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We describe a large SARS-CoV-2 outbreak involving an acute care hospital emergency department during December 2020 and January 2021, in which 27 healthcare personnel worked while infectious, resulting in multiple opportunities for SARS-CoV-2 transmission to patients and other healthcare personnel. We provide recommendations for improving infection prevention and control.
Spinal fusion surgery (SFS) is one of the most common operations in the United States, >450,000 SFSs are performed annually, incurring annual costs >$10 billion.
We used a nationwide longitudinal database to accurately assess incidence and payments associated with management of postoperative infection following SFS.
We conducted a retrospective, observational cohort analysis of 210,019 patients undergoing SFS from 2014 to 2018 using IBM MarketScan commercial and Medicaid–Medicare databases. We assessed rates of superficial/deep incisional SSIs, from 3 to 180 days after surgery using Cox proportional hazard regression models. To evaluate adjusted payments for patients with/without SSIs, adjusted for inflation to 2019 Consumer Price Index, we used generalized linear regression models with log-link and γ distribution.
Overall, 6.6% of patients experienced an SSI, 1.7% superficial SSIs and 4.9% deep-incisional SSIs, with a median of 44 days to presentation for superficial SSIs and 28 days for deep-incisional SSIs. Selective risk factors included surgical approach, admission type, payer, and higher comorbidity score. Postoperative incremental commercial payments for patients with superficial SSI were $20,800 at 6 months, $26,937 at 12 months, and $32,821 at 24 months; incremental payments for patients with deep-incisional SSI were $59,766 at 6 months, $74,875 at 12 months, and $93,741 at 24 months. Corresponding incremental Medicare payments for patients with superficial incisional at 6, 12, 24-months were $11,044, $17,967, and $24,096; while payments for patients with deep-infection were: $48,662, $53,757, and $73,803 at 6, 12, 24-months.
We identified a 4.9% rate of deep infection following SFS, with substantial payer burden. The findings suggest that the implementation of robust evidence-based surgical-care bundles to mitigate postoperative SFS infection is warranted.
Although prior scholarship has made considerable progress in measuring politicians’ positions, it has only rarely considered voters’ or activists’ perceptions of those positions. Here, we present a novel measure of U.S. senators’ perceived ideologies derived from 9,030 pairwise comparisons elicited from party activists in three 2016 YouGov surveys. By focusing on activists, we study a most-likely case for perceiving within-party ideological distinctions. We also gain empirical leverage from Donald Trump’s nomination and heterodox positions on some issues. Our measure of perceived ideology is correlated with nominate but differs in informative ways: senators with very conservative voting records were sometimes perceived as less conservative if they did not support Trump. A confirmatory test shows these trends extended into 2021. Even among activists, perceived ideology appears to be anchored by prominent people as well as policy positions.
Oceanic island ecosystems contain a disproportionate number of Earth’s terrestrial species, many of them endemic or indigenous to only one or a few islands. Consequently, the importance of islands in the quest to protect terrestrial biodiversity has been increasingly recognized and included in global environmental agreements. Nevertheless, oceanic island ecosystems remain extremely vulnerable to anthropogenic disturbance and its impacts, particularly in terms of the uncontrolled spread of introduced species, so-called biological invasions, leading to substantial biodiversity loss and fundamental changes in ecosystem functioning and structure. The South Pacific region is a hotspot of biodiversity but also has the world’s highest concentration of invasive alien plant species. Although the issue of biological invasions has been increasingly acknowledged by local governments and international agreements, invasive alien species are often not monitored properly on Pacific islands. Furthermore, knowledge of the potential impact of invasive alien species regularly does not result in on-the-ground action, adding to the growing extinction threat. This inaction persists despite international and national efforts for sustainable use and nature conservation of terrestrial biodiversity in the region’s Small Island Developing States. We illustrate this problem with two relatively recent biological invaders in Fiji: the ivory cane palm (Pinanga coronata) and the green iguana (Iguana iguana). We use these examples to examine the potential consequences of continuing inaction, despite awareness in relevant government departments, for native forest biodiversity and human livelihoods. Through an examination of the institutional background, we discuss steps towards good governance and sustainable development of terrestrial biodiversity in the Small Island Developing States of the tropical South Pacific, where on-the-ground action to control, eradicate, and prevent invasive alien species is desperately needed.
