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To estimate population-based rates and to describe clinical characteristics of hospital-acquired (HA) influenza.
US Influenza Hospitalization Surveillance Network (FluSurv-NET) during 2011–2012 through 2018–2019 seasons.
Patients were identified through provider-initiated or facility-based testing. HA influenza was defined as a positive influenza test date and respiratory symptom onset >3 days after admission. Patients with positive test date >3 days after admission but missing respiratory symptom onset date were classified as possible HA influenza.
Among 94,158 influenza-associated hospitalizations, 353 (0.4%) had HA influenza. The overall adjusted rate of HA influenza was 0.4 per 100,000 persons. Among HA influenza cases, 50.7% were 65 years of age or older, and 52.0% of children and 95.7% of adults had underlying conditions; 44.9% overall had received influenza vaccine prior to hospitalization. Overall, 34.5% of HA cases received ICU care during hospitalization, 19.8% required mechanical ventilation, and 6.7% died. After including possible HA cases, prevalence among all influenza-associated hospitalizations increased to 1.3% and the adjusted rate increased to 1.5 per 100,000 persons.
Over 8 seasons, rates of HA influenza were low but were likely underestimated because testing was not systematic. A high proportion of patients with HA influenza were unvaccinated and had severe outcomes. Annual influenza vaccination and implementation of robust hospital infection control measures may help to prevent HA influenza and its impacts on patient outcomes and the healthcare system.
To conduct a pilot study implementing combined genomic and epidemiologic surveillance for hospital-acquired multidrug-resistant organisms (MDROs) to predict transmission between patients and to estimate the local burden of MDRO transmission.
Pilot prospective multicenter surveillance study.
The study was conducted in 8 university hospitals (2,800 beds total) in Melbourne, Australia (population 4.8 million), including 4 acute-care, 1 specialist cancer care, and 3 subacute-care hospitals.
All clinical and screening isolates from hospital inpatients (April 24 to June 18, 2017) were collected for 6 MDROs: vanA VRE, MRSA, ESBL Escherichia coli (ESBL-Ec) and Klebsiella pneumoniae (ESBL-Kp), and carbapenem-resistant Pseudomonas aeruginosa (CRPa) and Acinetobacter baumannii (CRAb). Isolates were analyzed and reported as routine by hospital laboratories, underwent whole-genome sequencing at the central laboratory, and were analyzed using open-source bioinformatic tools. MDRO burden and transmission were assessed using combined genomic and epidemiologic data.
In total, 408 isolates were collected from 358 patients; 47.5% were screening isolates. ESBL-Ec was most common (52.5%), then MRSA (21.6%), vanA VRE (15.7%), and ESBL-Kp (7.6%). Most MDROs (88.3%) were isolated from patients with recent healthcare exposure.
Combining genomics and epidemiology identified that at least 27.1% of MDROs were likely acquired in a hospital; most of these transmission events would not have been detected without genomics. The highest proportion of transmission occurred with vanA VRE (88.4% of patients).
Genomic and epidemiologic data from multiple institutions can feasibly be combined prospectively, providing substantial insights into the burden and distribution of MDROs, including in-hospital transmission. This analysis enables infection control teams to target interventions more effectively.
COVID-19 has caused a major global pandemic and necessitated unprecedented public health restrictions in almost every country. Understanding risk factors for severe disease in hospitalised patients is critical as the pandemic progresses. This observational cohort study aimed to characterise the independent associations between the clinical outcomes of hospitalised patients and their demographics, comorbidities, blood tests and bedside observations. All patients admitted to Northwick Park Hospital, London, UK between 12 March and 15 April 2020 with COVID-19 were retrospectively identified. The primary outcome was death. Associations were explored using Cox proportional hazards modelling. The study included 981 patients. The mortality rate was 36.0%. Age (adjusted hazard ratio (aHR) 1.53), respiratory disease (aHR 1.37), immunosuppression (aHR 2.23), respiratory rate (aHR 1.28), hypoxia (aHR 1.36), Glasgow Coma Scale <15 (aHR 1.92), urea (aHR 2.67), alkaline phosphatase (aHR 2.53), C-reactive protein (aHR 1.15), lactate (aHR 2.67), platelet count (aHR 0.77) and infiltrates on chest radiograph (aHR 1.89) were all associated with mortality. These important data will aid clinical risk stratification and provide direction for further research.
