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To assess the national uptake of the Centers for Disease Control and Prevention’s (CDC) core elements of antibiotic stewardship in nursing homes from 2016 to 2018 and the effect of infection prevention and control (IPC) hours on the implementation of the core elements.
Retrospective, repeated cross-sectional analysis.
US nursing homes.
We used the National Healthcare Safety Network (NHSN) Long-Term Care Facility Component annual surveys from 2016 to 2018 to assess nursing home characteristics and percent implementation of the core elements. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all 7 core elements while controlling for confounding by facility characteristics.
We included 7,506 surveys from 2016 to 2018. In 2018, 71% of nursing homes reported implementation of all 7 core elements, a 28% increase from 2016. The greatest increases in implementation from 2016 to 2018 were in education (19%), reporting (18%), and drug expertise (15%). In 2018, 71% of nursing homes reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. Nursing homes that reported at least 20 hours of IPC activity per week were 14% (95% confidence interval, 7%–20%) more likely to implement all 7 core elements when controlling for facility ownership and affiliation.
Nursing homes reported substantial progress in antibiotic stewardship implementation from 2016 to 2018. Improvements in access to drug expertise, education, and reporting antibiotic use may reflect increased stewardship awareness and resource use among nursing home providers under new regulatory requirements. Nursing home stewardship programs may benefit from increased IPC staff hours.
It is evident that lean production variations have been applied by a wide array of private companies as well as public and third sector organizations in countries worldwide. Janoski and Lepadatu (2014) have even noted that lean is becoming a dominant division of labour, replacing gradually Taylorism and Fordism. We take this notion as the starting point in this chapter and examine the diffusion of lean and some other forms of work organization in Europe and the USA.
Background: Pneumonia (PNA) is an important cause of morbidity and mortality among nursing home residents. The McGeer surveillance definitions were revised in 2012 to help NHs better monitor infections for quality improvement purposes. However, the concordance between surveillance definitions and clinically diagnosed PNA has not been well studied. Our objectives were to identify nursing home residents who met the revised McGeer PNA definition, to compare them with residents with clinician documented PNA, and determine whether modifications to the surveillance criteria could increase concordance. Methods: We analyzed respiratory tract infection (RTI) data from 161 nursing homes in 10 states that participated in a 1-day healthcare-associated infection point-prevalence survey in 2017. Trained surveillance officers from the CDC Emerging Infections Program collected data on residents with clinician documentation, signs, symptoms, and diagnostic testing potentially indicating an RTI. Clinician-documented pneumonia was defined as any resident with a diagnosis of pneumonia identified in the medical chart. We identified the proportion of residents with clinician documented PNA who met the revised McGeer PNA definition. We evaluated the criteria reported to develop 3 modified PNA surveillance definitions (Box), and we compared them to residents with clinician documented PNA.
Results: Among the 15,296 NH residents surveyed, 353 (2%) had >1 signs and/or symptoms potentially indicating RTI. Among the 353 residents, the average age was 76 years, 105 (30%) were admitted to postacute care or rehabilitation, and 108 (31%) had clinician-documented PNA. Among those with PNA, 28 (26%) met the Revised McGeer definition. Among 81 residents who did not meet the definition, 39 (48%) were missing the chest x-ray requirement, and among the remaining 42, only 3 (7%) met the constitutional criteria requirement (Fig. 1). Modification of the constitutional criteria requirement increased the detection of clinically documented PNA from 28 (26%) to 36 (33%) using modified definition 1; to 51 (47%) for modified definition 2; and to 55 (51%) for modified definition 3. Conclusions: Tracking PNA among nursing home residents using a standard definition is essential to improving detection and, therefore, informing prevention efforts. Modifying the PNA criteria increased the identification of clinically diagnosed PNA. Better concordance with clinically diagnosed PNA may improve provider acceptance and adoption of the surveillance definition, but additional research is needed to test its validity.
