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Evaluate changes in antimicrobial use during COVID-19 and after implementation of a multispecialty COVID-19 clinical guidance team compared to pre–COVID-19 antimicrobial use.
Retrospective observational study.
Tertiary-care academic medical center.
Internal medicine and medical intensive care unit (MICU) provider teams and hospitalized COVID-19 patients.
Difference-in-differences analyses of antibiotic days of therapy per 1,000 patient days present (DOT) for internal medicine and MICU teams treating COVID-19 patients versus teams that did not were performed for 3 periods: before COVID-19, initial COVID-19 period, and after implementation of a multispecialty COVID-19 clinical guidance team which included daily, patient-specific antimicrobial stewardship recommendations. Patient characteristics associated with antibiotic DOT were evaluated using multivariable Poisson regression.
In the initial COVID-19 period, compared to the pre–COVID-19 period, internal medicine and MICU teams increased weekly antimicrobial use by 145.3 DOT (95% CI, 35.1–255.5) and 204.0 DOT (95% CI, −16.9 to 424.8), respectively, compared to non–COVID-19 teams. In the intervention period, internal medicine and MICU COVID-19 teams both had significant weekly decreases of 362.3 DOT (95% CI, −443.3 to −281.2) and 226.3 DOT (95% CI, −381.2 to –71.3). Of 131 patients hospitalized with COVID-19, 86 (65.6%) received antibiotics; no specific patient factors were significantly associated with an expected change in antibiotic days.
Antimicrobial use initially increased for COVID-19 patient care teams compared to pre–COVID-19 levels but significantly decreased after implementation of a multispecialty clinical guidance team, which may be an effective strategy to reduce unnecessary antimicrobial use.
The fragile Lancastrian state survived through the loyalty, commitment and consistent stalwart service of supporters such as William, Lord Roos. The Lancastrians were beset by many institutional fragilities: rebellions; Henry IV's poor health; tensions within the inner royal circle. There were also societal fragilities – some of them, especially those impinging on law and public order, parallel to the institutional problems. The challenges to religious orthodoxy, for example, which threatened both church and state, reached their peak as Henry V was still establishing himself on the throne. Money was a constant concern. That in 1400 the former crusader Henry IV could afford to give the Byzantine emperor, Manuel II, desperate for help against the encroaching Ottomans, no more than warm words and fine food starkly illustrates the problem. It was, however, not just the difficulties themselves which created fragility: it was their consequences. Executions and deaths in battle robbed the Lancastrians of men who, otherwise, could have been capable political leaders. Significant local areas were left without adequate lordship. Roos offered stability, dependability and experience.
Although Roos never assumed major leadership responsibilities, he played a significant support role through some of the most difficult times for the Lancastrian regime until his death in September 1414. Closer to Henry IV and Archbishop Arundel than to the prince of Wales, he survived the various vicissitudes of the later part of Henry IV's reign, emerging in Henry V's as a zealous prosecutor of lollards. He survived partly because he was not sufficiently important to be removed, so while his influence sometimes waned he never disappeared entirely from the court circle. His survival may be partly attributed to the esteem in which he appeared to be increasingly held by a sometimes truculent House of Commons. Largely, however, it stemmed from his dogged loyalty to the Lancastrian cause and his usefulness not just at court but also through his notable local connections.
Roos had extensive landed interests in north Yorkshire, with a substantial castle at Helmsley, but he was not exclusively a northern magnate. Importantly, he also held lands in Leicestershire, Lincolnshire and Nottinghamshire, giving him considerable influence in these central and eastern areas.
Herbicide resistance is the heritable ability of a weed biotype or population to survive a herbicide application that would effectively kill a susceptible population of the weed. In the U.K. the most widespread and financially important herbicide-resistant weed is blackgrass. Investigations to elucidate the molecular mechanisms conferring herbicide resistance to blackgrass populations have been ongoing for two decades. Although the identification of target site–resistant populations has proved to be relatively straightforward (using, for example, target site assays in vitro), the study and understanding of resistance mechanisms involved in enhanced metabolism has proven to be more problematic. Research has focused on the cytochrome P450 monooxygenase and glutathione S-transferase (GST) enzyme families, both of which have been shown to be important in herbicide metabolism in many weed and crop species. GST activity and abundance are greater in a selection of herbicide-resistant blackgrass biotypes, and herbicide treatment of field populations of blackgrass results in the survival of the proportion of population possessing the greatest GST activity and abundance. In addition, GST activity in the field increases between winter and spring, and this coincides with reduced efficacy of important blackgrass herbicides. GST activities within field populations of blackgrass are highly varied, and this plasticity is discussed in relation to the development of resistant populations in field situations. This article describes research results in blackgrass and compares them with GST studies in other weed species as well as with other mechanisms for enhanced metabolism-based resistance.
In 1867, Prince Alfred, Queen Victoria's second son, commissioned the Galatea for a voyage around the world which would include the first royal visit to Australia. Stopping along the way in Rio de Janeiro and Cape Town, Alfred was received with great ceremony at each port of call. These visits provided the ship's chaplain John Milner (1822–97) and the artist Oswald Brierly (1817–94) with ample material for this chronicle, published in 1869, which gives background details of each region alongside scenes from the tour, enhanced by illustrations based on Brierly's sketches. The authors drew on various recollections and writings, including a letter from Alfred to his brother describing an elephant hunt in South Africa. The tour was abruptly curtailed in Sydney when a Fenian sympathiser attempted to assassinate the prince, an act which boosted support for the British royal family.