Hearing loss affects over 1.3 billion individuals worldwide, with the greatest burden among adults. Little is known regarding the association between adult-onset hearing loss and employment.
Seven databases (PubMed, Embase, Cochrane Library, ABI/Inform Collection, Business Source Ultimate, Web of Science and Scopus) were searched through to October 2018. The key word terms used related to hearing loss and employment, excluding paediatric or congenital hearing loss and deaf or culturally deaf populations.
The initial search resulted in 13 144 articles. A total of 7494 articles underwent title and abstract screening, and 243 underwent full-text review. Twenty-five articles met the inclusion criteria. Studies were set in 10 predominantly high-income countries. Seven of the 25 studies analysed regionally or nationally representative datasets and controlled for key variables. Six of these seven studies reported associations between hearing loss and employment.
The highest quality studies currently available indicate that adult-onset hearing loss is associated with unemployment. However, considerable heterogeneity exists, and more rigorous studies that include low- and middle-income countries are needed.
Research suggests that cannabis use negatively impacts on onset and outcome of schizophrenia. Possible effects in mood disorders have received little investigation. The first study analysing the influence of cannabis exposure on clinical and social treatment outcomes within a bipolar disorder (BP) population during 1 year of treatment is presented.
3684 patients were enrolled in an observational study when psychotropic treatment for mania was initiated/changed. The influence of cannabis exposure on baseline-corrected clinical and social treatment outcome measures was examined. Mediating effects of six variables on associations between cannabis and outcome measures were investigated further.
Over 12 months of treatment, cannabis users exhibited higher levels of BP overall illness severity, mania and psychosis, and less severe depression symptoms compared to non-users. These associations were most frequently mediated by abuse of alcohol and other substances. Users more frequently abused alcohol and other substances; these associations were not mediated by other variables. Cannabis users engaged in more social activities but had a higher probability of not having a relationship and fewer dependents to care for. Associations with activities and dependents to care for were mediated by various variables, whereas no variables mediated the association with not having a relationship.
Cannabis use impacts on clinical outcomes in patients with BP, with a modest impact on social outcomes. More research is required to further elucidate the mechanism by which cannabis exerts its influence. Understanding the associations between cannabis use and outcome measures may offer valuable insights into treatment strategies.
To contrast the outcomes of olanzapine- and valproate-treated patients in an observational study of acute mania with the results of a RCT assessing the same treatments (Tohen et al., 2002).
EMBLEM (European Mania in Bipolar Evaluation of Medication) was a 2-year, prospective, observational study of health outcomes associated with treatment of mania. Severity of mania and depression was assessed at baseline and 6 weeks using the YMRS and 5-item version of the HAMD, respectively. The RCT was a 3-week, randomised, double-blind comparison of olanzapine (n=125) and divalproate-treated (n=123) patients hospitalised for acute manic or mixed episodes. The YMRS and HAMD were used to quantify manic and depressive symptoms, respectively.
621 EMBLEM patients were analysed (n=107 valproate, n=514 olanzapine). Both observed groups improved from baseline to 6 weeks in mean YMRS and HAMD-5 total scores, with significantly greater mean improvements in the olanzapine compared with the valproate group using linear regression to adjust for baseline differences. The RCT reported significantly greater mean YMRS improvement (but not HAMD) in the olanzapine-treated group. EMBLEM patients treated with olanzapine experienced significantly greater weight gain than patients treated with valproate, similar to RCT results. There was a significantly greater incidence of treatment-emergent gastrointestinal adverse events in EMBLEM patients treated with valproate.
The EMBLEM results support those of the RCT, which suggest that olanzapine monotherapy may be more effective than valproate monotherapy in the treatment of acute mania. Contrasting observational and RCT results present methodological challenges but can provide important complementary information.
The PAtient SAtisfaction with Psychotropic (PASAP) scale is a self-completed questionnaire measuring satisfaction with psychotropic medication. The aim of the study was to describe its development in French and its psychometric properties.
