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To evaluate random effects of volume (patient days or device days) on healthcare-associated infections (HAIs) and the standardized infection ratio (SIR) used to compare hospitals.
A longitudinal comparison between publicly reported quarterly data (2014–2020) and volume-based random sampling using 4 HAI types: central-line–associated bloodstream infections, catheter-associated urinary tract infections, Clostridioides difficile infections, methicillin-resistant Staphylococcus aureus infections.
Using 4,268 hospitals with reported SIRs, we examined relationships of SIRs to volume and compared distributions of SIRs and numbers of reported HAIs to the outcomes of simulated random sampling. We included random expectations into SIR calculations to produce a standardized infection score (SIS).
Among hospitals with volumes less than the median, 20%–33% had SIRs of 0, compared to 0.3%–5% for hospitals with volumes higher than the median. Distributions of SIRs were 86%–92% similar to those based on random sampling. Random expectations explained 54%–84% of variation in numbers of HAIs. The use of SIRs led hundreds of hospitals with more infections than either expected at random or predicted by risk-adjusted models to rank better than other hospitals. The SIS mitigated this effect and allowed hospitals of disparate volumes to achieve better scores while decreasing the number of hospitals tied for the best score.
SIRs and numbers of HAIs are strongly influenced by random effects of volume. Mitigating these effects drastically alters rankings for HAI types and may further alter penalty assignments in programs that aim to reduce HAIs and improve quality of care.
The experience of working from home changed drastically with the arrival of COVID-19. Compared to pre-pandemic experiences, key differences included the vast number of people involved, its involuntary nature, the suddenness of its implementation, its lengthy duration, and the presence of others at home. The demands of this form of remote work during lockdown have partly been mitigated by the resources employees have accessed. This study aimed to investigate the factors impacting employee performance and wellbeing while compulsorily working from home during New Zealand's first nationwide lockdown. We analyzed qualitative data gathered from employees in two organizations. The resulting aggregate dimensions across both demands and resources include organizational factors, furniture and technology factors, and individual factors. Given the ongoing nature of COVID-19 we identify new research directions for investigating remote work, and practical implications focusing on suitable home furniture and technology, plans for future remote work, and supporting employees.
Persons with Alzheimer’s disease and related dementias (ADRD) are prone to receiving reduced quality of care. We compared the quality of room cleaning of rooms with ADRD residents and rooms with non-ADRD residents in nursing homes using an ultraviolet (UV) marker. ADRD status was associated with greater failure of UV marker removal (odds ratio, 1.68; 95% confidence interval, 1.04–2.71; P = .03).
It is often argued by health professionals working within the field of palliative care that palliative care and euthanasia/assisted suicide are incompatible. Across the literature, this claim is grounded on the three claims that (1) palliative care and euthanasia/assisted suicide have different aims, (2) euthanasia/assisted suicide is at odds with the doctor’s fundamental role as a healer, and (3) euthanasia/assisted suicide constitutes patient abandonment. Furthermore, even if palliative care and euthanasia/assisted suicide are compatible, it is often argued that the availability of palliative care renders euthanasia/assisted suicide redundant. This depends on two claims that (1) palliative care is always available and effective, and (2) palliative care is always preferable to euthanasia/assisted suicide. This article argues that all of these claims are false, ultimately aiming to establish that palliative care and euthanasia/assisted suicide are complementary rather than mutually exclusive.
The Red Sea is a largely homogeneous water column beyond the top 300 m, unique in exhibiting warm bottom water (~21.5 °C) at depths down to ~2900 m. The unusual conditions coupled with barriers to colonization by primary deep-sea species has resulted in an impoverished but distinct deep fauna. This study presents a rare investigation of the deep Red Sea. The bigeye hound shark Iago omanensis is a known deep-sea shark in the Red Sea. However, its full depth distribution has never been conclusively studied. Here, we confirm with videographic evidence the presence of I. omanensis at depths to 2522 m in the Red Sea, along with observations of other deep-sea species. Iago omanensis was the only species of scavenging fish observed and only in moderate numbers. The additional six species were mostly crustacea in low abundance. The lack of scavenging species present in the deep Red Sea is likely explained by the low productivity of the overlying surface waters and unusually warm water temperature resulting in low energetic input but high metabolic demands in deep communities.
A machine learning model was created to predict the electron spectrum generated by a GeV-class laser wakefield accelerator. The model was constructed from variational convolutional neural networks, which mapped the results of secondary laser and plasma diagnostics to the generated electron spectrum. An ensemble of trained networks was used to predict the electron spectrum and to provide an estimation of the uncertainty of that prediction. It is anticipated that this approach will be useful for inferring the electron spectrum prior to undergoing any process that can alter or destroy the beam. In addition, the model provides insight into the scaling of electron beam properties due to stochastic fluctuations in the laser energy and plasma electron density.
