Background: In March 2012, the Veterans’ Health Administration (VHA) published the Guideline for the Prevention of Clostridium difficile infection (CDI) in VHA Inpatient Acute-Care Facilities, with a goal of 30% reduction of cases within 2 years. In March 2011, this facility, along with 31 others, served as a pilot site to develop the guidelines. Methods: The CDI prevention bundle was implemented to prevent new onset CDI cases in the facility with 4 core measures: (1) environmental cleaning (EMS), (2) hand hygiene, (3) contact precautions, and (4) cultural transformation. Education was provided to EMS staff, nursing, and care providers on the CDI case definition, criteria for testing, empiric isolation for patients with diarrhea, hand hygiene, and PPE to control spread. In 2014, antimicrobial stewardship was added, and within 5 years an algorithm for isolation and testing was published. Cases were reviewed weekly using TheraDoc software and were reported monthly to the national VHA Inpatient Evaluation Center (IPEC). Isolation was communicated using a ward roster/isolation list in TheraDoc for all unit champions to consult daily. CDI cases were classified using NHSN definitions for a laboratory-identified (LabID) event, recurrent cases, and community-onset cases. Real-time case review and weekly multidisciplinary case discussions identified opportunities for improved compliance with the core measures. Results: Over an 8-year period, CDI healthcare-onset LabID events decreased by 73%. The cases decreased from 149 to 40 over the 8-year period. The infection rate decreased 70% from 16.19 per 10,000 bed days of care in FY2011 (October 2010) to 4.88 in FY2019. The incidence of community onset infections increased from 75 in FY2011 to a high of 146 in FY2018 for a rate of 8.15 to 18.17. In FY2019, there was a decrease in both LabID events and community-onset cases to lows of 40 and 102, respectively. Inappropriate testing decreased by 84% from 50 in FY2011 to 8 in FY2019. Conclusions: A multidisciplinary team approach that included support from leadership and clinical providers as well as front line staff involvement, daily rounding, and case review by infection preventionists has reduced all CDI cases over an 8-year period using the modified VHA CDI bundle. TheraDoc enabled case review, correct isolation, changes to cleaning practices, and more appropriate lab testing. The antimicrobial stewardship program that includes clinical pharmacists working daily with providers was a strong driver for change.

Funding: None

Disclosures: None

The provision of manipulable material to pigs is a legal requirement to ensure their good welfare. Loose straw is edible, chewable, investigable and manipulable, and has been proven to be effective in reducing abnormal behaviour. However, it is incompatible with slatted systems and therefore not a viable option for many intensive units. Thus, there is a need to identify enrichment materials that are as effective as loose straw and compatible with slatted floors. This study investigated the viability of using compressed straw blocks on a commercial farm in terms of cost and effectiveness in reducing biting relative to plastic hanging toys. A total of 880 slaughter pigs were used, among which half (n = 440, 8 groups) were provided with commercial pig toys (TOY) and the other half (n = 440, 8 groups) were provided compressed straw blocks (STRAW BLOCK). Animals were separated according to sex to investigate whether there was a higher propensity to tail and ear bite depending on sex. Pigs were monitored from weaning to slaughter, with tails being examined post scalding and any condemnations recorded at the abattoir. Throughout their life, the tails and ears of all pigs were examined individually, and behavioural observations of each pig group were conducted fortnightly. Salivary cortisol was also obtained from a subsample of pigs from each group every fortnight to monitor stress levels. The highest straw usage was recorded in the second weaner stage (39 to 67 days after weaning). Enrichment type or sex had no effect on tail lesion scores or cold carcass weight recorded at the abattoir. There was also no effect of enrichment type or sex on body, tail, or ear lesion scores during either the weaner (0 to 39 days after weaning) or finisher stage (67 to145 days after weaning). Female pigs showed more biting behaviour than males, and female pigs that were provided STRAW BLOCK performed better than those provided TOY. In both the weaner and finisher accommodation, more instances of interaction were recorded with TOY pens as enrichment than with STRAW BLOCK, but the interaction duration was not recorded. There was no effect of sex on either stage. More instances of aggression were observed with the TOY than with STRAW BLOCK in the weaner stage (P < 0.05). Enrichment type or sex had no effect on cortisol levels. Thus, relative to plastic hanging toys, compressed straw blocks provided in this manner did not benefit pig welfare.

