Background: Hospital-acquired Clostridioides difficile infection (HA-CDI) rates are highly variable over time, posing problems for research assessing interventions that might improve rates. By understanding seasonality in HA-CDI rates and the impacts that other factors such as influenza admissions might have on these rates, we can account for them when establishing the relationship between interventions and infection rates. We assessed whether there were seasonal trends in HA-CDI and whether they could be accounted for by influenza rates. Methods: We assessed HA-CDI rates per 10,000 patient days, and the rate of hospitalized patients with influenza per 1,000 admissions in 4 acute-care facilities (n = 2,490 beds) in Calgary, Alberta, from January 2016 to December 2018. We used 4 statistical approaches in R (version 3.5.1 software): (1) autoregressive integrated moving average (ARIMA) to assess dependencies and trends in each of the monthly HA-CDI and influenza series; (2) cross correlation to assess dependencies between the HA-CDI and influenza series lagged over time; (3) Poisson harmonic regression models (with sine and cosine components) to assess the seasonality of the rates; and (4) Poisson regression to determine whether influenza rates accounted for seasonality in the HA-CDI rates. Results: Conventional ARIMA approaches did not detect seasonality in the HA-CDI rates, but we found strong seasonality in the influenza rates. A cross-correlation analysis revealed evidence of correlation between the series at a lag of zero (R = 0.41; 95% CI, 0.10–0.65) and provided an indication of a seasonal relationship between the series (Fig. 1). Poisson regression suggested that influenza rates predicted CDI rates (P < .01). Using harmonic regression, there was evidence of seasonality in HA-CDI rates (2 [2 df] = 6.62; P < .05) and influenza rates (2 [2 df] = 1,796.6; P < .001). In a Poisson model of HA-CDI rates with both the harmonic components and influenza admission rates, the harmonic components were no longer predictive of HA-CDI rates. Conclusions: Harmonic regression provided a sensitive means of identifying seasonality in HA-CDI rates, but the seasonality effect was accounted for by influenza admission rates. The relationship between HA-CDI and influenza rates is likely mediated by antibiotic prescriptions, which needs to be assessed. To improve precision and reduce bias, research on interventions to reduce HA-CDI rates should assess historic seasonality in HA-CDI rates and should account for influenza admissions.

Funding: None

Disclosures: None

Background:Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea in hospitalized patients. Probiotics have been studied as a measure to prevent CDI. Timely probiotic administration to at-risk patients receiving systemic antimicrobials presents significant challenges. We sought to determine optimal implementation methods to administer probiotics to all adult inpatients aged 55 years receiving a course of systemic antimicrobials across an entire health region. Methods: Using a randomized stepped-wedge design across 4 acute-care hospitals (n = 2,490 beds), the probiotic Bio-K+ was prescribed daily to patients receiving systemic antimicrobials and was continued for 5 days after antimicrobial discontinuation. Focus groups and interviews were conducted to identify barriers, and the implementation strategy was adapted to address the key identified barriers. The implementation strategy included clinical decision support involving a linked flag on antibiotic ordering and a 1-click order entry within the electronic medical record (EMR), provider and patient education (written/videos/in-person), and local site champions. Protocol adherence was measured by tracking the number of patients on therapeutic antimicrobials that received BioK+ based on the bedside nursing EMR medication administration records. Adherence rates were sorted by hospital and unit in 48- and 72-hour intervals with recording of percentile distribution of time (days) to receipt of the first antimicrobial. Results: In total, 340 education sessions with >1,800 key stakeholders occurred before and during implementation across the 4 involved hospitals. The overall adherence of probiotic ordering for wards with antimicrobial orders was 78% and 80% at 48 and 72 hours, respectively over 72 patient months. Individual hospital adherence rates varied between 77% and 80% at 48 hours and between 79% and 83% at 72 hours. Of 246,144 scheduled probiotic orders, 94% were administered at the bedside within a median of 0.61 days (75th percentile, 0.88), 0.47 days (75th percentile, 0.86), 0.71 days (75th percentile, 0.92) and 0.67 days (75th percentile, 0.93), respectively, at the 4 sites after receipt of first antimicrobial. The key themes from the focus groups emphasized the usefulness of the linked flag alert for probiotics on antibiotic ordering, the ease of the EMR 1-click order entry, and the importance of the education sessions. Conclusions: Electronic clinical decision support, education, and local champion support achieved a high implementation rate consistent across all sites. Use of a 1-click order entry in the EMR was considered a key component of the success of the implementation and should be considered for any implementation strategy for a stewardship initiative. Achieving high prescribing adherence allows more precision in evaluating the effectiveness of the probiotic strategy.