Innovative shoe insoles, designed to enhance sensory information on the plantar surface of the feet, could help to improve walking in people with Multiple Sclerosis.
To compare the effects of wearing textured versus smooth insoles, on measures of gait, foot sensation and patient-reported outcomes, in people with Multiple Sclerosis.
A prospective, randomised controlled trial was conducted with concealed allocation, assessor blinding and intention-to-treat analysis. Thirty ambulant men and women with multiple sclerosis (MS) (Disease Steps rating 1–4) were randomly allocated to wear textured or smooth insoles for 12 weeks. Self-reported insole wear and falls diaries were completed over the intervention period. Laboratory assessments of spatiotemporal gait patterns, foot sensation and proprioception, and patient-reported outcomes, were performed at Weeks 0 (Baseline 1), 4 (Baseline 2) and 16 (Post-Intervention). The primary outcome was the size of the mediolateral base of support (stride/step width) when walking over even and uneven surfaces. Independent t-tests were performed on change from baseline (average of baseline measures) to post-intervention.
There were no differences in stride width between groups, when walking over the even or uneven surfaces (P ≥ 0.20) at post-intervention. There were no between-group differences for any secondary outcomes including gait (all P values > 0.23), foot sensory function (all P values ≥ 0.08) and patient-reported outcomes (all P values ≥ 0.23).
In our small trial, prolonged wear of textured insoles did not appear to alter walking or foot sensation in people with MS who have limited foot sensory loss. Further investigation is needed to explore optimal insole design.
Clinical Trial Registration:
Australian and New Zealand Clinical Trials Registry (ACTRN12615000421538).
Admission laboratory screening for asymptomatic coronavirus disease 2019 (COVID-19) has been utilized to mitigate healthcare-associated severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission. An understanding of the impact of such testing across a variety of patient populations is needed.
SARS-CoV-2 nucleic acid amplification admission testing results for all asymptomatic patients across 4 distinct inpatient facilities between April 20, 2020, and June 14, 2021, were analyzed. Positivity rates and the number needed to test (NNT) to identify 1 asymptomatic infected patient were calculated. Admission results were compared to COVID-19 community incidence rates for the system’s surrounding metropolitan service area. Using a national survey of hospital epidemiologists, a clinically meaningful NNT of 1:100 was identified.
In total, 51,187 tests were collected (positivity rate, 1.8%). During periods of high transmission, the NNT met the clinically relevant threshold in all populations. The NNT approached or met the threshold for most locations during periods of lower transmission. For all transmission levels, the NNT for fully vaccinated patients did not meet the threshold.
Implementing an asymptomatic patient admission testing program can provide clinically relevant data based on the NNT, even during periods of lower transmission and among different patient populations. Limiting admission testing to non–fully vaccinated patients during periods of lower transmission may be a strategy to address resource concerns around this practice. Although the impact of such testing on healthcare-associated COVID-19 among patients and healthcare workers could not be clearly determined, these data provide important information as facilities weigh the costs and benefits of such testing.
Turbine wake and farm blockage effects may significantly impact the power produced by large wind farms. In this study, we perform large-eddy simulations (LES) of 50 infinitely large offshore wind farms with different turbine layouts and wind directions. The LES results are combined with the two-scale momentum theory (Nishino & Dunstan, J. Fluid Mech., vol. 894, 2020, p. A2) to investigate the aerodynamic performance of large but finite-sized farms as well. The power of infinitely large farms is found to be a strong function of the array density, whereas the power of large finite-sized farms depends on both the array density and turbine layout. An analytical model derived from the two-scale momentum theory predicts the impact of array density very well for all 50 farms investigated and can therefore be used as an upper limit to farm performance. We also propose a new method to quantify turbine-scale losses (due to turbine–wake interactions) and farm-scale losses (due to the reduction of farm-average wind speed). They both depend on the strength of atmospheric response to the farm, and our results suggest that, for large offshore wind farms, the farm-scale losses are typically more than twice as large as the turbine-scale losses. This is found to be due to a two-scale interaction between turbine wake and farm induction effects, explaining why the impact of turbine layout on farm power varies with the strength of atmospheric response.
We aimed to understand which non-household activities increased infection odds and contributed greatest to SARS-CoV-2 infections following the lifting of public health restrictions in England and Wales.
We undertook multivariable logistic regressions assessing the contribution to infections of activities reported by adult Virus Watch Community Cohort Study participants. We calculated adjusted weighted population attributable fractions (aPAF) estimating which activity contributed greatest to infections.