The Dutch Termination of Life on Request and Assisted Suicide (Review Procedure) Act (euthanasia law) came into force in 2002. The goals of the euthanasia law are to provide legal security for all involved in physician-assistance in dying, to assure prudent practice, and to provide a framework for physicians to be accountable and thus enable transparency and societal control. Every five years the law is evaluated to examine whether its objectives are (still) being met. In 2015–2017, this was done for the third time, by studying current practices, identifying new developments in the interpretation and conceptualisation of the legal criteria, which are formulated rather openly in the law, and analysing potential complexities of the review system. This chapter outlines the role of this evaluation in keeping the existing law under review. It is part of the ongoing examination of the operation, scope and effectiveness of the laws and so these findings contribute to deliberations about whether to change the law or not. The chapter also comments on the evaluation’s function in advising on suggested changes to the law.
Optimal preoperative therapy regimen in the treatment of resectable retroperitoneal sarcoma (RPS) remains unclear. This study compares the impact of preoperative radiation, chemoradiation and chemotherapy on overall survival (OS) in RPS patients.
Materials and Methods:
The National Cancer Database (NCDB) was queried for patients with non-metastatic, resectable RPS (2006–15). The primary endpoint was OS, evaluated by Kaplan–Meier method, log-rank test, Cox multivariable analysis and propensity score matching.
A total of 1,253 patients met the inclusion criteria, with 210 patients (17%) receiving chemoradiation, 850 patients (68%) receiving radiation and 193 patients (15%) receiving chemotherapy. On Cox multivariable analysis, when compared to preoperative chemoradiation, preoperative radiation was not associated with improved OS (hazards ratio [HR] 0·98, 95% CI 0·76–1·25, p = 0·84), while preoperative chemotherapy was associated with worse OS (HR 1·64, 95% CI 1·24–2·18, p < 0·001). Similar findings were observed in 199 and 128 matched pairs for preoperative radiation and chemotherapy, respectively, when compared to preoperative chemoradiation.
Our study suggested an OS benefit in using preoperative chemoradiation compared to chemotherapy alone, but OS outcomes were comparable between preoperative chemoradiation and radiation alone.
To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution.
Retrospective cohort study.
Two affiliated academic medical centers in Los Angeles, California.
Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards.
We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation.
Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91–4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28–3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34–0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22–0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria.
Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.
Evidence suggests a link between smaller hippocampal volume (HV) and post-traumatic stress disorder (PTSD). However, there has been little prospective research testing this question directly and it remains unclear whether smaller HV confers risk or is a consequence of traumatization and PTSD.
U.S. soldiers (N = 107) completed a battery of clinical assessments, including structural magnetic resonance imaging pre-deployment. Once deployed they completed monthly assessments of traumatic-stressors and symptoms. We hypothesized that smaller HV would potentiate the effects of traumatic stressors on PTSD symptoms in theater. Analyses evaluated whether total HV, lateral (right v. left) HV, or HV asymmetry (right – left) moderated the effects of stressor-exposure during deployment on PTSD symptoms.
Findings revealed no interaction between total HV and average monthly traumatic-stressors on PTSD symptoms b = −0.028, p = 0.681 [95% confidence interval (CI) −0.167 to 0.100]. However, in the context of greater exposure to average monthly traumatic stressors, greater right HV was associated with fewer PTSD symptoms b = −0.467, p = 0.023 (95% CI −0.786 to −0.013), whereas greater left HV was unexpectedly associated with greater PTSD symptoms b = 0.435, p = 0.024 (95% CI 0.028–0.715).