Funding: Partnerships for Research and Innovation in the Health System, Alberta Innovates/Health Solutions Funding: Award

Disclosures: None

Current policy emphasises the importance of ‘living well’ with dementia, but there has been no comprehensive synthesis of the factors related to quality of life (QoL), subjective well-being or life satisfaction in people with dementia. We examined the available evidence in a systematic review and meta-analysis. We searched electronic databases until 7 January 2016 for observational studies investigating factors associated with QoL, well-being and life satisfaction in people with dementia. Articles had to provide quantitative data and include ⩾75% people with dementia of any type or severity. We included 198 QoL studies taken from 272 articles in the meta-analysis. The analysis focused on 43 factors with sufficient data, relating to 37639 people with dementia. Generally, these factors were significantly associated with QoL, but effect sizes were often small (0.1–0.29) or negligible (<0.09). Factors reflecting relationships, social engagement and functional ability were associated with better QoL. Factors indicative of poorer physical and mental health (including depression and other neuropsychiatric symptoms) and poorer carer well-being were associated with poorer QoL. Longitudinal evidence about predictors of QoL was limited. There was a considerable between-study heterogeneity. The pattern of numerous predominantly small associations with QoL suggests a need to reconsider approaches to understanding and assessing living well with dementia.

In his Natural Law and Natural Rights, Fundamentals of Ethics, and other works, the Oxford professor of jurisprudence and moral theologian John Finnis has elaborated a theory of ethics and natural law that he presents as being based on the thought of St. Thomas Aquinas. (Finnis has been influenced in this project by the moral theologian Germain Grisez, and has worked in cooperation with Grisez and Joseph Boyle on these issues, but I will confine myself to a discussion of Finnis’s thought, while noting that my conclusions will have implications for the views of Grisez and Boyle as well.) His account of natural law incorporates a particular account of human life as a good for practical reasoning, from which he concludes — in disagreement with Aquinas — that capital punishment is immoral. This conclusion has gained wide acceptance among Catholics, partly because of the influence of Finnis and Grisez’s moral theories. I want to examine his understanding of the good of life, contrasting it with the actual views of St. Thomas, and argue that it is mistaken. I will then explain why I think his mistake is an important one that needs to be avoided.

Finnis presents his account of natural law as being modelled on St. Thomas’s account of the first principles of natural law, which is given chiefly in the Summa Theologiae, la2ae q.94 a.2. It may be helpful to sketch St. Thomas’s understanding of practical as opposed to theoretical reason. Theoretical reason aims at knowledge of how things are, and its activity terminates in belief about how things are.

The deep sea protobranch bivalve species Ledella pustulosa recently has been described as comprised of four subspecies, differentiated on subtle and qualitative differences in shell morphology. Two of these, L. p. pustulosa and L. p. marshalli, possess overlapping geographic distributions, L. p. pustulosa occurring on the continental slope, and L. p. marshalli occurring on the continental rise and at upper abyssal depths. Principal components analysis was applied to six samples of Ledella pustulosa from the Rockall Trough in order to explore patterns of variation in shell shape and to test whether the variability follows a depth-related cline which might be under environmental control. Two of these samples had previously been identified as L. p. pustulosa and L. p. marshalli, respectively. The distributions of shapes at every depth overlapped broadly with the distributions from other depths and none of the depths had uniformly distinct shells. However, the mean shapes of the six samples divided into two clusters: a shallow cluster characterized by a lower dorsal profile (smaller ‘shoulders’) and a deep cluster with larger ‘shoulders’. No bathymetric cline in shape was found within these clusters. A discriminant function based on training samples of L. p. pustulosa and L. p. marshalli correctly identified 84% of the shells in the training samples and was applicable over a wide range in shell size. It showed that the subspecies differed primarily in the dorsal profile. The discriminant function was applied to 598 shells from depths of 1632–2900 m in the Rockall Trough in order to test the hypothesis of depth-related segregation of the subspecies. Although individual variability was high, the results indicated a gradual transition from L. p. pustulosa dominance at ∼2000 m to L. p. marshalli dominance at 3000 m depth, but not marked segregation. A sample from 1632 m depth with large proportions of both subspecies disrupted the bathymetric trend and suggested a latitudinal gradient in distribution. Possible environmental factors, including bottom currents, acting on a common genotype to cause the observed pattern of differentiation, are also discussed.

In his important book Revelation: From Metaphor to Analogy, Richard Swinburne has proposed a comprehensive account of the nature of Christian revelation. This account has been criticized by Eleonore Stump. Stump has raised objections to Swinburne's views on biblical interpretation, and to his deistic view of revelation. I will argue that her objections to his views on biblical interpretation are ill-founded. Her criticism of a deistic conception of revelation is justified, but the alternative that she offers to such a conception is unsatisfactory. I will suggest a different alternative, and argue that Swinburne's general account would be improved if he incorported it.

I wish to argue against the widespread view that divine revelation does not consist in a set of propositions. I think that I can show conclusively that a non-propositional view of revelation cannot be reconciled with Christianity.

What are propositions? I cannot do better than quote from Natham Salmon and Scott Soames:

A literature review of the occurrence of multiple pregnancies associated with artificial induction of ovulation is reported. This report considers three treatment schedules: (1) clomiphene citrate; (2) human pituitary gonadotrophin with human chorionic gonadotrophin; and (3) human menopausal gonadotrophin with human chorionic gonadotrophin. The majority of the increase in twinning is related to hyperstimulation of the ovary by these medications, resulting in dizygotic twinning. The true incidence of twin pregnancy cannot be calculated because the vital statistics of all nations report live birth rates. Increased rates of fetal wastage, late abortion and prematurity associated with the occurrence of multiple pregnancies are overlooked by these statistics. The increased incidence of twinning appears to be related to the type and dosage of medication used, and the patient's underlying problem.