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The literary comedians were a loose group of writers from the Northeast, sometimes called “Phunny Phellows” because of their use of misspelling to drive their humor. They usually wrote under pseudonyms, which were often comic and outrageous in themselves: Petroleum V. Nasby, Orpheus C. Kerr, and Artemus Ward, among others. The mask of ignorance presented by their seeming illiteracy belied a great intelligence in the writers, often with a goal of satirical political and social comment. Although Twain did not use the central device of comic misspelling in his writing, he was greatly influenced by these writers, especially Artemus Ward, who also provided for Twain a model in his lecturing career, the mask of a seemingly uneducated speaker who actually made sharp political comment.
Identify changes in the prevalence and antimicrobial resistance patterns of potentially pathogenic bacteria in urine cultures during a 2-year antimicrobial stewardship intervention program in nursing homes (NHs).
Before-and-after intervention study.
The study included 27 NHs in North Carolina.
We audited all urine cultures ordered before and during an antimicrobial stewardship intervention. Analyses compared culture rates, culture positive rates, and pathogen antimicrobial resistance patterns.
Of 6,718 total urine cultures collected, 68% were positive for potentially pathogenic bacteria. During the intervention, significant reductions in the urine culture and positive culture rates were observed (P = .014). Most of the identified potentially uropathogenic isolates were Escherichia coli (38%), Proteus spp (13%), and Klebsiella pneumoniae (12%). A significant decrease was observed during the intervention period in nitrofurantoin resistance among E. coli (P ≤ .001) and ciprofloxacin resistance among Proteus spp (P ≤ .001); however carbapenem resistance increased for Proteus spp (P ≤ .001). Multidrug resistance also increased for Proteus spp compared to the baseline. The high baseline resistance of E. coli to the commonly prescribed antimicrobials ciprofloxacin and trimethoprim-sulfamethoxazole (TMP/SMX) did not change during the intervention.
The antimicrobial stewardship intervention program significantly reduced urine culture and culture-positive rates. Overall, very high proportions of antimicrobial resistance were observed among common pathogens; however, antimicrobial resistance trended downward but reductions were too small and scattered to conclude that the intervention significantly changed antimicrobial resistance. Longer intervention periods may be needed to effect change in resistance patterns.
To describe current practice around urine testing and identify factors leading to overtreatment of asymptomatic bacteriuria in community nursing homes (NHs)
Observational study of a stratified random sample of NH patients who had urine cultures ordered in NHs within a 1-month study period
31 NHs in North Carolina
254 NH residents who had a urine culture ordered within the 1-month study period
We conducted an NH record audit of clinical and laboratory information during the 2 days before and 7 days after a urine culture was ordered. We compared these results with the urine antibiogram from the 31 NHs.
Empirical treatment was started in 30% of cases. When cultures were reported, previously untreated cases received antibiotics 89% of the time for colony counts of ≥100,000 CFU/mL and in 35% of cases with colony counts of 10,000–99,000 CFU/mL. Due to the high rate of prescribing when culture results returned, 74% of these patients ultimately received a full course of antibiotics. Treated and untreated patients did not significantly differ in temperature, frequency of urinary signs and symptoms, or presence of Loeb criteria for antibiotic initiation. Factors most commonly associated with urine culture ordering were acute mental status changes (32%); change in the urine color, odor, or sediment (17%); and dysuria (15%).
Urine cultures play a significant role in antibiotic overprescribing. Antibiotic stewardship efforts in NHs should include reduction in culture ordering for factors not associated with infection-related morbidity as well as more scrutiny of patient condition when results become available.
Walt Whitman devoted his career to defining and enacting a new poetics that would be distinctive to the American nation and its democratic aspirations. Whitman's influence has extended well beyond poetry. He has been examined seriously by political scientists and cultural theorists as a philosopher of democracy, and he has been a central figure in gay history and queer studies, often credited with inventing the language of homosexual love. Whitman's notebooks and surviving manuscripts reveal the intensity and fluidity of the development of his poetic style. He was teaching Americans how to begin to think and speak democratically, in a freer and looser idiom, in a more conversational and less formal tone, in an absorptive and indiscriminate way. Major historical events like the Civil War and Reconstruction had a palpable effect on the physical makeup of his books.
Gas hydrates are typically formed when water and gas (e.g., light hydrocarbons) come into contact at high pressure and low temperature. Current estimates of the amount of energy trapped in naturally occurring gas hydrate deposits, which are found in ocean sediments along the continental margins and in sediments under the permafrost, range from twice to orders of magnitude larger than conventional gas reserves. This has led to gas hydrates being considered as a potential future unconventional energy source.
Gas hydrates (or clathrate hydrates) are icelike crystalline solids imprisoning gas molecules (e.g., methane, carbon dioxide, hydrogen) within icy cages. These fascinating solids present an attractive medium for storing energy: naturally in the deep oceans and permafrost regions, which hold vast quantities of energy waiting to be unlocked and used as an alternative energy supply; and artificially by manipulating synthetic clathrate materials to store clean fuel (natural gas or hydrogen). Conversely, the formation of these solids in oil and gas flowlines (the pipes through which oil and gas are transported, for example, from a well to a processing facility) can lead to blockage of the flowlines and disastrous consequences if not carefully controlled. This chapter on gas hydrates begins with an overview of the discovery and evolving scientific interest in gas hydrates, followed by a basic description of the structural and physical properties of gas hydrates and the different energy applications of gas hydrates. The main focus of this chapter is on surveying the potential prospect of producing energy in the form of clean gas from naturally occurring gas hydrates, which present a potential alternative energy resource and could be a significant component of the alternative energy portfolio. The paradigm shift from exploration to production of energy from gas hydrates is clearly illustrated by the production tests that have either been performed or are planned in the Mackenzie Delta in Canada, on the North Slope of Alaska, and off the coast of Japan.
To study the epidemiology and preventability of blood contact with skin and mucous membranes during surgical procedures.
Observers present at 1,382 surgical procedures recorded information about the procedure, the personnel present, and the contacts that occurred.
Four US teaching hospitals during 1990.
Operating room personnel in five surgical specialties.
Main Outcome Measures:
Numbers and circumstances of contact between the patient's blood (or other infective fluids) and surgical personnel's mucous membranes (mucous membrane contacts) or skin (skin contacts, excluding percutaneous injuries).
A total of 1,069 skin (including 620 hand, 258 body, and 172 face) and 32 mucous membrane (all affecting eyes) contacts were observed. Surgeons sustained most contacts (19% had ≥1 skin contact and 0.5% had ≥1 mucous membrane-eye contact). Hand contacts were 72% lower among surgeons who double gloved, and face contacts were prevented reliably by face shields. Mucous membrane-eye contacts were significantly less frequent in surgeons wearing eyeglasses and were absent in surgeons wearing goggles or face shields. Among surgeons, risk factors for skin contact depended on the area of contact: hand contacts were associated most closely with procedure duration (adjusted odds ratio [OR], 9.4; ≥4 versus <1 hour); body contacts (arms, legs, and torso) with estimated blood losses (adjusted OR, 8.4; ≥1,000 versus <100 mL); and face contacts, with orthopedic service (adjusted OR, 7.5 compared with general surgery).
Skin and mucous membrane contacts are preventable by appropriate barrier precautions, yet occur commonly during surgery. Surgeons who perform procedures similar to those included in this study should strongly consider double gloving, changing gloves routinely during surgery, or both.
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