Among 11 413 participants (493 infections), infection was associated with: leaving home for work (aOR 1.35 (1.11–1.64), aPAF 17%), public transport (aOR 1.27 (1.04–1.57), aPAF 12%), shopping once (aOR 1.83 (1.36–2.45)) vs. more than three times a week, indoor leisure (aOR 1.24 (1.02–1.51), aPAF 10%) and indoor hospitality (aOR 1.21 (0.98–1.48), aPAF 7%). We found no association for outdoor hospitality (1.14 (0.94–1.39), aPAF 5%) or outdoor leisure (1.14 (0.82–1.59), aPAF 1%).
Essential activities (work and public transport) carried the greatest risk and were the dominant contributors to infections. Non-essential indoor activities (hospitality and leisure) increased risk but contributed less. Outdoor activities carried no statistical risk and contributed to fewer infections. As countries aim to ‘live with COVID’, mitigating transmission in essential and indoor venues becomes increasingly relevant.
LiDAR coverage of a large contiguous area within the Mirador-Calakmul Karst Basin (MCKB) of northern Guatemala has identified a concentration of Preclassic Maya sites (ca. 1000 b.c.–a.d. 150) connected by causeways, forming a web of implied social, political, and economic interactions. This article is an introduction to one of the largest, contiguous, regional LiDAR studies published to date in the Maya Lowlands. More than 775 ancient Maya settlements are identified within the MCKB, and 189 more in the surrounding karstic ridge, which we condensed into 417 ancient cities, towns, and villages of at least six preliminary tiers based on surface area, volumetrics, and architectural configurations. Many tiered sites date to the Middle and Late Preclassic periods, as determined by archaeological testing, and volumetrics of contemporaneously constructed and/or occupied architecture with similar morphological characteristics. Monumental architecture, consistent architectural formats, specific site boundaries, water management/collection facilities, and 177 km of elevated Preclassic causeways suggest labor investments that defy organizational capabilities of lesser polities and potentially portray the strategies of governance in the Preclassic period. Settlement distributions, architectural continuities, chronological contemporaneity, and volumetric considerations of sites provide evidence for early centralized administrative and socio-economic strategies within a defined geographical region.
This study assessed the incidence rate of all-cause pneumonia (ACP) and invasive pneumococcal disease (IPD) and associated medical costs among individuals aged ≥16 in the German InGef database from 2016 to 2019. Incidence rate was expressed as the number of episodes per 100 000 person-years (PY). Healthcare resource utilisation was investigated by age group and by risk group (healthy, at-risk, high-risk). Direct medical costs per ACP/IPD episode were estimated as the total costs of all inpatient and outpatient visits. The overall incidence rate of ACP was 1345 (95% CI 1339–1352) and 8.25 (95% CI 7.76–8.77) per 100 000 PY for IPD. For both ACP and IPD, incidence rates increased with age and were higher in the high-risk and at-risk groups, in comparison to the healthy group. ACP inpatient admission rate increased with age but remained steady across age-groups for IPD. The mean direct medical costs per episode were €8075 (95% CI 7121–9028) for IPD and €1454 (95% CI 1426–1482) for ACP. The aggregate direct medical costs for IPD and ACP episodes were estimated to be €8.5 million and €248.9 million respectively. The clinical and economic burden of IPD and ACP among German adults is substantial regardless of age.
Starting from the biblical depiction of Christ’s incarnate personhood, this chapter traces the early church’s discernment of the deity and humanity of Christ that culminated in the Chalcedonian definition. Exploring the range of christological options, the chapter emphasizes the promise of a kenotic christology for making sense of Chalcedon’s intentions and parameters, including a fuller appreciation of Christ’s humanity.
This chapter articulates the identity of the church by way of key biblical metaphors and the Nicene Creed. It then examines the church’s mission, the role of proclamation and the sacraments, and the missional shape of the doctrine of election.
This chapter considers the meaning of the claim that human beings are created in God’s image (imago Dei), offering a representational-relational conception of the doctrine. It also examines how the corruptive effects of sin deface humanity’s image-bearing, pointing to the need for the image to be restored through the person of Jesus Christ, the true image of God.
This chapter takes up the doctrine of God generally, concentrating on the traditional understanding of divine being as a complex of attributes derived via positiva and via negative (i.e., “classical theism”). Given classical theism’s tensions with the biblical narrative, as well as its role in helping to foster the rise of modern atheism, the chapter argues for a rigorous trinitarian rethinking of key traditional divine attributes.
This chapter looks at the reality of religious plurality – more particularly, the relationship between the Christian church and other religious traditions – including the common typology of exclusivism, inclusivism, and pluralism. It also explores the significance of the fact that the Christian church’s numerical center has shifted from the West to the South and East, with significant consequences for the mission and theology of the church.
This chapter explores how the life, death, and resurrection of Jesus Christ make reconciliation possible. It surveys the diverse biblical motifs surrounding reconciliation/atonement, the variety of traditional “atonement theories” that flowed out of those motifs, and a way of coherently integrating a variety of atonement approaches.