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An accurate estimate of the average number of hand hygiene opportunities per patient hour (HHO rate) is required to implement group electronic hand hygiene monitoring systems (GEHHMSs). We sought to identify predictors of HHOs to validate and implement a GEHHMS across a network of critical care units.
Multicenter, observational study (10 hospitals) followed by quality improvement intervention involving 24 critical care units across 12 hospitals in Ontario, Canada.
Critical care patient beds were randomized to receive 1 hour of continuous direct observation to determine the HHO rate. A Poisson regression model determined unit-level predictors of HHOs. Estimates of average HHO rates across different types of critical care units were derived and used to implement and evaluate use of GEHHMS.
During 2,812 hours of observation, we identified 25,417 HHOs. There was significant variability in HHO rate across critical care units. Time of day, day of the week, unit acuity, patient acuity, patient population and use of transmission-based precautions were significantly associated with HHO rate. Using unit-specific estimates of average HHO rate, aggregate HH adherence was 30.0% (1,084,329 of 3,614,908) at baseline with GEHHMS and improved to 38.5% (740,660 of 1,921,656) within 2 months of continuous feedback to units (P < .0001).
Unit-specific estimates based on known predictors of HHO rate enabled broad implementation of GEHHMS. Further longitudinal quality improvement efforts using this system are required to assess the impact of GEHHMS on both HH adherence and clinical outcomes within critically ill patient populations.
Gravitational waves from coalescing neutron stars encode information about nuclear matter at extreme densities, inaccessible by laboratory experiments. The late inspiral is influenced by the presence of tides, which depend on the neutron star equation of state. Neutron star mergers are expected to often produce rapidly rotating remnant neutron stars that emit gravitational waves. These will provide clues to the extremely hot post-merger environment. This signature of nuclear matter in gravitational waves contains most information in the 2–4 kHz frequency band, which is outside of the most sensitive band of current detectors. We present the design concept and science case for a Neutron Star Extreme Matter Observatory (NEMO): a gravitational-wave interferometer optimised to study nuclear physics with merging neutron stars. The concept uses high-circulating laser power, quantum squeezing, and a detector topology specifically designed to achieve the high-frequency sensitivity necessary to probe nuclear matter using gravitational waves. Above 1 kHz, the proposed strain sensitivity is comparable to full third-generation detectors at a fraction of the cost. Such sensitivity changes expected event rates for detection of post-merger remnants from approximately one per few decades with two A+ detectors to a few per year and potentially allow for the first gravitational-wave observations of supernovae, isolated neutron stars, and other exotica.
Poor motivation to engage in goal-oriented behavior has been recognized as a hallmark feature of schizophrenia spectrum disorders (SZ). Low drive in SZ may be related to anticipating rewards as well as to poor working memory. However, few studies to date have examined beliefs about self-efficacy and satisfaction for future rewards (anticipatory pleasure). Additionally, few studies to date have examined how these deficits may impact SZ patients’ real world functioning.
The present study examined SZ patients’ (n = 57) anticipatory pleasure, working memory, self-efficacy and real world functioning in relation to their negative symptom severity.
Results revealed that SZ patients’ negative symptom severity was related to decisions in effort allocation and reward probability, working memory deficits, self-efficacy and anticipatory pleasure for future reward. Effort allocation deficits also predicted patients’ daily functioning skills.
SZ patients with high levels of negative symptoms are not merely effort averse, but have more difficulty effectively allocating effort and anticipating pleasure engaging in effortful activities. It may be the case that continuously failing to achieve reinforcement from engagement and participation may lead SZ patients to form certain negative beliefs about their abilities which contributes to amotivation and cognitive deficits. Lastly, our findings provide further support for a link between SZ patients functional daily living skills their effort allocation.
This study used a single case experimental design to investigate the use of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) among a sample of individuals with depression and anxiety who also presented with borderline personality disorder (BPD). Eight women received individual treatment with the UP over the course of 14–16 treatment sessions, and were assessed for anxiety and depression severity on a weekly basis over a 2–6 week baseline period and throughout treatment. Three of the eight participants demonstrated reliable pre- to post-treatment clinical improvements on depression and stress scales, and one participant demonstrated a reliable reduction on an anxiety scale. Two participants demonstrated a reliable improvement in overall anxiety. The results indicate that the UP applied to individuals diagnosed with primary BPD may lead to clinical improvement in depression, stress and anxiety for some individuals. However, the majority of individuals with BPD in our sample did not show strong improvement, and this suggests the need for additional sessions of UP or an intervention that focuses on the symptoms of BPD specifically for some women.