Materials and methods:
Scale construction was based on an extensive search of the literature. The item reduction process required semi-structured interviews of psychiatric outpatients (n = 30). The final version of the PASAP is a 9-item, 5-point Likert-type scale, covering the scope of effectiveness and adherence. To assess the psychometric properties of the scale, French patients with an acute manic episode (n = 314) from a large European observational cohort completed the PASAP scale 3 months after psychotropic treatment initiation/change. Internal validity and reliability were assessed using principal component analysis (PCA). Concurrent validity was assessed using comparisons to physician-rated satisfaction with life, illness severity, mood relapse, compliance and side effects.
Participation rate was 68.4%. PCA was in favour of uni-dimensionality. Cronbach's α coefficient was 0.85 (95%CI 0.83–0.88). All five concurrent measures were significantly associated with the PASAP score.
The PASAP scale showed good psychometric properties in a large bipolar population and thus seems adequate for evaluating treatment satisfaction. Its short length and good acceptability makes it suitable for clinical research.
One of the WHO's innovations for improving the ICD-11 chapter Mental and Behavioral Disorders was the creation of the Global Clinical Practice Network (GCPN), an international network of more than 12,000 mental health and primary care professionals from 144 countries.
Aims and objectives
In order to evaluate perceived clinical utility of the ICD-11 guidelines, the case-controlled field studies that involved the application of the proposed diagnostic guidelines to standardized case material were implemented via the Internet in different languages.
Two hundred and seventy-eight Russian mental health care professionals, the GCPN members, have participated in case controlled Internet study for the chapter “Schizophrenia and Other Primary Psychotic Disorders”. Russian participants were represented by psychiatrists mostly (89%) and much less by psychologists (8%) which corresponds with the general situation in the Russian mental health care system.
Russian clinicians have used the proposed ICD-11 diagnostic guidelines successfully to assess delusional disorder as well as schizophrenia. But there were certain categories (schizoaffective disorder, subthreshold delusions) with which the participants seemed to struggle. The critical comments were focused on opposing so called syndrome-based assessment and nosological diagnostics. Most concerns were about elimination of Schizophrenia subtypes.
Russian mental health care professionals proved to be interested in ICD revision process and demonstrated their special diagnostics opinion based on rich clinical traditions and psychopathological approach. In order to use ICD-11 guidelines in clinical practice more efficiently supplementary appropriate training would be needed.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
A survey of hospital antimicrobial stewardship programs was performed to validate core element achievement data from the National Healthcare Safety Network’s (NHSN) Patient Safety Component Annual Survey. In total, 89% of hospitals met all 7 core elements, compared to only 68% according to the NHSN survey.
Fomesafen is a protoporphyrinogen oxidase–inhibitor herbicide with an alternative mode of action that provides PRE weed control in strawberry [Fragaria×ananassa (Weston) Duchesne ex Rozier (pro sp.) [chiloensis×virginiana]] produced in a plasticulture setting in Florida. Plasticulture mulch could decrease fomesafen dissipation and increase crop injury in rotational crops. Field experiments were conducted in Balm, FL, to investigate fomesafen persistence and movement in soil in Florida strawberry systems for the 2014/2015 and 2015/2016 production cycles. Treatments included fomesafen preplant at 0, 0.42, and 0.84 kg ai ha−1. Soil samples were taken under the plastic from plots treated with fomesafen at 0.42 kg ha−1 throughout the production cycle. Fomesafen did not injure strawberry or decrease yield. Fomesafen concentration data for the 0.0- to 0.1-m soil depth were described using a three-parameter logistic function. The fomesafen 50% dissipation times were 37 and 47 d for the 2014/2015 and 2015/2016 production cycles, respectively. At the end of the study, fomesafen was last detected in the 0.0- to 0.1-m depth soil at 167 and 194 d after treatment in the 2014/2015 and 2015/2016 production cycles, respectively. Fomesafen concentration was less than 25 ppb on any sampling date for 0.1- to 0.2-m and 0.2- to 0.3-m depths. Fomesafen concentration decreased significantly after strawberry was transplanted and likely leached during overhead and drip irrigation used during the crop establishment.
