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To evaluate the impact of a standardized, process-validated intervention utilizing daily hospital-wide patient-zone sporicidal disinfectant cleaning on incidence density of healthcare-onset Clostridioides difficile infection (HO-CDI) standardized infection ratios (SIRs).
Multi-site, quasi-experimental study, with control hospitals and a nonequivalent dependent variable.
The study was conducted across 8 acute-care hospitals in 6 states with stable endemic HO-CDI SIRs.
Following an 18-month preintervention control period, each site implemented a program of daily hospital-wide sporicidal disinfectant patient zone cleaning. After a wash-in period, thoroughness of disinfection cleaning (TDC) was monitored prospectively and optimized with performance feedback utilizing a previously validated process improvement program. Mean HO-CDI SIRs were calculated by quarter for the pre- and postintervention periods for both the intervention and control hospitals. We used a difference-in-differences analysis to estimate the change in the average HO-CDI SIR and HO-CAUTI SIR for the pre- and postintervention periods.
Following the wash-in period, the TDC improved steadily for all sites and by 18 months was 93.6% for the group. The mean HO-CDI SIRs decreased from 1.03 to 0.6 (95% CI, 0.13–0.75; P = .009). In the adjusted difference-in-differences analysis in comparison to controls, there was a 0.55 reduction (95% CI, −0.77 to −0.32) in HO-CDI (P < .001) or a 50% relative decrease from baseline.
This study represents the first multiple-site, quasi-experimental study with control hospitals and a nonequivalent dependent variable to evaluate a 4-component intervention on HO-CDI. Following ongoing improvement in cleaning thoroughness, there was a sustained 50% decrease in HO-CDI SIRs compared to controls.
In this study, we outline a maritime perspective on interaction in the Late Bronze/early Iron Age Mediterranean. In response to what has elsewhere been termed the ‘maximalist’ approach, which foregrounds direct, long-distance trading connections between distant Mediterranean regions as a key feature of Late Bronze Age exchange systems, we propose a more nuanced, ‘minimalist’ and argue that notions of contact, connectivity and mobility need to be carefully distinguished if we wish to discuss both the material and social dimensions of maritime mobility. In particular, we critique the prominently proposed, allegedly direct trade route between Sardinia and Cyprus. The network we suggest hinges on multiply connected nodes, where a variety of social actors take part in the creation and maintenance of maritime connections. By unpacking several such nodes between Sardinia and Cyprus, we demonstrate that simply asserting the dominance of Sardinian, Cypriot or Aegean mariners falls short of the complex archaeological evidence and eschews possible social interpretations. In conclusion, we submit that maritime connectivity is an inherently social activity, and that a culturally diverse prehistoric Mediterranean was connected by multiple interlocking and overlapping networks.
Background: Despite ongoing efforts over the past 3 decades, hospital-onset Clostridioides difficile infection (HO-CDI) continues to challenge interventions aimed at its prevention and control. We describe the impact of a model environmental services (EVS) program on the incidence of HO-CDI across 8 hospitals that are part of a nationwide integrated health system. Methods: Eight acute-care hospitals with 44–532 beds (mean, 263 beds) in 6 states with stable endemic HO-CDI incidence densities independently implemented identical sporicidal environmental hygiene interventions in 2017. The program combined the use of a hydrogen peroxide/peroxyacetic acid surface disinfectant for all patient-zone hygienic cleaning combined with a structured model EVS cleaning program that included optimized cleaning and disinfection technique, staff training, and auditing with objective performance feedback, which aligned with 2008 HICPAC/CDC categories I and II as well as 2010 CDC Guidance Level II monitoring program recommendations. After a 3-month phase-in, we compared NHSN-reported LabID HO-CDI SIRs for 18 months before and 12 months after implementation of the program. Results were not shared between sites and data were not collated by the authors until a year after the postintervention results were initially available. Multiple possible confounding factors were evaluated and determined not to have identifiably affected the outcome. Results: Mean preintervention HO-CDI SIRs over the 18 months measured ranged from 0.5 to 1.4 (mean, 1.0 for the group). Following the wash-in period, SIRs decreased precipitously in all sites to a mean of 0.42 for the group by the end of 12 months of the intervention. (P < .0001) (Fig. 1). Individual site improvement ranged from 20% to 92% (mean, 57%) (Fig. 2.) Conclusions: Overall, HO-CDI SIRs decreased almost 60% in the study hospitals following daily sporicidal disinfection cleaning of all patient-zone surfaces in association with ongoing programmatic optimization of cleaning practice. As predicted by earlier single-site studies reporting a favorable impact of sporicidal disinfectant cleaning in outbreak settings, this multisite quasi-experimental study has illustrated the substantial potential impact of hospital-wide sporicidal disinfection integrated with objectively sustained optimized thoroughness of cleaning to decrease the incidence of HO-CDI.
