To save 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 saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
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 saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved 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.
Polymerase chain reaction (PCR) testing for the detection of C. difficile is a highly sensitive test. Some clinical laboratories have included a 2-step testing algorithm utilizing PCR plus toxin enzyme immunoassays (EIAs) to increase specificity.
To determine the risk factors and outcomes of C. difficile PCR-positive/toxin-positive encounters compared to PCR-positive/toxin-negative encounters.
A Veterans’ Affairs hospital.
A retrospective case–control study of patient encounters with a positive C. difficile test by PCR and either a toxin EIA–positive assay (ie, cases) or toxin EIA–negative assay (ie, controls). Clinically relevant exposures and risk factors were determined to assess CDI recurrence at 30 days. Available encounter stool specimens were cultured for C. difficile and were subjected to restriction endonuclease analysis (REA) strain typing.
Among 130 C. difficile PCR-positive patient encounters, 80 (61.5%) were toxin EIA negative and 50 (38.5%) were toxin EIA positive. Encounters that were toxin positive were more frequently treated (96.0%) compared to toxin-negative encounters (71.3%; P < .01). A multivariable logistic regression model revealed that toxin-negative encounters were less likely to suffer a recurrent CDI episode within 30 days (odds ratio [OR], 0.20, 95% confidence interval [CI], 0.05–0.83). Additionally, a higher C. difficile PCR cycle threshold predicted a lower risk of CDI recurrence at 30 days. (OR, 0.82; 95% CI, 0.68–0.98). During the study period, the REA group Y strain accounted for most toxin-negative encounters (32.5%; P = .05), whereas REA group BI strain accounted for most toxin-positive encounters (24.3%; P = .02).
A testing strategy of PCR plus toxin EIA helped predict recurrent CDI.
Ethnohistoric accounts indicate that the people of Australia's Channel Country engaged in activities rarely recorded elsewhere on the continent, including food storage, aquaculture and possible cultivation, yet there has been little archaeological fieldwork to verify these accounts. Here, the authors report on a collaborative research project initiated by the Mithaka people addressing this lack of archaeological investigation. The results show that Mithaka Country has a substantial and diverse archaeological record, including numerous large stone quarries, multiple ritual structures and substantial dwellings. Our archaeological research revealed unknown aspects, such as the scale of Mithaka quarrying, which could stimulate re-evaluation of Aboriginal socio-economic systems in parts of ancient Australia.
The Fontan Outcomes Network was created to improve outcomes for children and adults with single ventricle CHD living with Fontan circulation. The network mission is to optimise longevity and quality of life by improving physical health, neurodevelopmental outcomes, resilience, and emotional health for these individuals and their families. This manuscript describes the systematic design of this new learning health network, including the initial steps in development of a national, lifespan registry, and pilot testing of data collection forms at 10 congenital heart centres.
Maintaining physical, psychological and social wellbeing is integral to older adults being able to age well in their community. Therefore, an environment that facilitates and supports ageing well is imperative. The aim of this study was to explore the views of older people about their preparation for ageing well in a rural community. Forty-nine community-dwelling older people aged between 65 and 93 years participated in a semi-structured and digitally recorded interview. The resulting qualitative data were analysed using a thematic approach. Three main themes were identified: (a) ‘sensible planning: the right place and the right people’; (b) ‘remaining independent: “it's up to me”’; and (c) ‘facing challenges: “accepting my lot”’. Findings from this study identify that across all age groups, these older people were actively and realistically preparing for ageing well. All valued their independence, believing individually they were responsible for being independent and planning for their future. Consequently, environmental planners, policy makers and practitioners need to understand that older people are a heterogeneous group and ageing policies should be geared towards older people's individual abilities and circumstances. Consideration of diversity enables inclusion of older people with a wide range of abilities and needs to achieve the perceived goals of ageing well.
High-quality cardiopulmonary resuscitation (CPR) is a fundamental intervention for cardiac arrest, yet health care providers rarely adhere to recommended guidelines. Real-time feedback improves CPR performance. It is currently unknown how Canadian emergency physicians assess CPR quality during cardiac arrest and if they use feedback devices. Our aim was to describe how emergency physicians assess CPR quality and to describe eventual barriers to implementation of feedback technology.
This was a cross-sectional survey that was distributed to attending and resident emergency physicians through the Canadian Association of Emergency Physicians. Responses were summarized and analyzed using descriptive statistics.
The response rate was 19% (323/1735). Visual observation was the most common method of assessing CPR quality (41.2%), with leaders standing at the foot of the bed (67.4%). This was followed by real-time pulse check (29.7%) and end-tidal CO2 values (21.7%). Only 12% of physicians utilized CPR feedback technology. The most common perceived barrier to utilization was unavailability, inexperience with devices and lack of guidelines/evidence for their use.
Most Canadian emergency physicians that responded to our survey, assess quality of CPR by standing at the foot of the bed and utilize visual observation and palpation methods which are known to be inaccurate. A minority utilize objective measurements such as ETCO2 or feedback devices, with the greatest barrier being lack of availability.