Key learning aims
(1) To describe the applicability of the Unified Protocol in the treatment of individuals with borderline personality and co-occurring anxiety or depression.
(2) To understand the value of utilizing a transdiagnostic approach as an alternative to diagnosis-specific approaches to treatment.
(3) To identify the four core modules of the Unified Protocol and describe the general format for individual treatment.
Despite extensive research on organizational virtue, our understanding about factors that promote virtue within organizations remains unclear. Drawing on upper echelon theory, we examine the relationship between five top management team (TMT) characteristics and organizational virtue orientation (OVO)—the integrated set of values and beliefs that support ethical traits and virtuous behaviors of an organization. Specifically, we utilize prospectuses of initial public offering (IPO) firms and 10-K post-IPO filings to explore how TMT composition with respect to member age, tenure, education, functional background, and gender influences OVO. Additionally, we examine the moderating effects of organizational size, and argue that the more expansive structures and processes associated with larger organizations diminish the main relationships. Our findings, using two sources of data, are consistent, but somewhat mixed in their support for our hypotheses. Overall, TMT characteristics do appear to influence OVO, but in more complex and counterintuitive ways than initially expected.
The Iranian Empire emerged in the third century in the interstices of the Silk Road that increasingly linked the markets of the Mediterranean and the Near East with South, Central, and East Asia. The ensuing four centuries of Iranian rule corresponded with the heyday of trans-Eurasian trade, as the demand of moneyed imperial elites across the continent for one another's high-value commodities stimulated the development of long-distance networks. Despite its position at the nexus of trans-continental and trans-oceanic commerce, accounts of Iran in late antiquity relegate trade to a marginal role in its political economy. The present article seeks to foreground the contribution of trans-continental mercantile networks to the formation of Iran and to argue that its development depended as much on the political economies of its western and eastern neighbours as on internal Near Eastern factors.
The Omani basement is located spatially distant from the dominantly juvenile Arabian–Nubian Shield (ANS) to its west, and its relationship to the amalgamation of those arc terranes has yet to be properly constrained. The Jebel Ja'alan (NE Oman) basement inlier provides an excellent opportunity to better understand the Neoproterozoic tectonic geography of Oman and its relationship to the ANS. To understand the origin of this basement inlier, we present new radiogenic isotopic data from igneous bodies in Jebel Ja'alan. U–Pb and 40Ar/39Ar geochronological data are used to constrain the timing of magmatism and metamorphism in the jebel. Positive εHf and εNd values indicate a juvenile origin for the igneous lithologies. Phase equilibria modelling is used to constrain the metamorphic conditions recorded by basement. Pressure–temperature (P–T) pseudosections show that basement schists followed a clockwise P–T path, reaching peak metamorphic conditions of c. 650–700°C at 4–7.5 kbar, corresponding to a thermal gradient of c. 90–160°C/kbar. From the calculated thermal gradient, in conjunction with collected trace-element data, we interpret that the Jebel Ja'alan basement formed in an arc environment. Geochronological data indicate that this juvenile arc formed during Tonian time and is older than basement further west in Oman. We argue that the difference in timing is related to westwards arc accretion and migration, which implies that the Omani basement represents its own tectonic domain separate to the ANS and may be the leading edge of the Neoproterozoic accretionary margin of India.
Universal screening for postpartum depression is recommended in many countries. Knowledge of whether the disclosure of depressive symptoms in the postpartum period differs across cultures could improve detection and provide new insights into the pathogenesis. Moreover, it is a necessary step to evaluate the universal use of screening instruments in research and clinical practice. In the current study we sought to assess whether the Edinburgh Postnatal Depression Scale (EPDS), the most widely used screening tool for postpartum depression, measures the same underlying construct across cultural groups in a large international dataset.
Ordinal regression and measurement invariance were used to explore the association between culture, operationalized as education, ethnicity/race and continent, and endorsement of depressive symptoms using the EPDS on 8209 new mothers from Europe and the USA.
Education, but not ethnicity/race, influenced the reporting of postpartum depression [difference between robust comparative fit indexes (∆*CFI) < 0.01]. The structure of EPDS responses significantly differed between Europe and the USA (∆*CFI > 0.01), but not between European countries (∆*CFI < 0.01).
Investigators and clinicians should be aware of the potential differences in expression of phenotype of postpartum depression that women of different educational backgrounds may manifest. The increasing cultural heterogeneity of societies together with the tendency towards globalization requires a culturally sensitive approach to patients, research and policies, that takes into account, beyond rhetoric, the context of a person's experiences and the context in which the research is conducted.