Introduction: Emergency medicine (EM) is a demanding specialty with high rates of physician burnout. As emergency physicians, we must stay healthy to promote healthy living, optimize our ability to care for our patients, extend our careers, and be there for our families. While we all desire a healthy lifestyle, maintaining one in practice can be difficult. We sought to investigate the strategies emergency physician employ to maintain and improve health and wellness while mitigating the professions stressors. Methods: From April 2015 to July 2017, forty-three wellness champions from Canada, the USA, and Australia were identified using a snowball sampling technique. Each participant answered 5 introductory questions and 8 productivity questions pertaining to health and wellness. These were transcribed and loaded to a publicly accessible blog, ALiEM.com, as part of the Healthy in EM series. Two investigators reviewed the transcripts using inductive methods and a grounded theory approach to generate themes and subthemes using coding software, NVivo (Burlington, Massachusetts), until saturation was achieved. Consensus between investigators (JC, ZP) established the master code and audit trail. An external audit by investigators (TC, BT) not involved with the initial analysis was performed to ensure reliability. Results: Major themes including diet, sleep, exercise and social activities were coded and further subcategorized along with perspectives, habits, personal philosophies, and career diversity. These themes translated across both professional and personal aspects of participants lives. For example, the pre-shift and post-shift strategies often included some form of regimented activities-of-daily-living that required discipline to adhere to at work and home. Conclusion: Our findings show the importance of homeostasis in the professional and personal realm among expert emergency medicine physicians. Among healthy emergency physicians, diet, sleep, and exercise patterns intertwined with perspectives, habits, personal philosophies, and social activities contributed to maintenance of wellness.

A compact hybrid rocket motor design that incorporates a dual-vortical-flow (DVF) concept is proposed. The oxidizer (nitrous oxide, N2O) is injected circumferentially into various sections of the rocket motor, which are sectored by several solid fuel “rings” (made of hydroxyl-terminated polybutadiene, HTPB) that are installed along the central axis of the motor. The proposed configuration not only increases the residence time of the oxidizer flow, it also implies an inherent “roll control” capability of the motor. Based on a DVF motor geometry with a designed thrust level of 11.6 kN, the characteristics of the turbulent reacting flow within the motor and its rocket performance were analyzed with a comprehensive numerical model that implements both real-fluid properties and finite-rate chemistry. Data indicate that the vacuum specific impulse (Isp) of the DVF motor could reach 278 s. The result from a preliminary ground test of a lab-scale DVF hybrid rocket motor (with a designed thrust level of 3,000 N) also shows promising performance. The proposed DVF concept is expected to partly resolve the issue of scalability, which remains challenging for hybrid rocket motors development.

Swaziland has the highest prevalence of human immunodeficiency virus (HIV) in the world. Attrition (loss to follow-up and mortality) in people living with HIV/AIDS (PLWHA) already on treatment is a major challenge, undermining achievements of the antiretroviral treatment (ART) programme in Swaziland. The contributing factors to attrition in the Swazi context are unclear. This study aims to (1) estimate attrition from the ART programme 12 months after ART initiation in Swaziland, and (2) determine the predictors of attrition in PLWHA treated with ART in Swaziland. A retrospective cohort study using national baseline data was conducted. A competing-risk Cox proportional hazard regression was used to determine the predictors of attrition. We estimated 10·3% (95% confidence interval 10·1–10·6) attrition in 16 423 participants that initiated ART in 2012. Attrition was significantly associated with sex, age, district, treatment supporter at initiation, co-infection of HIV and TB, functional status, WHO clinical stage, and ownership of facility. Our study can form a base of policies, plans, and service delivery strategies for preventing and controlling attrition in Swaziland.

