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Skin and soft-tissue infections (SSTIs) account for 3% of all emergency department (ED) encounters and are frequently associated with inappropriate antibiotic prescribing. We characterized barriers and facilitators to optimal antibiotic use for SSTIs in the ED using a systems engineering framework and matched them with targeted stewardship interventions.
Design and participants:
We conducted semistructured interviews with a purposefully selected sample of emergency physicians.
An interview guide was developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Interviews were recorded, transcribed, and analyzed iteratively until conceptual saturation was achieved. Themes were identified using deductive directed content analysis guided by the SEIPS model.
We conducted 20 interviews with physicians of varying experience and from different practice settings. Identified barriers to optimal antibiotic prescribing for SSTIs included poor access to follow-up (organization), need for definitive diagnostic tools (tools and technology) and fear over adverse outcomes related to missed infections (person). Identified potential interventions included programs to enhance follow-up care; diagnostic aides (eg, rapid MRSA assays for purulent infections and surface thermal imaging for cellulitis); and shared decision-making tools.
Using a systems engineering informed qualitative approach, we successfully characterized barriers and developed targeted antibiotic stewardship interventions for SSTIs managed in the ED work system. The interventions span multiple components of the ED work system and should inform future efforts to improve antibiotic stewardship for SSTIs in this challenging care setting.
The article considers the global historiography of Europe from two angles. First it outlines the difficulties, both historical and epistemological, that Europe poses as an object of study, especially after the historiographical transformations prompted by the events of 1989, the rise of postcolonial studies, the growing critique of Eurocentrism, and, most recently, the “global turn.” The conceptions of Europe that emerge from these currents have often been based on a rather homogenized vision of the continent, centered on the great nation-states of western Europe and their imperial policies. They also perpetuate, even as they criticize it, the legacy of a conception of modernity that positions Europe as both its historical center and the agent of its expansion on a global scale. The second part of the paper proposes to limit the blind spots inherent in this kind of vision by shifting our gaze to the eastern and Balkan margins of Europe, where the Austro-Hungarian, Ottoman, and Russian empires intersected over the “long” nineteenth century. This change of perspective displaces the history of Europe’s connection to modernity, revealing the great diversity of local actors, the importance of multicultural and pluriethnic societies, and the particular role of transnational populations such as Jews, who, while negotiating their own relationship to a European modernity, escaped the grip of national movements.
L’article aborde la question d’une historiographie globale de l’Europe à partir de deux angles. Dans un premier temps, il s’attache aux difficultés, tant historiques qu’épistémologiques, à saisir l’objet Europe, notamment après les transformations historiographiques induites par 1989, l’affirmation des études postcoloniales, l’émergence progressive de la critique de l’eurocentrisme et, enfin, aujourd’hui, l’invitation à prendre le « tournant global ». Les conceptions de l’Europe qui se dégagent de ces propositions ont l’inconvénient de se fonder sur une vision de l’Europe plutôt homogénéisée, centrée sur les grands États-nations de l’Europe occidentale et leurs politiques impériales. Elles véhiculent également, tout en la critiquant, l’idée d’une modernité dont l’Europe aurait été à la fois le foyer historique et l’agent d’expansion à l’échelle mondiale. Dans un second temps, afin de circonscrire les taches aveugles inhérentes à ce genre de visions, l’article propose un déplacement du regard, en fixant le poste d’observation dans les confins orientaux et balkaniques de l’Europe, à l’intersection des trois empires austro-hongrois, ottoman et russe, pour une période équivalant au « long » xixe siècle. Ce changement de perspective fait apparaître non seulement une grande diversité de vues des acteurs locaux, mais aussi le déplacement qui s’opère dans la conception du lien entre Europe et modernité, l’importance des sociétés locales multiculturelles et pluriethniques ainsi que le rôle particulier de populations transnationales qui, comme les juifs, tout en négociant leur rapport propre à une modernité européenne, échappent à l’emprise des mouvements nationaux.
With the increased training loads at very early ages in European elite youth soccer, there is an interest to analyse coronary artery remodelling due to high-intensity exercise.
