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To determine the relative risk of invasive methicillin-resistant Staphylococcus aureus (MRSA) infection among non-colonized (NC) patients, intermittently colonized (IC) patients, and persistently colonized (PC) patients.
Observational cohort study of patient data collected longitudinally over a 41-month period.
Department of Veterans Affairs Eastern Colorado Healthcare System, a tertiary care medical center.
Any patient who received ≥5 MRSA nasal swab tests between February 20, 2010, and July 26, 2013. In total, 3,872 patients met these criteria, 0 were excluded, 95% were male, 71% were white, and the mean age was 62.9 years on the date of study entry.
Patients were divided into cohorts based on MRSA colonization status. Physicians reviewed medical records to identify invasive infection and were blinded to colonization status. Cox and Kaplan-Meier analyses were used to assess the relationship between colonization status and invasive infection.
In total, 102 patients developed invasive MRSA infections, 16.3% of these were PC patients, 11.2% of these were IC patients, and 0.5% of these were NC patients. PC patients were at higher risk of invasive infection than NC patients (hazard ratio [HR] 36.8; 95% CI, 18.4–73.6; P<.001). IC patients were also at higher risk than NC patients (HR, 22.8; 95% CI, 13.3–39.3; P<.001). The difference in risk between PC and IC patients was not statistically significant (HR, 1.61; 95% CI, 0.94–2.78, P=.084). Alternate analysis methods confirmed these results.
The risk of invasive MRSA infection is much higher among PC and IC patients, supporting routine clinical testing for colonization. However, this risk is similar among PC and IC patients, suggesting that distinguishing between the 2 colonization states may not be clinically important.
Infect. Control Hosp. Epidemiol. 2015;36(11):1292–1297
To explore the role of psychiatric admission, diagnosis and reported unfair treatment in the relationship between ethnicity and mistrust of mental health services.
The Mental Illness-Related Investigations on Discrimination (MIRIAD) study was a cross-sectional study of 202 individuals using secondary mental health services in South London. Two structural equation models were estimated, one using Admission (whether admitted to hospital for psychiatric treatment in the past 5 years) and one using involuntary admission to hospital in the past 5 years.
Increased mistrust was directly associated with the latent variable ‘unfair treatment by mental health services and staff’ and with Black or mixed ethnicity in both models. Those with a diagnosis of schizophrenia spectrum (as compared to depression and bipolar disorder) had a lower average score on the latent variable, suggesting that on average they reported less unfair treatment. We found evidence of increased reporting of unfair treatment by those who had an admission in the past 5 years, had experienced involuntary admission, and for people of Black of mixed Black and White ethnicity.
Neither prevalence of schizophrenia spectrum nor rates of hospital admission explained the greater mistrust of mental health services found among people of Black and mixed Black and White ethnicity compared with White ethnicity. Rather, people of Black and mixed Black and white ethnicity may be more likely to experience unfair treatment, generating mistrust; furthermore, this group is more likely to express mistrust even after accounting for reporting of unfair treatment by mental health services and staff.
We conducted a systematic review to examine the relationship between intracranial pressure monitors (ICP) monitors and mortality in traumatic brain injury (TBI). We systematically searched for articles that met the following criteria: (1) adults patients, (2) TBI, (3) use of an ICP monitor, (4) point estimate for mortality with ICP monitoring (5) adjustment for potential confounders. Six observational studies were identified with 11,371 patients. There was marked between-study heterogeneity that precluded a pooled analysis. Patients with ICP monitors had different clinical characteristics and received more ICP targeted therapy in the ICU. Four studies found no significant relationship between ICP monitoring and survival, while the other two studies demonstrated conflicting results. Significant confounding by indication in observational studies limits the examination of isolated TBI interventions. More research should focus on interventions that affect TBI careplan systems. Further research is needed to identify which subset of severe TBI patients may benefit from ICP monitoring.
Many U.S. Gulf War-era veterans complained of poor cognition following the war. This study assessed neuropsychological functioning in veterans 10 years after the war through objective tests. 2189 Gulf War-era veterans (1061 deployed, 1128 non-deployed) were examined at 1 of 16 U.S. Veterans Affairs medical centers. Outcomes included neuropsychological domains derived from factor analysis and individual test scores. Deployed veterans performed significantly worse than non-deployed veterans on 2 of 8 factors (motor speed & sustained attention, analysis not corrected for multiple comparisons) and on 4 of 27 individual test variables (Trails A & B, California Verbal Learning Test – List B, and Continuous Performance Test sensitivity, with only Trails B surviving Bonferroni correction). Within deployed veterans, Khamisiyah exposure was negatively correlated with motor speed after controlling for emotional distress. Depressive symptoms and self-reported exposure to toxicants were independently and significantly associated with worse sustained attention. Other factors were also associated with self-reported exposures. The findings were not a result of differential effort across groups. Gulf War deployment is associated with subtle declines of motor speed and sustained attention, despite overall intact neuropsychological functioning. Evidence suggests that toxicant exposures influence both these functions, and depressive symptoms also influence attention. (JINS, 2009, 15, 717–729.)
Gulf War veterans reported multiple psychological symptoms immediately after the war; the temporal course of these symptoms remains unclear.
To assess the prevalence of war-era onset mental disorders in US veterans deployed to the Gulf War and in non-deployed veterans 10 years after the war.
Mental disorders were diagnosed using structured clinical interviews. Standard questionnaires assessed symptoms and quality of life.
Gulf War-era onset mental disorders were more prevalent in deployed veterans (18.1%, n=1061) compared with non-deployed veterans (8.9%, n=1128). The prevalence of depression and anxiety declined 10 years later in both groups, but remained higher in the deployed group, who also reported more symptoms and a lower quality of life than the non-deployed group. Remission of depression may be related to the presence of comorbid psychiatric disorders and level of education. Remission of anxiety was related to treatment with medication.