We recently demonstrated a sub-bandgap photoresponse with our wafer-scale Au/TiO2 metallic-semiconductor photonic crystals (MSPhC). The sub-bandgap energy with 590 nm peak could be absorbed in the form of hot electron and injected to TiO2, which provides 5.28 times more energy for photolysis than that of energy absorbed to flat TiO2. If the solar energy already absorbed above 700 nm could be injected to the catalyst, higher than 10 times improvement will be achieved, and above 20% solar to fuel efficiency will be feasible with the robust but inefficient TiO2 catalyst. In order to achieve photocurrent near and above 700 nm spectrum, we deposited gold nanorods on the surface of MSPhC to incur localized surface plasmon (LSP) modes absorption and subsequent injection to the TiO2 catalyst. We used electrophoretic deposition (EPD) method to deposit nanorods on the top, sidewall and bottom well surface of the photonic nanocavities. The deposition of nanorods was achieved reasonably uniform and sparse not to block the optical cavities of MSPhC. Flat gold surfaces were tested at 4 different suspension densities to get the optimum gold nanorods density. Under 10V applied electric field, positively charged gold nanorods at the concentration of 6.52×1013 #/mL could deposit MSPhC surface with the density of 230 #/µm2, which was reasonably uniform and sparse. Preliminary tests show an absorbance increase near 700 nm on flat device coated with gold nanorods. Photocurrent measurement is under way to demonstrate the enhanced hot electron transfer over full visible light and near-infrared solar spectrum.

The Rho/ROCK pathway is involved in numerous pivotal cellular processes that have made it an area of intense study in cancer medicine, however, Rho-associated coiled-coil containing protein kinase (ROCK) inhibitors are yet to make an appearance in the clinical cancer setting. Their performance as an anti-cancer therapy has been varied in pre-clinical studies, however, they have been shown to be effective vasodilators in the treatment of hypertension and post-ischaemic stroke vasospasm. This review addresses the various roles the Rho/ROCK pathway plays in angiogenesis, tumour vascular tone and reciprocal feedback from the tumour microenvironment and explores the potential utility of ROCK inhibitors as effective vascular normalising agents. ROCK inhibitors may potentially enhance the delivery and efficacy of chemotherapy agents and improve the effectiveness of radiotherapy. As such, repurposing of these agents as adjuncts to standard treatments may significantly improve outcomes for patients with cancer. A deeper understanding of the controlled and dynamic regulation of the key components of the Rho pathway may lead to effective use of the Rho/ROCK inhibitors in the clinical management of cancer.

The relationship between subjective memory complaints (SM) and objective memory (OM) performance in aging has been variably characterized in a substantial literature, to date. In particular, cross-sectional studies often observe weak or no associations. We investigated whether subjective memory complaints and objectively measured cognition influence each other over time, and if so, which is the stronger pathway of change—objective to subjective, or subjective to objective—or whether they are both important. Using bivariate latent change score modeling in data from a population study (N=1980) over 5 annual assessment cycles, we tested four corresponding hypotheses: (1) no coupling between SM and OM over time; (2) SM as leading indicator of change in OM; (3) OM as leading indicator of change in SM; (4) dual coupling over time, with both SM and OM leading subsequent change in the other. We also extended objective cognition to two other domains, language and executive functions. The dual-coupling models best fit the data for all three objective cognitive domains. The SM–OM temporal dynamics differ qualitatively compared to other domains, potentially reflecting changes in insight and self-awareness specific to memory impairment. Subjective memory and objective cognition reciprocally influence each other over time. The temporal dynamics between subjective and objective cognition in aging are nuanced, and must be carefully disentangled to shed light on the underlying processes. (JINS, 2015, 21, 732–742)