequently we developed a set of tools and procedures to directly address these issues. WISSARD hot water drilling efforts will include a custom water treatment system designed to remove micron and sub-micron sized particles (biotic and abiotic), irradiate the drilling water with germicidal ultraviolet (UV) radiation, and pasteurize the water to reduce the viability of persisting microbial contamination. Our clean access protocols also include methods to reduce microbial contamination on the surfaces of cables/hoses and down-borehole equipment using germicidal UV exposure and chemical disinfection. This paper presents experimental data showing that our protocols will meet expectations established by international agreement between participating Antarctic nations.
We are developing a purely commensal survey experiment for fast (<5 s) transient radio sources. Short-timescale transients are associated with the most energetic and brightest single events in the Universe. Our objective is to cover the enormous volume of transients parameter space made available by ASKAP, with an unprecedented combination of sensitivity and field of view. Fast timescale transients open new vistas on the physics of high brightness temperature emission, extreme states of matter and the physics of strong gravitational fields. In addition, the detection of extragalactic objects affords us an entirely new and extremely sensitive probe on the huge reservoir of baryons present in the IGM. We outline here our approach to the considerable challenge involved in detecting fast transients, particularly the development of hardware fast enough to dedisperse and search the ASKAP data stream at or near real-time rates. Through CRAFT, ASKAP will provide the testbed of many of the key technologies and survey modes proposed for high time resolution science with the SKA.