Our findings highlight the importance of considering the complex role of HV, in particular HV asymmetry, in predicting the emergence of PTSD symptoms in response to war-zone trauma.
This paper presents a study of a novel type of magnetic nozzle that allows for three-dimensional (3-D) steering of a plasma plume. Numerical simulations were performed using Tech-X’s USim® software to quantify the nozzle’s capabilities. A 2-D planar magnetic nozzle was applied to plumes of a nominal pulsed inductive plasma (PIP) source with discharge parameters similar to those of Missouri S&T’s Missouri Plasmoid Experiment (MPX). Argon and xenon plumes were considered. Simulations were verified and validated through a mesh convergence study as well as comparison with available experimental data. Periodicity was achieved over the simulation run time and phase angle samples were taken to examine plume evolution over pulse cycles. The resulting pressure, velocity, and density fields were analysed for nozzle angles from 0° to 14°. It was found that actual plume divergence was small compared to the nozzle angle. Even with an offset angle of 14° for the magnetic nozzle, the plume vector angle was only about 2° for argon and less than 1° for xenon. The parameters that had the most effect on the vectoring angle were found to be the coil current and inlet velocity.
Background: Despite efforts toward gender equality in clinical trial enrollment, females are frequently underrepresented and gender-specific data analysis is often unavailable. The purpose of this study was to determine if gender equality exists in the management of degenerative lumbar disease. Methods: Part 1: A systematic scoping review was conducted according to PRISMA guidelines, in order to synthesize the adult surgical literature regarding gender differences in pre- and post-operative clinical assessment scores for patients diagnosed with degenerative lumbar disease.
Part 2: An ambispective cohort analysis (multi-variate logistic regression) of the Canadian Spine Outcomes Research Network registry was performed to address knowledge gaps identified in “Part 1”. Results: Part 1: Thirty articles were identified, accounting for 32,951 patients. Female patients have worse absolute pre-operative pain, disability and health-related quality-of-life (HRQoL). Following surgery, females have worse absolute pain, disability, and HRQoL, but demonstrate an equal or greater interval change compared to males.
Part 2: Data was analyzed for 5,039 patients. Significant gender differences in pre-operative utilization of healthcare resources (medication use, diagnostic testing, medical and allied healthcare professional visits) were identified. Conclusions: Significant gender disparities in clinical assessment scores and the pre-operative utilization of healthcare resources were identified for patients undergoing surgery for degenerative lumbar disease.
We investigated the quality of life (QoL) of patients hospitalized with C. difficile infection (CDI).
Prospective survey study.
US tertiary-care referral center, acute-care setting.
Adults hospitalized with a diagnosis of CDI, defined as ≥3 episodes of unformed stool in 24 hours and a positive laboratory test for C. difficile.
We surveyed patients from July 2019 to March 2020 using the disease-specific Cdiff32 questionnaire and the generic PROMIS GH survey. We compared differences in Cdiff32 scores among demographic and clinical subgroups (including CDI severity, CDI recurrence, and various comorbidities) using 2-sample t tests. We compared PROMIS GH scores to the general population T score of 50 using 1-sample t tests. We performed multivariable linear regression to identify predictors of Cdiff32 scores.
In total, 100 inpatients (mean age, 58.6 ±17.1 years; 53.0% male; 87.0% white) diagnosed with CDI completed QoL surveys. PROMIS GH physical health summary scores (T = 37.3; P < .001) and mental health summary scores (T = 43.4; P < .001) were significantly lower than those of the general population. In bivariate analysis, recurrent CDI, severe CDI, and number of stools were associated with lower Cdiff32 scores. In multivariable linear regression, recurrent CDI, severe CDI, and each additional stool in the previous 24 hours were associated with significantly decreased Cdiff32 scores.
Patients hospitalized with CDI reported low scores on the Cdiff32 and PROMIS GH, demonstrating a negative impact of CDI on QoL in multiple health domains. The Cdiff32 questionnaire is particularly sensitive to QoL changes in patients with recurrent or severe disease.