A study conducted as part of the development of the Eleventh International Classification of Mental Disorders for Primary Health Care (ICD-11 PHC) provided an opportunity to test the relationships among depressive, anxious and somatic symptoms in PHC.
Primary care physicians participating in the ICD-11 PHC field studies in five countries selected patients who presented with somatic symptoms not explained by known physical pathology by applying a 29-item screening on somatic complaints that were under study for bodily stress disorder. Patients were interviewed using the Clinical Interview Schedule-Revised and assessed using two five-item scales that measure depressive and anxious symptoms. Structural models of anxious-depressive symptoms and somatic complaints were tested using a bi-factor approach.
A total of 797 patients completed the study procedures. Two bi-factor models fit the data well: Model 1 had all symptoms loaded on a general factor, along with one of three specific depression, anxiety and somatic factors [x2 (627) = 741.016, p < 0.0011, RMSEA = 0.015, CFI = 0.911, TLI = 0.9]. Model 2 had a general factor and two specific anxious depression and somatic factors [x2 (627) = 663.065, p = 0.1543, RMSEA = 0.008, CFI = 0.954, TLI = 0.948].
These data along with those of previous studies suggest that depressive, anxious and somatic symptoms are largely different presentations of a common latent phenomenon. This study provides support for the ICD-11 PHC conceptualization of mood disturbance, especially anxious depression, as central among patients who present multiple somatic symptoms.
The study aimed to examine variations in the use of International Classification of Diseases, Tenth Edition (ICD-10) diagnostic categories for mental and behavioural disorders across countries, regions and income levels using data from the online World Psychiatric Association (WPA)-World Health Organization (WHO) Global Survey that examined the attitudes of psychiatrists towards the classification of mental disorders.
A survey was sent to 46 psychiatric societies which are members of WPA. A total of 4887 psychiatrists participated in the survey, which asked about their use of classification, their preferred system and the categories that were used most frequently.
The majority (70.1%) of participating psychiatrists (out of 4887 psychiatrists) reported using the ICD-10 the most and using at least one diagnostic category once a week. Nine out of 44 diagnostic categories were considerably variable in terms of frequency of use across countries. These were: emotionally unstable personality disorder, borderline type; dissociative (conversion) disorder; somatoform disorders; obsessive–compulsive disorder (OCD); mental and behavioural disorders due to the use of alcohol; adjustment disorder; mental and behavioural disorders due to the use of cannabinoids; dementia in Alzheimer's disease; and acute and transient psychotic disorder. The frequency of use for these nine categories was examined across WHO regions and income levels. The most striking differences across WHO regions were found for five out of these nine categories. For dissociative (conversion) disorder, use was highest for the WHO Eastern Mediterranean Region (EMRO) and non-existent for the WHO African Region. For mental and behavioural disorders due to the use of alcohol, use was lowest for EMRO. For mental and behavioural disorders due to the use of cannabinoids, use was lowest for the WHO European Region and the WHO Western Pacific Region. For OCD and somatoform disorders, use was lowest for EMRO and the WHO Southeast Asian Region. Differences in the frequency of use across income levels were statistically significant for all categories except for mental and behavioural disorders due to the use of alcohol. The most striking variations were found for acute and transient psychotic disorder, which was reported to be more commonly used among psychiatrists from countries with lower income levels.
The differences in frequency of use reported in the current study show that cross-cultural variations in psychiatric practice exist. However, whether these differences are due to the variations in prevalence, treatment-seeking behaviour and other factors, such as psychiatrist and patient characteristics as a result of culture, cannot be determined based on the findings of the study. Further research is needed to examine whether these variations are culturally determined and how that would affect the cross-cultural applicability of ICD-10 diagnostic categories.
Aberrant emotional biases have been reported in bipolar disorder (BD), but results are inconsistent. Despite the clinical relevance of chronic mood variability in BD, there is no previous research investigating how the extent of symptom fluctuations in bipolar disorder might relate to emotional biases. This exploratory study investigated, in a large cohort of bipolar patients, whether instability in weekly mood episode symptoms and other clinical and demographic factors were related to emotional bias as measured in a simple laboratory task.
