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To develop and evaluate a program to presvent hospital-acquired pneumonia (HAP).
Prospective, observational, surveillance program to identify HAP before and after 7 interventions. An order set automatically triggered in programmatically identified high-risk patients.
All 21 hospitals of an integrated healthcare system with 4.4 million members.
All hospitalized patients.
Interventions for high-risk patients included mobilization, upright feeding, swallowing evaluation, sedation restrictions, elevated head of bed, oral care and tube care.
HAP rates decreased between 2012 and 2018: from 5.92 to 1.79 per 1,000 admissions (P = .0031) and from 24.57 to 6.49 per 100,000 members (P = .0014). HAP mortality decreased from 1.05 to 0.34 per 1,000 admissions and from 4.37 to 1.24 per 100,000 members. Concomitant antibiotic utilization demonstrated reductions of broad-spectrum antibiotics. Antibiotic therapy per 100,000 members was measured as follows: carbapenem days (694 to 463; P = .0020), aminoglycoside days (154 to 61; P = .0165), vancomycin days (2,087 to 1,783; P = .002), and quinolone days (2,162 to 1,287; P < .0001). Only cephalosporin use increased, driven by ceftriaxone days (264 to 460; P = .0009). Benzodiazepine use decreased between 2014 to 2016: 10.4% to 8.8% of inpatient days. Mortality for patients with HAP was 18% in 2012% and 19% in 2016 (P = .439).
HAP rates, mortality, and broad-spectrum antibiotic use were all reduced significantly following these interventions, despite the absence of strong supportive literature for guidance. Most interventions augmented basic nursing care. None had risks of adverse consequences. These results support the need to examine practices to improve care despite limited literature and the need to further study these difficult areas of care.
This article argues that discourses of constitutional pluralism contain a strong normative core which is made up of a series of largely unacknowledged implicit claims about legitimacy and community. This argument is illustrated by reference to various constitutional pluralist responses to the Hungarian Constitutional Court's ruling concerning the protection of constitutional identity in the context of EU asylum and refugee protection law and policy, demonstrating that whether this decision falls ‘inside’ or ‘outside’ constitutional pluralist tolerance depends on how the observer defines the minimum amount of shared substantive or procedural content that is fundamental to the EU order.
Unequal obesity distributions among adult populations have been reported in low- and middle-income countries, but mainly based on data of women of reproductive age. Moreover, incorporation of ever-changing skewed BMI distributions in analyses has been a challenge. Our study aimed to assess magnitude and rates of change in BMI distributions by age and sex.
Shapes of BMI distributions were estimated for 2005 and 2010, and their changes were assessed, using the generalized additive model for location, scale and shape (GAMLSS) and assuming BMI follows a Box–Cox power exponential (BCPE) distribution.
Nationally representative, repeated cross-sectional health surveys conducted between 2005 and 2013 in Mexico, Colombia and Peru.
Adult men and non-pregnant women aged 20–69 years.
Whereas women had more right-shifted and wider BMI distributions than men in almost all age groups across the countries in 2010, men in their 30s–40s experienced more rapid increases in BMI between 2005 and 2010, notably in Peru. The highest increase in overweight and obesity prevalence was observed among Peruvian men of 35–39 years, with a 5-year increase of 21 percentage points.
The BCPE–GAMLSS method is an alternative to analyse measurements with time-varying distributions visually, in addition to conventional indicators such as means and prevalences. Consideration of differences in BMI distributions and their changes by sex and age would provide vital information in tailoring relevant policies and programmes to reach target populations effectively. Increases in BMI portend increases of obesity-associated diseases, for which preventive and preparative actions are urgent.
The high Antarctic plateau provides exceptional conditions for infrared observations on account of the cold, dry and stable atmosphere above the ice surface. This paper describes the scientific goals behind the first program to examine the time-varying universe in the infrared from Antarctica — the Kunlun Infrared Sky Survey (KISS). This will employ a 50cm telescope to monitor the southern skies in the 2.4μmKdark window from China's Kunlun station at Dome A, on the summit of the Antarctic plateau, through the uninterrupted 4-month period of winter darkness. An earlier paper discussed optimisation of the Kdark filter for sensitivity (Li et al. 2016). This paper examines the scientific program for KISS. We calculate the sensitivity of the camera for the extrema of observing conditions that will be encountered. We present the parameters for sample surveys that could then be carried out for a range of cadences and sensitivities. We then discuss several science programs that could be conducted with these capabilities, involving star formation, brown dwarfs and hot Jupiters, exoplanets around M dwarfs, the terminal phases of stellar evolution, fast transients, embedded supernova searches, reverberation mapping of AGN, gamma ray bursts and the detection of the cosmic infrared background.
This chapter argues that it is illuminating to read ‘crisis’ not as a fact, but as a political discourse that functions as a ‘technique of government’. Drawing examples from the context of the EU’s contemporary policy responses to the financial crisis, it illustrates how experts produce knowledge about ‘crises’, and how the discourse of crisis is operationalized as a tool for giving effect to governmental ambitions. This reading of crisis as a technique of government raises three inter-related challenges to the implied assumptions of the crisis narrative. First, it puts into question the idea that crises are ‘uncommon’ or ‘special’ events, and instead argues that the discourse of crisis is commonplace in the EU, and acts as a normative assertion about the status quo. Second, it undermines the simplistic logic of cause and effect by emphasizing the production of truth that lies at the heart of crisis discourse and how these truths shape expectations and policy proposals. Third, this reading complicates the idea that crises are ‘game changing’ moments of social or political shift, arguing rather that their political effects remain uncertain and tied up with the success of particular forms of knowledge.
Debates about ‘constitutionalism’ have become an important trend in WTO scholarship. Despite over two decades of interest, however, a coherent definition of the term and its content remain out of reach. This paper argues that ‘constitutionalism’ should be approached not as something that can be measured or assessed empirically, but rather as a ‘discursive contest’: a debate in which participants intervene on behalf of particular understandings of how the system does or should operate. Approaching constitutionalism as a discursive contest adds to the literature by shifting the focus to an analysis of how ‘constitutional talk’ produces knowledge about the WTO, and how this knowledge in turn structures perceptions about the way government works and the possibilities for action. Providing examples from scholarly debates and WTO practice, the article aims to make concrete the relationship between truth and government and the implications of discursive contests over constitutionalism in the field of WTO law.