To determine the scope, source, and mode of transmission of a multifacility outbreak of extensively drug-resistant (XDR) Acinetobacter baumannii.
SETTING AND PARTICIPANTS
Residents and patients in skilled nursing facilities, long-term acute-care hospital, and acute-care hospitals.
A case was defined as the incident isolate from clinical or surveillance cultures of XDR Acinetobacter baumannii resistant to imipenem or meropenem and nonsusceptible to all but 1 or 2 antibiotic classes in a patient in an Oregon healthcare facility during January 2012–December 2014. We queried clinical laboratories, reviewed medical records, oversaw patient and environmental surveillance surveys at 2 facilities, and recommended interventions. Pulsed-field gel electrophoresis (PFGE) and molecular analysis were performed.
We identified 21 cases, highly related by PFGE or healthcare facility exposure. Overall, 17 patients (81%) were admitted to either long-term acute-care hospital A (n=8), or skilled nursing facility A (n=8), or both (n=1) prior to XDR A. baumannii isolation. Interfacility communication of patient or resident XDR status was not performed during transfer between facilities. The rare plasmid-encoded carbapenemase gene blaOXA-237 was present in 16 outbreak isolates. Contact precautions, chlorhexidine baths, enhanced environmental cleaning, and interfacility communication were implemented for cases to halt transmission.
Interfacility transmission of XDR A. baumannii carrying the rare blaOXA-237 was facilitated by transfer of affected patients without communication to receiving facilities.
We present an analysis of changes of state, pressures and conservation responses over 20 years in the Tanzanian portion of the Coastal Forests of Eastern Africa biodiversity hotspot. Baseline data collected during 1989–1995 are compared with data from a synthesis of recently published papers and reports and new field work carried out across the region during 2010–2014. We show that biodiversity endemism values are largely unchanged, although two new species (amphibian and mammal) have been named and two extremely rare tree species have been relocated. However, forest habitat continues to be lost and degraded, largely as a result of agricultural expansion, charcoal production to supply cities with cooking fuel, logging for timber and cutting of wood for firewood and building poles. Habitat loss is linked to an increase in the number of species threatened over time. The government-managed forest reserve network has expanded slightly but has low effectiveness. Three forest reserves have been upgraded to National Parks and Nature Reserves, which have stricter protection and more effective enforcement. There has also been rapid development of village-owned forest reserves, with more than 140 now existing; although usually small, they are an important addition to the areas being managed for sustainable resource use, and also provide tangible benefits to local people. Human-use pressures remain intense in many areas, and combined with emerging pressures from mining, gas and oil exploration, many endemic species remain threatened with extinction.
Bipolar disorder is a highly heritable polygenic disorder. Recent
enrichment analyses suggest that there may be true risk variants for
bipolar disorder in the expression quantitative trait loci (eQTL) in the
We sought to assess the impact of eQTL variants on bipolar disorder risk
by combining data from both bipolar disorder genome-wide association
studies (GWAS) and brain eQTL.
To detect single nucleotide polymorphisms (SNPs) that influence
expression levels of genes associated with bipolar disorder, we jointly
analysed data from a bipolar disorder GWAS (7481 cases and 9250 controls)
and a genome-wide brain (cortical) eQTL (193 healthy controls) using a
Bayesian statistical method, with independent follow-up replications. The
identified risk SNP was then further tested for association with
hippocampal volume (n = 5775) and cognitive performance
(n = 342) among healthy individuals.
Integrative analysis revealed a significant association between a brain
eQTL rs6088662 on chromosome 20q11.22 and bipolar disorder (log Bayes
factor = 5.48; bipolar disorder P =
5.85×10–5). Follow-up studies across multiple independent
samples confirmed the association of the risk SNP (rs6088662) with gene
expression and bipolar disorder susceptibility (P =
3.54×10–8). Further exploratory analysis revealed that
rs6088662 is also associated with hippocampal volume and cognitive
performance in healthy individuals.
Our findings suggest that 20q11.22 is likely a risk region for bipolar
disorder; they also highlight the informative value of integrating
functional annotation of genetic variants for gene expression in
advancing our understanding of the biological basis underlying complex
disorders, such as bipolar disorder.
To investigate the display of food at non-food store checkouts; and to classify foods by type and nutrient content, presence of price promotions and whether food was at child height.
Cross-sectional survey of checkout displays at non-food stores. Foods were classified as ‘less healthy’ or healthier using the UK Food Standards Agency’s Nutrient Profile Model. Written price promotions were recorded. Child height was defined as the sight line of an 11-year-old approximated from UK growth charts.
A large indoor shopping mall, Gateshead, UK, February–March 2014.
Two hundred and five out of 219 non-food stores in the shopping mall directory which were open for trading.