Gulf War deployment was associated with an increased prevalence of mental disorders, psychological symptoms and a lower quality of life beginning during the war and persisting at a lower rate 10 years later.
Simulation-based policy iteration (SBPI) is a modification
of the policy iteration algorithm for computing optimal policies
for Markov decision processes. At each iteration, rather than
solving the average evaluation equations, SBPI employs simulation
to estimate a solution to these equations. For recurrent
average-reward Markov decision processes with finite state and
action spaces, we provide easily verifiable conditions that
ensure that simulation-based policy iteration almost-surely
eventually never leaves the set of optimal decision rules. We
analyze three simulation estimators for solutions to the average
evaluation equations. Using our general results, we derive simple
conditions on the simulation run lengths that guarantee the
almost-sure convergence of the algorithm.
The Vietnam Era Twin (VET) Registry is composed of 7369 middle-aged male-male twin pairs both of whom served in the military during the time of the Vietnam conflict (1965–1975). The Registry is a United States Department of Veterans Affairs resource that was originally constructed from military records; the Registry has been in existence for more than 15 years. It is one of the largest national twin registries in the US and currently has subjects living in all 50 states. Initially formed to address questions about the long-term health effects of service in Vietnam the Registry has evolved into a resource for genetic epidemiologic studies of mental and physical health conditions. The management and administration of the VET Registry is described with particular attention given to the processes involved with database maintenance and study coordination. Several waves of mail and telephone surveys have collected a wealth of health-related information on Registry twins. More recent data collection efforts have focused on specific sets of twin pairs and conducted detailed clinical or laboratory testing. New Registry initiatives for the future include the construction of a web site and the development of a DNA repository.
Key features of reproductive behavior in China vary systematically through space and time. In this article we present an analysis of fertility change in regional space, using a 1% household sample from China’s 1990 population census. Elsewhere,we use the same data to analyze reproductive strategizing, but here we pursue the big picture with a straightforward analysis that takes reported births as an uncomplicated indicator of fertility.The article has three objectives: first, to introduce a novel, multilevel spatial model of regional structure constructed using a geographic information system (GIS); second, to demonstrate the potential for longitudinal data derived from onetime censuses to contribute to historical demography in conjunction with regional analysis; and third, to document the manner in which China’s fertility transition has unfolded in regional space.
Excavations at two sites in Gwynedd have produced new evidence for highland zone rural settlement during the Romano-British period. At Bryn Eryr this activity was the culmination of a long sequence of development during the Iron Age. At Bush Farm, similarly, a Romano-British phase succeeded earlier, probably late prehistoric occupation of the site. At both locations significant structural changes took place during the Romano-British period as small stone-walled houses replaced larger, clay-walled buildings. Changes in the local farming economy have been identified and the proximity of the vicus at Segontium provided access to Roman pottery vessels. The quality and range of pottery from Bryn Eryr and Bush Farm are considerable in comparison with other ‘Highland Zone’ settlements and the material is discussed in detail.
A comparative study was undertaken of Amazonian fish diversity and density (abundance and biomass) in nutrient poor (blackwater) and richer (whitewater – várzea) habitats in the vicinity of Tefé, Brazil. The whitewater sampling sites, in the floodplain of the Rios Solimōes and Japurá, had high turbidity (Secchi disc 0.03–0.7 m), a conductivity of 64–110 μS cm–1 at 25°C and a pH of 6.6–6.9. The blackwater sites Lagos Amanã, Iamã and Tefé had a low turbidity (Secchi disc 2.0–2.2 m), a conductivity of 7–11 μS cm–1 at 25°C and a pH of 5.3–6.0. The fish communities of open water, floating meadow and forest margin were sampled. Both whitewater and blackwater sites held high diversity fish communities with many species in common. Whitewater habitats were more diverse yielding 108 species, compared with only 68 from blackwater. Fish density within floating meadow was estimated during high water April and May 1994, and low water October 1994 and March 1995. During the high water season fish biomasses in blackwater lakes (31.1 gm–2) were significantly greater than those of either whitewater lakes (13.4 gm–2) or whitewater river channels (3.45 g m–2). At low water, in October, whitewater channels were generally found to hold the highest fish biomass (204 g m–2) although in March a blackwater site yielded the highest fish biomass recorded (285.9 g m–2). The amount of floating meadow habitat within Whitewaters is however much greater than that in blackwaters. It is suggested that blackwaters may offer a stable habitat resulting in a high standing crop. In comparison, variation in conditions such as dissolved oxygen concentration in the whitewater may limit standing crop, but still allow periods of high productivity. Evidence was found for migration of fish from várzea lakes during periods of low oxygen availability. The high diversity and biomass of fish caught in both whitewater and blackwater lakes indicates that water acidity and conductivity are poor predictors of fish diversity and density in tropical floodplain lakes.
Parasuicide is not a single syndrome. Subtypes at present recognized are based largely on clinically derived stereotypes. When considering a series of patients, the clinician is unable to handle more than a few attributes at a time. This paper describes the application of three very different clustering algorithms to a material of 350 treated parasuicide patients. Mathematically, three types emerge. Clinically, two of these are interpretable and make sense. The types established are: I (n = 107) a group not characterized by any of the variables we examined; this group is a puzzle, mainly because the reasons for the parasuicidal act are not clear. II (n = 132) a depressed, alienated group with high life-endangerment. III (n = 111) a group whose act was highly operant: they felt alienated and were angry with others. These groups did not differ significantly on demographic variables. The usefulness of this typology, particularly for management, after-care and prevention, has now to be assessed.
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