Design and methods:
Prospective echocardiographic study in 259 adolescent elite male soccer players and 48 matched controls.
The mean age was 12.7 ± 0.63 years in soccer players and 12.6 ± 0.7 years in controls (p > 0.05). Soccer players had significant greater indexed left ventricular mass (93 ± 13 g/m2 versus 79 ± 12 g/m2, p = 0.001). Both coronary arteries origin could be identified in every participant. In soccer players, the mean diameter of the left main coronary artery was 3.67 mm (SD ± 0.59) and 2.61 mm (SD ± 0.48) for right main coronary artery. Controls showed smaller mean luminal diameter (left main coronary artery, p = 0.01; right main coronary artery, p = 0.025). In soccer players, a total of 91% (n = 196) and in controls a total of 94% (n = 45) showed left main coronary artery z scores within the normal range: −2.0 to 2.0. In right main coronary artery, a pattern of z score values distribution was comparable (soccer players 94%, n = 202 vs. controls 84%, n = 40). A subgroup of soccer players had supernormal z score values (>2.0 to 2.5) for left main coronary artery (9%, n = 19, p = 0.01) and right main coronary artery (6%, n = 10, p = 0.025), respectively.
Elite soccer training in early adolescence may be a stimulus strong enough to develop increased coronary arteries diameters. In soccer players, a coronary artery z score >2.0–2.5 might reflect a physiologic response induced by multiannual high-intensity training.
This research paper addresses the hypotheses (1) that milk produced from hay-fed cows differs from that of silage-fed cows and (2) that silage type has an important impact, too. Four diets differing in forage type but with equal estimated milk production potential and a forage:concentrate ratio of 0.85 : 0.15 were compared regarding their effect on feed intake, milk yield and milk properties. The forages tested were hay, grass silage, conventional short-chopped and long-chopped maize silage subjected to a novel processing technology (Shredlage®). Twenty-four dairy cows were fed two of the four diets in two consecutive runs in an incomplete (4 × 2) Latin-square design (n = 12 per diet). Each experimental period lasted 22 d, with 12 d of adaptation and 10 d of sampling. During sampling, feed intake and milk yield were recorded daily, milk composition and coagulation properties were determined four times. The composition of the diet ingredients was analysed weekly. Data were analysed with a mixed model considering feed, period and their interaction as fixed effects. Stage of lactation, milk yield and milk composition from the pre-experimental period were used as covariates in the model. Dry matter intake was lower with the long-chopped processed maize silage compared to the other three groups. There were some diet differences in intakes of net energy for lactation and absorbable protein in the duodenum, but this did not result in changes in milk yield. The milk fat content was higher with the grassland-based diets compared to the maize silage diets. No treatment effect on milk acidity and rennet coagulation properties was observed. In conclusion, there were no indications for specific physico-chemical properties of milk from a hay-based diet, and maize processing technology was not of large effect either. Future investigations should focus on sensory differentiation of the milk produced with different forages.
IT IS ONLY A SMALL EXAGGERATION to say that from the outset in 1919, Red Vienna was in a state of permanent election campaigning. The social and political claims and achievements were widely communicated with great material input, professional expertise, and ambitious experimentation. The young generation of internationally renowned graphic artists in Red Vienna worked intensively and applied the latest advertising psychology. Otto Neurath's Vienna Method of Pictorial Statistics, as well as exhibitions at the Social and Economic Museum (Gesellschafts- und Wirtschaftsmuseum), blurred the boundaries between education and propaganda. From the mid-1920s, new media such as film, radio, or photomontage were used increasingly in election campaigns. In addition, the politician Robert Danneberg (1885–1942) regularly published sophisticated election analyses in the Social Democratic theoretical journal Der Kampf. The extensive and highly visible social housing construction program can also be regarded as an effective propaganda tool. It was for that reason that Siegfried Mattl spoke of Red Vienna as a project “in the spirit of advertising.”