Background: Catheter-associated symptomatic urinary tract infections (CA-SUTIs) are a common adverse healthcare event in nursing homes and have been the focus of multiple prevention strategies.1 In 2012, the CDC launched the NHSN Long-Term Care Facility (LTCF) Component, which nursing homes, the CDC, and prevention collaborators can use to monitor nursing home CA-SUTI incidence and prevention progress.2 The objective of this analysis was to compare CA-SUTI rates and reporting patterns of nursing homes between 2013–2015 and 2016–2018. Methods: We analyzed CA-SUTI data from nursing homes reporting to the NHSN during 2013–2018. Consistent reporters submitted ≥6 months of complete data in any calendar year during the period. To potentially confirm patterns in CA-SUTI rates, we defined “consecutive” reporters, as nursing homes that submitted data for ≥6 months each year during 2013–2018. CA-SUTI incidence rates were calculated as the number of CA-SUTI events divided by the number of catheter days multiplied by 1,000. Likelihood ratio tests using negative binomial regression were used to compare CA-SUTI rates from 2016–2018 and 2013–2015 among both consistent and consecutive reporters. Results: During 2013–2018, the number of nursing homes submitting at least 1 month of CA-SUTI data to NHSN increased from 60 to 120 (Fig. 1). Among these nursing homes, 194 (88%) were consistent reporters. The pooled CA-SUTI rate of 1.77 per 1,000 catheter days in 2016–2018 was significantly lower than the pooled CA-SUTI rate of 2.45 per 1,000 catheter days in 2013–2015 among consistent reporters by ~24% (Table 1). Also, 50 consecutive reporters submitted CA-SUTI data during 2013–2018. Among these consecutive reporters, the pooled CA-SUTI rate of 2.11 per 1,000 catheter days in 2016–2018 was significantly lower than the rate of 2.53 per 1,000 catheter days in 2013–2015 by ~21% (Table 1). Conclusions: This analysis suggests that nursing homes using NHSN for CA-SUTI surveillance have made progress in prevention efforts. During 2013–2018, evidence showed that CA-SUTI incidence rates declined among consistent reporters between the 2 reporting periods. This decrease was verified among consecutive reporters. Additional study is needed to determine which factors account for varying reporting patterns and differential CA-SUTI incidence.
In the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.
We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.
We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = −0.71; 95% confidence interval [CI] −1.01 to −0.41; I2 = 83%; 95% CI 78–88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = −1.02; 95% CI −1.52 to −0.51; I2 = 89%; 95% CI 82–93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = −1.05; 95% CI −1.55 to −0.56; I2 = 87%; 95% CI 79–92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.
Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.
In 1936, Gerhard Gentzen published a proof of consistency for Peano Arithmetic using transfinite induction up to ε0, which was considered a finitistically acceptable procedure by both Gentzen and Paul Bernays. Gentzen’s method of arithmetising ordinals and thus avoiding the Platonistic metaphysics of set theory traces back to the 1920s, when Bernays and David Hilbert used the method for an attempted proof of the Continuum Hypothesis. The idea that recursion on higher types could be used to simulate the limit-building in transfinite recursion seems to originate from Bernays. The main difficulty, which was already discovered in Gabriel Sudan’s nearly forgotten paper of 1927, was that measuring transfinite ordinals requires stronger methods than representing them. This paper presents a historical account of the idea of nominalistic ordinals in the context of the Hilbert Programme as well as Gentzen and Bernays’ finitary interpretation of transfinite induction.
This article studies two questions related to al-Khansā'’s mutaqārib poem, rhyming in -ālahā: how was it changed through anthologisation and what is its relation to the Qur'ān and Surah 99? Whereas the six-verse excerpt in al-Mubarrad's Kāmil is full of Qur'ānic echoes, the Dīwān version of the poem has few such echoes. The analysis, however, opens up a possibility that the Qur'ān's first audience may well have recognised in Surah 99 features familiar to them from marthiyas.
Research has repeatedly shown that individuals and organisations tend to obtain information from others whose beliefs are similar to their own, forming “echo chambers” with their network ties. Echo chambers are potentially harmful for evidence-based policymaking as they can hinder policy learning and consensus building. Policy forums could help alleviate the effects of echo chambers if organisations with different views were to participate and to use the opportunities that forums provide to learn from those outside their networks. Applying exponential random graph models on survey data of the Irish climate change policy network, we find that policy actors do indeed tend to obtain policy advice from those whose beliefs are similar to their own. We also find that actors tend not to obtain policy advice from the those that they encounter at policy forums, suggesting forums are not enabling policy learning.