Older people with dementia are at increased risk of physical decline and falls. Balance and mood are significant predictors of falls in this population. The aim of this study was to determine the effect of a tailored home-based exercise program in community-dwelling older people with dementia.
Forty-two participants with mild to moderate dementia were recruited from routine health services. All participants were offered a six-month home-based, carer-enhanced, progressive, and individually tailored exercise program. Physical activity, quality of life, physical, and psychological assessments were administered at the beginning and end of the trial.
Of 33 participants (78.6%) who completed the six-month reassessment ten (30%) reported falls and six (18%) multiple falls during the follow-up period. At reassessment, participants had better balance (sway on floor and foam), reduced concern about falls, increased planned physical activity, but worse knee extension strength and no change in depression scores. The average adherence to the prescribed exercise sessions was 45% and 22 participants (52%) were still exercising at trial completion. Those who adhered to ≥70% of prescribed sessions had significantly better balance at reassessment compared with those who adhered to <70% of sessions.
This trial of a tailored home-based exercise intervention presents preliminary evidence that this intervention can improve balance, concern about falls, and planned physical activity in community-dwelling older people with dementia. Future research should determine whether exercise interventions are effective in reducing falls and elucidate strategies for enhancing uptake and adherence in this population.
At least in conventional hydrostatic ice-sheet models, the numerical error associated with grounding line dynamics can be reduced by modifications to the discretization scheme. These involve altering the integration formulae for the basal traction and/or driving stress close to the grounding line and exhibit lower – if still first-order – error in the MISMIP3d experiments. MISMIP3d may not represent the variety of real ice streams, in that it lacks strong lateral stresses, and imposes a large basal traction at the grounding line. We study resolution sensitivity in the context of extreme forcing simulations of the entire Antarctic ice sheet, using the BISICLES adaptive mesh ice-sheet model with two schemes: the original treatment, and a scheme, which modifies the discretization of the basal traction. The second scheme does indeed improve accuracy – by around a factor of two – for a given mesh spacing, but $\lesssim 1$ km resolution is still necessary. For example, in coarser resolution simulations Thwaites Glacier retreats so slowly that other ice streams divert its trunk. In contrast, with $\lesssim 1$ km meshes, the same glacier retreats far more quickly and triggers the final phase of West Antarctic collapse a century before any such diversion can take place.
In the Iranian Empire (226–636 CE), jurists drawn from the ranks of the Zoroastrian priestly elite developed a complex of institutions designed to guarantee the reproduction of aristocratic males as long as the empire endured. To overcome the high rate of mortality characteristic of preindustrial demographic regimes, they aimed to maximize the fertility rate without compromising their endogamous ideals through the institutions of reproductive coercion, temporary marriage, and “substitute-successorship.” Occupying a position between the varieties of monogamy and polygyny hitherto practiced in the Ancient Near East, the Iranian organization of sex enabled elites not only to reproduce their patrilineages reliably across multiple generations, but also to achieve an appropriate ratio of resources to number of offspring. As the backbone of this juridical architecture, the imperial court became the anchor of aristocratic power, and ruling and aristocratic dynasties became increasingly intertwined and interdependent, forming the patrilineal networks of the “Iranians”—the agents and beneficiaries of Iranian imperialism. The empire's aristocratic structure took shape through a sexual economy: the court created and circulated sexual and reproductive incentives that incorporated elite males into its network that was, thanks to its politically enhanced inclusive fitness, reliable and reproducible. In demonstrating the centrality of Zoroastrian cosmology to the construction and operation of the relevant juridical institutions, I seek to join the approaches of evolutionary biology and cultural anthropology to reproduction that have been pursued in opposition, to account for the historical role of sex in the consolidation of the Iranian Empire.