The 1919, 1920, and 1923 election campaigns in Vienna were notable for the unprecedented use of posters. Compared with other countries, this form of mass communication was relatively late in arriving in Austria. In contrast to the United States, Great Britain, and France, the political and legal basis was absent for a long time. Austrian election legislation became gradually democratized after 1867. The basis for a modern election campaign was not established until the new election legislation in 1896, which gave an unevenly weighted vote to all male citizens over the age of twenty-four. On the state level, unweighted male suffrage for the Austrian Imperial Council (Reichsrat) was introduced in 1907; on the local level, however, for the municipal council, it was not introduced until 1918. Added to this was a restrictive censorship policy by the police. For a long time, therefore, the election campaigns in Austria remained “premodern,” as Pippa Norris described it in her political campaign model, in which direct communication at meetings was still the dominant mode.
The posters used in the first unrestrictedly democratic elections in 1919, after the introduction of women's suffrage, were pointed and confrontational. They were also seen as a reaction to the years of war rhetoric, from which the Christian Socials, for example, borrowed poignant motifs, such as the dragon demonizing the Social Democratic Workers’ Party.
WHEN CONSIDERING RED VIENNA's international presence, it is important to keep three different facets in mind: first, the advertising aimed at international recognition of the institutions of Red Vienna which became increasingly professional over the course of the 1920s; second, the way that this recognition was successfully maintained vis-à-vis Red Vienna's base of support and its political enemies; and finally, the evidence that would substantiate this recognition. The city's active advertising campaigns sought to reach both an international socialist audience and a wider bourgeois public. This strategy reflects Red Vienna's interior publicity efforts as well, which were often seen as being at cross purposes when they tried to reach both their own base and the moderate bourgeois voters. Evidence for the massive advertising campaigns can be found in all of Red Vienna's political fields, from educational politics to the massive communal building program. Brochures were printed in different languages for distribution through the socialist parties in England or Holland. The strategic center for the dissemination of the advertising was the Social and Economic Museum (Gesellschafts- und Wirtschaftsmuseum), which used innovative methods to communicate the aspirations and accomplishments of Red Vienna both nationally and internationally. To accomplish this task, new photo formats were developed, and the so-called Vienna Method of Pictorial Statistics (later referred to as Isotype) was developed and successfully implemented by Otto Neurath (1882–1945) and his team. International reaction to the public relations campaigns contain proof of the active policy of inviting visitors to Vienna. In addition to these measures, the city hosted huge international events such as the International Socialist Youth Meeting in 1929 and the Second Workers’ Olympics in 1931.
Claims of international legitimacy were primarily aimed at forces within Austria. Beginning in the late 1920s, these assertions of legitimacy became stronger in response to the economic crisis and increasingly heated altercations with the National Socialists. Vienna was showcased as a model for the world. The full-length campaign film Das Notizbuch des Mr. Pim (Mr. Pim's Trip to Europe), produced in 1930, is built around this narrative. It follows an American newspaper editor as he witnesses first-hand the achievements of Red Vienna. In this phase, the Social Democratic media portray a global perspective that integrates even nonsocialist ideas from around the world, such as Gandhi's struggle for Indian independence or the political and cultural developments within the African American community in the United States.
BY BUILDING NEARLY FOUR HUNDRED municipal housing complexes (Gemeindebauten) with almost sixty-four thousand apartments, as well as welfare, sports, and culture facilities, Red Vienna permanently inscribed itself on the space of the city. Seizing the opportunity to create a new social and democratic city, the building program began in 1923 with large-scale efforts to define housing as a public responsibility, embedded in a complex series of education and welfare policies. Initially, however, the officials did not have a unified vision of how this “new city” was supposed to be created, as urban history scholar Eve Blau has shown. The dire social and economic situations in Vienna at the end of World War I left little room for the questions of planning. The supply chain was in total disarray. In spite of the starkly falling number of residents, the housing crisis in Vienna was steadily worsening. Even before the war broke out in 1914, the housing market had been driven almost exclusively by capitalism and private property rights, characterized by real estate speculation and fluctuating property prices. The market could not even come close to providing the amount of new housing that was needed. This market-driven approach resulted in urban spaces that were, compared with international standards, more densely built: 85 percent of the land space was devoted to buildings, with many small, crowded apartments. During the war, building activity came to a standstill. The introduction of rent control in 1917—including a rental price freeze and protection against evictions—made investment in existing housing unprofitable. After the end of the war, the number of marriages increased, and the rental market was overwhelmed by young couples and families. The most important public means of controlling the situation was the 1919 apartment requisition policy, which allowed the government to force residents to provide private rooms for those in need.