This Research Communication describes the effect of post-operative pain and non-steroidal anti-inflammatory drug (NSAID) treatment on heart rate variability (HRV) of dairy cows. Postoperative pain in farm animals is often left untreated, and HRV could be a promising tool for assessing pain. The aim of this study was to assess if postoperative state after subcutaneous surgery affects HRV in dairy cows and to determine whether this could be modulated by NSAID. Nine cows were inserted with an implantable electrocardiograph logger. Cows were divided into the NSAID treatment group and the control group. The cows in the NSAID group had higher HRV than the control group, indicating a higher sympathetic activity in control animals, most likely due to untreated post-operative pain. Besides the ethical need for treating pain in production animals, ongoing pain has an adverse effect on animal productivity. Thus post-operative pain alleviation is recommended.
Objectives: The need to consider the patient perspective in health technology assessments (HTA) has been widely recognized. In July 2012, the Finnish Medicines Agency (Fimea) published a national recommendation for integrating the patient perspective into the HTAs of pharmaceuticals. The aim of this study is to describe the development of the recommendation for integrating the patient perspective into the HTA process of pharmaceuticals in Finland.
Methods: The development of the recommendation was based on a review of international recommendations and experiences of patient and public involvement in HTA. The draft recommendation was tested in two focus group discussions (n = 7 patients) and three individual interviews among diabetes patients (type 1 or 2) using long-acting insulin treatment. The recommendation was open for public consultation in April 2012 and revised according to the comments received.
Results: Patients will be involved in multiple stages of Fimea's HTA process. The recommendation includes step-by-step instructions on how to assess the patient perspective. The main focus is on qualitative interviews, which will be conducted at the beginning of the assessments to gain information, particularly on patient preferences and values, including positive and negative outcomes important to patients and ethical and social aspects of the medicine's use.
Conclusions: The recommendation will act as a tool to integrate patients’ experiences, needs and preferences into Fimea's HTAs of pharmaceuticals.
Harriet Finne-Soveri, National Institute for Health and Welfare, Helsinki,
Teija Hammar, National Institute for Health and Welfare, Helsinki,
Anja Noro, National Institute for Health and Welfare, Helsinki,
Sari Anttila, National Supervisory Authority for Welfare and Health (Valvira), Helsinki,
Päivi Voutilainen, Ministry of Social Affairs and Health, Finland
Vincent Mor, Brown University, Rhode Island,Tiziana Leone, London School of Economics and Political Science,Anna Maresso, London School of Economics and Political Science
The constitution of Finland stipulates that society must guarantee adequate social, health and medical services for each of its 5.3 million inhabitants, and promote the health of the population. Due to decentralized governance, responsibility for financing long-term care for older people rests heavily on the shoulders of 336 relatively independent local authorities (municipalities), as does the delivery of long-term care services. Obliged by law to provide long-term care services for older dependent people, these municipalities are free either to provide services themselves or to purchase them from various for-profit or not-for-profit providers. Historically, municipalities have tended to rely on providing their own services.
According to the Statistical Yearbook on Social Welfare and Healthcare (National Institute for Health and Welfare, 2010), 87 per cent of all long-term care days in residential facilities were produced in public facilities, 10 per cent in not-for-profit private facilities and only 3 per cent in for-profit private facilities. In contrast, when it comes to sheltered housing for older people, officially known as ‘service houses’ or ‘sheltered housing’, only 42 per cent of long-term care days were furnished by public providers while the private sector provided 32 per cent of care days in not-for-profit facilities and 26 per cent in for-profit facilities. Chronic care hospitals, known as ‘health centres’, are predominantly public (95 per cent). Recent statistics are not available for home care. In all these types of facilities municipalities are responsible for monitoring care but they are aided in this task by other entities. The National Supervisory Authority for Welfare and Health (known as Valvira), supervised by the Ministry of Social Affairs and Health, undertakes a national supervisory role, together with six Regional State Administrative Agencies (AVI).