The small size of Early Triassic marine organisms has important implications for the ecological and environmental pressures operating during and after the end-Permian mass extinction. However, this “Lilliput Effect” has only been documented quantitatively in a few invertebrate clades. Moreover, the discovery of Early Triassic gastropod specimens larger than any previously known has called the extent and duration of the Early Triassic size reduction into question. Here, we document and compare Permian-Triassic body size trends globally in eight marine clades (gastropods, bivalves, calcitic and phosphatic brachiopods, ammonoids, ostracods, conodonts, and foraminiferans). Our database contains maximum size measurements for 11,224 specimens and 2,743 species spanning the Late Permian through the Middle to Late Triassic. The Permian/Triassic boundary (PTB) shows more size reduction among species than any other interval. For most higher taxa, maximum and median size among species decreased dramatically from the latest Permian (Changhsingian) to the earliest Triassic (Induan), and then increased during Olenekian (late Early Triassic) and Anisian (early Middle Triassic) time. During the Induan, the only higher taxon much larger than its long-term mean size was the ammonoids; they increased significantly in median size across the PTB, a response perhaps related to their comparatively rapid diversity recovery after the end-Permian extinction. The loss of large species in multiple clades across the PTB resulted from both selective extinction of larger species and evolution of surviving lineages toward smaller sizes. The within-lineage component of size decrease suggests that only part of the size decrease can be related to the end-Permian kill mechanism; in addition, Early Triassic environmental conditions or ecological pressures must have continued to favor small body size as well. After the end-Permian extinction, size decrease occurred across ecologically and physiologically disparate clades, but this size reduction was limited to the first part of the Early Triassic (Induan). Nektonic habitat or physiological buffering capacity may explain the contrast of Early Triassic size increase and diversification in ammonoids versus size reduction and slow recovery in benthic clades.
Magnetic resonance imaging studies of maltreated children with posttraumatic stress disorder (PTSD) suggest that maltreatment-related PTSD is associated with adverse brain development. Maltreated youth resilient to chronic PTSD were not previously investigated and may elucidate neuromechanisms of the stress diathesis that leads to resilience to chronic PTSD. In this cross-sectional study, anatomical volumetric and corpus callosum diffusion tensor imaging measures were examined using magnetic resonance imaging in maltreated youth with chronic PTSD (N = 38), without PTSD (N = 35), and nonmaltreated participants (n = 59). Groups were sociodemographically similar. Participants underwent assessments for strict inclusion/exclusion criteria and psychopathology. Maltreated youth with PTSD were psychobiologically different from maltreated youth without PTSD and nonmaltreated controls. Maltreated youth with PTSD had smaller posterior cerebral and cerebellar gray matter volumes than did maltreated youth without PTSD and nonmaltreated participants. Cerebral and cerebellar gray matter volumes inversely correlated with PTSD symptoms. Posterior corpus callosum microstructure in pediatric maltreatment-related PTSD differed compared to maltreated youth without PTSD and controls. The group differences remained significant when controlling for psychopathology, numbers of Axis I disorders, and trauma load. Alterations of these posterior brain structures may result from a shared trauma-related mechanism or an inherent vulnerability that mediates the pathway from chronic PTSD to comorbidity.
In the United States alone, ∼14,000 children are hospitalised annually with acute heart failure. The science and art of caring for these patients continues to evolve. The International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute was held on February 4 and 5, 2015. The 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute was funded through the Andrews/Daicoff Cardiovascular Program Endowment, a philanthropic collaboration between All Children’s Hospital and the Morsani College of Medicine at the University of South Florida (USF). Sponsored by All Children’s Hospital Andrews/Daicoff Cardiovascular Program, the International Pediatric Heart Failure Summit assembled leaders in clinical and scientific disciplines related to paediatric heart failure and created a multi-disciplinary “think-tank”. The purpose of this manuscript is to summarise the lessons from the 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute, to describe the “state of the art” of the treatment of paediatric cardiac failure, and to discuss future directions for research in the domain of paediatric cardiac failure.
Each year, tobacco use causes over 6 million deaths and is responsible for hundreds of billions of dollars in health care and economic costs in the world (WHO, 2011). If current trends continue, tobacco is expected to kill over 1 billion people in the 21st century, making it one of the single greatest causes of preventable death and disease in history (WHO, 2011). Long-term abstinence from tobacco use dramatically improves individuals’ health, reduces the incidence of tobacco-related disease, and is clearly responsible for saving lives (Anthonisen et al., 2005). Most tobacco users express a desire to achieve long-term abstinence from tobacco use and make numerous unsuccessful quit attempts over the course of many years (Borland, Partos, Yong, Cummings, & Hyland, 2012; CDC, 2011). Evidence-based treatments for tobacco use and dependence greatly improve the chances that quit attempts result in long-term abstinence (Chambless & Hollon, 1998; Chambless et al., 1998; Compas, Haaga, Keefe, Leitenberg, & Williams, 1998; Fiore et al., 2008; Zwar et al., 2004). Increasing the availability of high-quality evidence-based treatment for tobacco use and dependence will make it more likely that tobacco users use evidence-based treatments and that quit attempts translate into long-term abstinence. The professionalisation of treatment for tobacco dependence by the development of a rigorous, unified Tobacco Treatment Specialist (TTS) certification process will increase the availability of high-quality evidence-based treatment for tobacco use and dependence for all tobacco users.