Thirty-two (15·6 %) of 205 non-food stores displayed food at the checkout. All displayed less healthy foods, and fourteen (43·8 %) had healthier foods. Overall, 5911 checkout foods were identified. Of these, 4763 (80·6 %) were ‘less healthy’. No fruits, vegetables, nuts or seeds were found. Of 4763 less healthy foods displayed, 195 (4·1 %) were subject to price promotions, compared with twelve of 1148 (1·0 %) healthier foods (χ2(df=1)=25·4, P<0·0001). There was no difference in the proportion of less healthy (95·1 %) and healthier (96·2 %) foods displayed at child height.
Almost one-sixth of non-food stores displayed checkout food, the majority of which was ‘less healthy’ and displayed at child height. Less healthy food was more likely to be subject to a written price promotion than healthier food. Further research into the drivers and consequences of checkout food in non-food stores is needed. Public health regulation may be warranted.
Although genetic epidemiological studies have confirmed increased rates of major depressive disorder among the relatives of people with bipolar affective disorder, no report has compared the clinical characteristics of depression between these two groups.
To compare clinical features of depressive episodes across participants with major depressive disorder and bipolar disorder from within bipolar disorder pedigrees, and assess the utility of a recently proposed probabilistic approach to distinguishing bipolar from unipolar depression. A secondary aim was to identify subgroups within the relatives with major depression potentially indicative of ‘genetic’ and ‘sporadic’ subgroups.
Patients with bipolar disorder types 1 and 2 (n = 246) and patients with major depressive disorder from bipolar pedigrees (n = 120) were assessed using the Diagnostic Interview for Genetic Studies. Logistic regression was used to identify distinguishing clinical features and assess the utility of the probabilistic approach. Hierarchical cluster analysis was used to identify subgroups within the major depressive disorder sample.
Bipolar depression was characterised by significantly higher rates of psychomotor retardation, difficulty thinking, early morning awakening, morning worsening and psychotic features. Depending on the threshold employed, the probabilistic approach yielded a positive predictive value ranging from 74% to 82%. Two clusters within the major depressive disorder sample were found, one of which demonstrated features characteristic of bipolar depression, suggesting a possible ‘genetic’ subgroup.
A number of previously identified clinical differences between unipolar and bipolar depression were confirmed among participants from within bipolar disorder pedigrees. Preliminary validation of the probabilistic approach in differentiating between unipolar and bipolar depression is consistent with dimensional distinctions between the two disorders and offers clinical utility in identifying patients who may warrant further assessment for bipolarity. The major depressive disorder clusters potentially reflect genetic and sporadic subgroups which, if replicated independently, might enable an improved phenotypic definition of underlying bipolarity in genetic analyses.
Historically, few randomized controlled trials (RCTs) have been conducted in primary care and problems have been experienced applying this methodology in these settings. In 2001, The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) was developed. This RCT aimed to compare two detoxification drugs to inform best practice for the treatment of opiate users presenting to primary care requesting detoxification. This paper presents descriptive data from a postal survey of 12 general practitioners (GPs) from 10 primary care practices who were involved in the LEEDS trial. The questionnaire was sent out in November 2004, used open and closed questions and was self-administered. It uncovered factors that affected patient recruitment, GPs' views on the trial and their experience of randomizing opiate using patients. Flexible solutions to overcoming recruitment difficulties are presented alongside idealistic solutions to the problems experienced. The implications of our experiences of conducting this RCT in primary care practices are discussed in the light of conducting RCTs in primary care settings. This will benefit other research teams and clinicians who may be planning to use a similar research methodology.
Microsatellite primers are often developed in one species and used to assess neutral variability in related species. Such analyses may be confounded by ascertainment bias (i.e. a decline in amplification success and allelic variability with increasing genetic distance from the source of the microsatellites). In addition, other factors, such as the size of the microsatellite, whether it consists of perfect or interrupted tandem repeats, and whether it is autosomal or X-linked, can affect variation. To test the relative importance of these factors on microsatellite variation, we examine patterns of amplification and allelic diversity in 52 microsatellite loci amplified from five individuals in each of six populations of Cyrtodiopsis stalk-eyed flies that range from 2·2% to 11·2% mitochondrial DNA sequence divergence from the population used for microsatellite development. We find that amplification success and most measures of allelic diversity declined with genetic distance from the source population, in some cases an order of magnitude faster than in birds or mammals. The median and range of the repeat array length did not decline with genetic distance. In addition, for loci on the X chromosome, we find evidence of lower observed heterozygosity compared with loci on autosomes. The differences in variability between X-linked and autosomal loci are not adequately explained by differences in effective population sizes of the chromosomes. We suggest, instead, that periodic selection events associated with X-chromosome meiotic drive, which is present in many of these populations, reduces X-linked variation.
An outbreak of gastroenteritis caused by Norwalk-like virus occurred in two areas of the hospital: area 1, consisting of three adjacent and interconnected wards, with mostly elderly patients; and area 2, an acute ward in a separate building with elderly patients. In area 1, 40 patients and 20 staff were affected; in area 2, 18 patients and 14 staff were affected. Infection control measures were instituted in consultation with the government health authority. These measures did not appear to affect the course of the outbreak, but may have prevented spread to other wards.