Research on psychotic illness is loosening emphasis on diagnostic stringency in favour of including a more dimensionally based conceptualization of psychopathology and pathobiology. However, to clarify these notions requires investigation of the full scope of psychotic diagnoses.
The Cavan–Monaghan First Episode Psychosis Study ascertained cases of first episode psychosis across all 12 DSM-IV psychotic diagnoses via all routes to care: public, private or forensic; home-based, outpatient or inpatient. There was no arbitrary upper age cut-off and minimal impact of factors associated with variations in social milieu, ethnicity or urbanicity. Cases were evaluated epidemiologically and assessed for psychopathology, neuropsychology, neurology, antecedent factors, insight and quality of life.
Among 432 cases, the annual incidence of any DSM-IV psychotic diagnosis was 34.1/100 000 of population and encompassed functional psychotic diagnoses, substance-induced psychopathology and psychopathology due to general medical conditions, through to psychotic illness that defied contemporary diagnostic algorithms. These 12 DSM-IV diagnostic categories, including psychotic disorder not otherwise specified, showed clinical profiles that were consistently more similar than distinct.
There are considerable similarities and overlaps across a broad range of diagnostic categories in the absence of robust discontinuities between them. Thus, psychotic illness may be of such continuity that it cannot be fully captured by operational diagnostic algorithms that, at least in part, assume discontinuities. This may reflect the impact of diverse factors each of which acts on one or more overlapping components of a common, dysfunctional neuronal network implicated in the pathobiology of psychotic illness.
Objectives: To describe multivariate base rates (MBRs) of low scores and reliable change (decline) scores on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) in college athletes at baseline, as well as to assess MBR differences among demographic and medical history subpopulations. Methods: Data were reported on 15,909 participants (46.5% female) from the NCAA/DoD CARE Consortium. MBRs of ImPACT composite scores were derived using published CARE normative data and reliability metrics. MBRs of sex-corrected low scores were reported at <25th percentile (Low Average), <10th percentile (Borderline), and ≤2nd percentile (Impaired). MBRs of reliable decline scores were reported at the 75%, 90%, 95%, and 99% confidence intervals. We analyzed subgroups by sex, race, attention-deficit/hyperactivity disorder and/or learning disability (ADHD/LD), anxiety/depression, and concussion history using chi-square analyses. Results: Base rates of low scores and reliable decline scores on individual composites approximated the normative distribution. Athletes obtained ≥1 low score with frequencies of 63.4% (Low Average), 32.0% (Borderline), and 9.1% (Impaired). Athletes obtained ≥1 reliable decline score with frequencies of 66.8%, 32.2%, 18%, and 3.8%, respectively. Comparatively few athletes had low scores or reliable decline on ≥2 composite scores. Black/African American athletes and athletes with ADHD/LD had higher rates of low scores, while greater concussion history was associated with lower MBRs (p < .01). MBRs of reliable decline were not associated with demographic or medical factors. Conclusions: Clinical interpretation of low scores and reliable decline on ImPACT depends on the strictness of the low score cutoff, the reliable change criterion, and the number of scores exceeding these cutoffs. Race and ADHD influence the frequency of low scores at all cutoffs cross-sectionally.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
The World Health Organization’s (WHO; Geneva, Switzerland) Emergency Medical Team (EMT) Initiative created guidelines which define the basic procedures to be followed by personnel and teams, as well as the critical points to discuss before deploying a field hospital. However, to date, there is no formal standardized training program established for EMTs before deployment. Recognizing that the World Association of Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA) Congress brings together a diverse group of key stakeholders, a pre-Congress workshop was organized to seek out collective expertise and to identify key EMT training competencies for the future development of training programs and protocols. The future of EMT training should include standardization of curriculum and the recognition or accreditation of selected training programs. The outputs of this pre-WADEM Congress workshop provide an initial contribution to the EMT Training Working Group, as this group works on mapping training, competencies, and curriculum. Common EMT training themes that were identified as fundamental during the pre-Congress workshop include: the ability to adapt one’s professional skills to low-resource settings; context-specific training, including the ability to serve the needs of the affected population in natural disasters; training together as a multi-disciplinary EMT prior to deployment; and the value of simulation in training.
AlbinaA, ArcherL, BoivinM, CranmerH, JohnsonK, KrishnarajG, ManeshiA, OddyL, Redwood-CampbellL, RussellR. International Emergency Medical Teams Training Workshop Special Report. Prehosp Disaster Med. 2018;33(3):335–338.