Participants (N = 271, BDI = 206, BDII = 121) completed an ‘emotional categorization and memory’ task. Weekly self-reported symptoms of depression and mania were collected prospectively. In linear regression analyses, associations between cognitive bias and mood variability were explored together with the influence of demographic and clinical factors, including current medication.
Greater accuracy in the classification of negative words relative to positive words was associated with greater instability in depressive symptoms. Furthermore, greater negative bias in free recall was associated with higher instability in manic symptoms. Participants diagnosed with BDII, compared with BDI, showed overall better word recognition and recall. Current antipsychotic use was associated with reduced instability in manic symptoms but this did not impact on emotional processing performance.
Emotional processing biases in bipolar disorder are related to instability in mood. These findings prompt further investigation into the underpinnings as well as clinical significance of mood instability.
Habitat suitability models can guide species conservation by identifying correlates of occurrence and predicting where species are likely to occur. We created habitat suitability models for the White-breasted Thrasher Ramphocinclus brachyurus, a narrowly distributed endangered songbird that occupies dry forest in Saint Lucia and Martinique. Eighty-five percent of the global population inhabits two ranges in Saint Lucia, both of which are largely unprotected and threatened by development. We developed three habitat suitability models using Maxent techniques and published occupancy datasets collected from the species’ two Saint Lucian ranges, and used abiotic, land cover, and predator distribution predictors. We built one model with occupancy data from both ranges, and two others with occupancy data specific to each range. The best full-range model included 11 predictors; high suitability was associated with close proximity to Saint Lucia fer-de-lance Bothrops caribbeaus range, moderately low precipitation, and areas near streams. Our assessment of suitable sites island-wide was more restricted than results from a recent model that considered older land cover data and omitted predator distributions. All sites identified in our full-range model as highly suitable were in or adjacent to the species’ current designated range. The model trained on southern range occurrences predicted zero suitable habitat in the northern range, where the population is much smaller. In contrast, the model trained on northern range occurrences identified areas of moderate suitability within the southern range and patches of moderately suitable habitat in the western part of the island, where no White-breasted Thrashers currently occur. We interpret these results as suggesting that White-breasted Thrashers currently occupy virtually all suitable habitat on the island, that birds in the northern range occupy marginal habitat, or that an important correlate of suitability is missing from the model. Our results suggest that habitat management should focus on currently occupied areas.
Introduction: Recent years have brought an epidemic of opioid abuse to Canada. At present, in Ontario, Naloxone may not be administered by any paramedic without the direct online medical approval of a Base Hospital Physician (BHP). The objective of this study was to review the use of Naloxone by Emergency Medical Service (EMS) personnel, under the existing Advanced Life Support Patient Care Standards (ALS-PCS) medical directive for opioid toxicity, for safety and potential complications that may occur with removal of the mandatory patch point. Methods: This study was a retrospective ambulance call report review of consecutive Naloxone requests placed to a BHP of the Regional Paramedic Program of Eastern Ontario (RPPEO) between Oct 1st, 2013 and Oct 31st, 2015. The RPPEO consists of 10 prehospital services, both urban and rural jurisdictions, and has a mix of advance care and primary care paramedics. All ambulance call reports are electronically stored at the secured RPPEO data warehouse. Data was extracted using a standardized data collection tool. All ambulance call reports were reviewed by 2 independent authors (VC, NC). Compliance with the existing medical directive for opioid toxicity was determined. We calculated the frequency of denied Naloxone requests and the rationale for each patch refusal was recorded. We also categorized all adverse events associated with Naloxone administration. Results: From 244 patches, 215 patients were administered Naloxone. Only 7.8% (19/215) of requests for Naloxone were refused; 78.9% (15/19) did not meet existing inclusion criteria for Naloxone administration in the ALS-PCS medical directive for opioid toxicity because the patient’s respiration rate was above 12/min. Of the 215 patients who were administered Naloxone, adverse events were extremely uncommon: 5 (2.3%) became violent or verbally abusive, 1 (0.5%) was transiently hypertensive and 4 (1.9%) vomited. Conclusion: Requests for Naloxone to a BHP are common and yet are seldom declined. The use of prehospital Naloxone is associated with few adverse events. These results demonstrate that it would be safe to remove online medical direction for Naloxone from the ALS-PCS medical directive for opioid toxicity if combined with updated paramedic education.