A surface roughness measurement system for snow is presented. It is based on a background board with scales on the edges and a digital camera. Analysis software is developed for automatic processing of images to produce calibrated profiles. The image analysis and calibration was fully automatic in >99% of the studied cases. In the others, the intensity adjustment or board detection needed manual intervention. Profile detection, control point picking and calibration always worked autonomously. The accuracy of the system depends on the photographing configuration, and is typically of the order of 0.1 mm vertically and 0.04 mm horizontally. The method tolerates relatively well cases of snowfall, traces of wiping the black background dry, uneven shading, reflected sunlight, reflected flash light, litter on the snow surface and a tilted plate. The repeatability of the system is at least 1%.
The analog front-end of a direct-conversion transmitter suffers from several performance-degrading circuit implementation impairments. The main impairments are power amplifier (PA) nonlinear distortion, in-phase/quadrature-phase (I/Q) imbalance, and local oscillator (LO) leakage. Each of these impairments has been treated separately in the literature as well as on the pages of this book. For details on state-of-the-art PA predistortion, the reader is referred to the related chapters in Part II of this book and the references therein, and for a comprehensive review on I/Q imbalance compensation, to Chapter 16 of this book and the literature cited therein. It has been demonstrated that, when treated separately, each of the impairments can be mitigated by using digital predistortion. What is often overlooked, however, is that in direct-conversion transmitters these impairments interact in a manner that may severely cripple the overall transmitted signal quality. In addition to the obvious effects of I/Q imbalance and LO leakage (mirror-frequency interference (MFI) and spurious signal energy at the LO frequency, respectively), there are several other performance-degrading phenomena arising from their interaction with the nonlinearity that need addressing. First, I/Q imbalance and LO leakage cause extra intermodulation distortion (IMD) products to appear at the PA output , . Effectively this means that even with access to ideal PA predistorter (PD) coefficients, spectral regrowth will not be fully mitigated. Second, the extra IMD products at the PA output will interfere with the estimation of an adaptive PA PD , . In other words, if the PA PD is trained with no regard for I/Q imbalance and LO leakage, the resulting PD will be biased, and thus the overall transmitted signal quality will be further compromised. Third, PA nonlinearity interferes with the estimation of the I/Q modulator (IQM) predistorter, yielding biased estimates. This makes it difficult to compensate for IQM impairments prior to PA PD estimation. These aspects will be discussed in more detail in Section 17.2.
The implementation challenges in building compact and low-cost radios for future wireless systems are continuously growing. This is partially due to the introduction of multi-antenna transmission techniques as well as the use of wideband communication waveforms and high-order symbol alphabets, in addition to the increasing demands for more efficient radio spectrum utilization through e.g. carrier aggregation and scattered spectrum use. In general, implementations of several parallel radios with wide operating bandwidth and high performance, in terms of linearity and spurious free dynamic range, are required in a single device. Then, to keep the overall implementation costs and size feasible, simplified radio architectures and lower-cost radio electronics are typically used. This in turn implies that various nonidealities in the deployed analog radio frequency (RF) modules, stemming from the unavoidable physical limitations of the electronics used, are expected to play a critical role in future radio devices.
Good examples of the above “dirty-RF” paradigm ,  are, e.g., oscillator phase noise, power amplifier (PA) nonlinearities, imperfections of the sampling and analog-to-digital (A/D) interface, in-phase/quadrature (I/Q) branch amplitude and phase mismatches, as well as nonlinearities of receiver small signal components like low-noise amplifiers (LNAs) and mixers. In this chapter, we will focus on the behavioral modeling and digital signal processing (DSP) based mitigation of I/Q imbalances and the resulting mirror-frequency interference in direct-conversion type radio transmitters and receivers. For generality, in most of the developments, the I/Q imbalances are assumed to be frequency-dependent within the processed bandwidth, which is then built in to both modeling as well as mitigation algorithms. Also an extensive list of state-of-the-art literature is given.
Almost every Finnish child and adolescent takes an interest in music in some form. However, many young people feel dissatisfaction with what music education institutions provide and fail to find them motivating. According to the results of a series of empirical studies, school music education can have a negative effect on many pupils and undermine their musical self-esteem. At the music education institutions where this research was undertaken, music was narrowly defined and there was an absence of contemporary music cultures. Forms of music making were limited and active music listening absent from lessons. Assessment too was a problem with many pupils feeling that the evaluation of their work lacked legitimacy and fairness.