Clozapine causes significant metabolic disturbances including obesity and type 2 diabetes. Recent evidence that reduced glucagon-like-peptide-1 (GLP-1) may contribute to aetiology of clozapine-associated metabolic dysregulation suggests a potential therapeutic role for GLP-1 agonists.
This open-label, pilot randomised controlled trial evaluates the effect of exenatide in clozapine-treated obese adults who have schizophrenia, with or without poorly controlled diabetes. Sixty out-patients will be randomised to once weekly extended release exenatide or treatment as usual for 24 weeks.
To evaluate the feasibility of larger studies regarding methodology, acceptability, tolerability and estimate efficacy for glycaemic control or weight loss. Secondary outcomes are psychosis severity and metabolic parameters.
This is the first trial investigating GLP-1 agonists for glycaemic control and weight loss in clozapine-treated patients with either diabetes or obesity. Clozapine-associated obesity and diabetes with exenatide (CODEX) will provide proof-of-concept empirical evidence addressing whether this novel treatment is practical and worthy of further investigation.
Studies have found positive correlations between prenatal exposure to testosterone and masculinization of offspring traits, particularly among females. The present study sought to determine if physical or sexual activity by the mother during pregnancy was related to masculinized/defeminized offspring traits in adulthood. Data were obtained from a large sample of North American college students (offspring) and their mothers. Information about maternal activity levels during pregnancy were reported retrospectively by each mother. The offspring provided self-ratings of various sexually dimorphic traits. Several significant correlations were found. By and large, as maternal physical activity increased, feminine mannerisms decreased and masculine mannerisms increased in the offspring, particularly for females. Maternal physical activity was also associated with increased upper- and lower-body strength and especially with adult height among offspring. Sexual activity by the mother was only associated with upper-body strength and adult height, particularly of the female offspring. Several sexually dimorphic physical traits in offspring are associated with maternal activity levels during pregnancy. Prenatal testosterone is almost certainly involved. The associations could either reflect genetic influences (given that prenatal testosterone is highly heritable) or an effect of maternal testosterone being transferred to the developing fetus. More research is needed to assess the relative merit of these two possibilities.
Recent research reveals what we term a ‘discourse of certainty’ regarding an assumed predominant socio-economic and cultural impact of Late Bronze Age Cypriotes or Mycenaeans on the local peoples of Sardinia and/or Sicily and Italy, not least in terms of a systematic, seaborne trading network extending from the Cyprus to the Tyrrhenian Sea. ‘Minimalist’ approaches to such a phenomenon have a long and venerable but more limited pedigree. In this study, we question why minimalist views have been so summarily dismissed in much current literature that seeks to evaluate an eastern Mediterranean presence or influence in the central Mediterranean. We focus on Sardinia, and on the range of Cypriot or ‘Cypriot-type’ materials found there. We consider the nature of the Cypriot–Sardinian relationship, and suggest that we should decouple foreign objects from foreign agents. We question several of the perceived Cypriot influences on Sardinian artefacts, and consider possible alternative mechanisms and routes of exchange between the east and central Mediterranean. We outline and discuss the array of presumed or actual Cypriot artefacts found on Sardinia, and argue that these do not add up to a ‘significant’ corpus of Late Cypriot materials and connections.
The objective was to investigate parents’ motives for selecting foods for their children and the associations between these motives and children’s food preferences.
Cross-sectional survey. A modified version of the Food Choice Questionnaire was used to assess parents’ food choice motives. Parents also reported children’s liking/disliking of 176 food and beverage items on 5-point Likert scales. Patterns of food choice motives were examined with exploratory principal component analysis. Associations between motives and children’s food preferences were assessed with linear regression while one-way and two-way ANOVA were used to test for sociodemographic differences.
Two Australian cities.
Parents (n 371) of 2–5-year-old children.
Health, nutrition and taste were key motivators for parents, whereas price, political concerns and advertising were among the motives considered least important. The more parents’ food choice for their children was driven by what their children wanted, the less children liked vegetables (β =−0·27, P<0·01), fruit (β=−0·19, P<0·01) and cereals (β=−0·28, P<0·01) and the higher the number of untried foods (r=0·17, P<0·01). The reverse was found for parents’ focus on natural/ethical motives (vegetables β=0·17, P<0·01; fruit β=0·17, P<0·01; cereals β=0·14, P=0·01). Health and nutrition motives bordered on statistical significance as predictors of children’s fruit and vegetable preferences.
Although parents appear well intentioned in their motives for selecting children’s foods, there are gaps to be addressed in the nature of such motives (e.g. selecting foods in line with the child’s desires) or the translation of health motives into healthy food choices.