Culture does not change because we desire to change it. Culture changes when the organization is transformed; the culture reflects the realities of people working together every day.
– Frances Hesselbein
Have you ever had a job you loved and felt empowered to fulfill your responsibilities? If so, what was it about your co-workers, your manager/supervisor, and your work environment that made your experience so positive? Perhaps you've never felt that way about a job and, instead, you've dreaded heading to work every morning. Your boss might have rarely recognized your efforts. It's possible you weren't sure how to perform your job, but felt uncomfortable asking for help. Your co-workers might have seemed like characters from the movie Mean Girls. In this perfect storm of the forces of disengagement, we suspect you didn't last too long at that job. Or you felt overwhelmed with too much to do, with too little support, as depicted in the illustration on the next page.
According to a 2013 survey, more than half of workers in the United States were dissatisfied with their jobs. This statistic is alarming; after all, we spend approximately one-third of our waking hours and energy at work, plus dissatisfied employees tend to find new employers. Because we spend so much of our time and energy at work, the organizational culture can have a profound impact on our lives and the lives of those around us. If work cultures support interdependent, prosocial behavior instead of individualism and competition, we believe the business world, indeed our everyday lives, will be more positive and productive for almost everyone.
Any organization's mission will benefit from employees who care about their work and their colleagues. It's a win-win scenario. What factors influence employee job satisfaction? Aside from the obvious – job security, pay, and benefits (e.g., health insurance) – employees report that feeling safe at work, having a positive relationship with their immediate supervisor, and communicating openly and cooperatively with other employees and senior management contribute significantly to their work satisfaction. The bad news: In many organizational cultures, managers/supervisors struggle with these very issues, resulting in unacceptably high rates of employee dissatisfaction and turnover and a climate of distrust.
Imagine these disgruntled employees as supervisors who are responsible for mentoring newly recruited employees.
Poor maternal nutrition inhibits muscle development and postnatal muscle growth. Satellite cells are myogenic precursor cells that contribute to postnatal muscle growth, and their activity can be evaluated by the expression of several transcription factors. Paired-box (Pax)7 is expressed in quiescent and active satellite cells. MyoD is expressed in activated and proliferating satellite cells and myogenin is expressed in terminally differentiating cells. Disruption in the expression pattern or timing of expression of myogenic regulatory factors negatively affects muscle development and growth. We hypothesized that poor maternal nutrition during gestation would alter the in vitro temporal expression of MyoD and myogenin in satellite cells from offspring at birth and 3 months of age. Ewes were fed 100% or 60% of NRC requirements from day 31±1.3 of gestation. Lambs from control-fed (CON) or restricted-fed (RES) ewes were euthanized within 24 h of birth (birth; n=5) or were fed a control diet until 3 months of age (n=5). Satellite cells isolated from the semitendinosus muscle were used for gene expression analysis or cultured for 24, 48 or 72 h and immunostained for Pax7, MyoD or myogenin. Fusion index was calculated from a subset of cells allowed to differentiate. Compared with CON, temporal expression of MyoD and myogenin was altered in cultured satellite cells isolated from RES lambs at birth. The percent of cells expressing MyoD was greater in RES than CON (P=0.03) after 24 h in culture. After 48 h of culture, there was a greater percent of cells expressing myogenin in RES compared with CON (P<0.001). After 72 h of culture the percent of satellite cells expressing myogenin in RES was less than CON (P<0.01). There were no differences in the gene expression of Pax7, Myf5 or MyoD in isolated satellite cells at birth (P>0.05). In satellite cells from RES lambs at 3 months of age, the percent of cells expressing MyoD and myogenin were greater than CON after 72 h in culture (P<0.05). Fusion index was reduced in RES lambs at 3 months of age compared with CON (P<0.001). Restricted nutrition during gestation alters the temporal expression of myogenic regulatory factors in satellite cells of the offspring, which may reduce the pool of myoblasts, decrease myoblast fusion and contribute to the poor postnatal muscle growth previously observed in these animals.