At the same time, the extreme housing shortage led to an active do-it-yourself movement among the city's residents. After the war, “wild settlers” occupied land on the outskirts of Vienna in order to provide for themselves by growing fruit and vegetables and by raising small livestock. In the early 1920s, this do-it-yourself activism gave rise to the Vienna settler movement. The movement was founded upon the ideals of nonprofit cooperative ownership of housing, voluntary labor, shared infrastructure, and self-administration.
AFTER WORLD WAR I, the population of Vienna dropped from some 2.1 million inhabitants to fewer than 1.9 million. One reason for this decline was the high death rate caused by food shortages during and after the war. Infants and children were chronically malnourished and thus among the most affected by the food shortages. In addition, epidemics such as the Spanish flu also took their toll across the entire population. Other reasons for this decline included the relocation of ethnic minorities to the successor states of the monarchy, war refugees returning home (most notably those who returned to the former Galicia, which had become part of the Republic of Poland), and, most importantly, the emigration of over one hundred thousand members of the Czech minority to the newly founded state of Czechoslovakia. Despite high pressure to assimilate, the Czech minority had been prominent in the city since the late nineteenth century, and it continued to remain an important cultural and demographic element in the years following 1918.
In the immediate postwar years, the question of social inclusion and exclusion in Red Vienna centered on two specific concerns: first, who would be eligible to benefit from the city's municipal services, and second, how would the city address the question of immigration? The answers to both must be understood in the context of racial anti-Semitism, the main targets of which were the Jewish refugees that had migrated from Galicia during the war. Accordingly, the question of citizenship in the new state—the determination of who belonged to the German-Austrian nation and could therefore benefit from its services—was defined almost exclusively by an attempt to exclude Galician Jews, despite their numbers not exceeding thirty thousand after 1918.
The provisional German-Austrian constitution of 1918 had openly discriminated against long-standing Austrians from Galicia (which, to conceal its true aim, was also extended to include those from Istria and Dalmatia) with respect to those from other former crown lands; their citizenship had been made dependent on the right of residence in an Austrian municipality, which had carried a residency requirement of at least ten years. The Treaty of Saint-Germain suspended this regulation in 1919, but unintentionally continued to enable discrimination against Jewish refugees.
The treatment of patients in the triage category “expectant” is not in the focus of the prehospital disaster medicine. The aim is to save as many lives as possible in situations with very limited resources. It is necessary to allocate the life-saving interventions to those who have the chance to survive, but there is a human right of best assistance even for those who are expected to die.
In Germany, it is possible to use the triage category “expectant” in overwhelming disasters, so there should be preparedness for those patients, who receive this categorization. A survey was conducted to find out what the needs are of those patients.
An online-survey was submitted to German medical incident commanders and palliative care physician in function of expert groups via their national associations.
219 physicians participated. The majority confirmed a necessity to treat those patients and to be prepared. Currently, in most of the areas, there is no preparation. The main needs are the treatment of pain, dyspnoea, fear, and loneliness. Following the “Dying person’s bill of rights” (1), the most relevant rights are:
To be treated as living human being until I die
To be free from pain
To express the feelings and emotions
To die in peace and dignity
Palliative care should be part of disaster medicine planning. It is not too difficult to prepare a special group of helper for the care of dying patients. Medical incident commanders and palliative care physicians agree in the majority about the necessity, so SOPs can be implemented to teach non-medics. The medics will be needed for the first aim of disaster medicine.
After five positive randomized controlled trials showed benefit of mechanical thrombectomy in the management of acute ischemic stroke with emergent large-vessel occlusion, a multi-society meeting was organized during the 17th Congress of the World Federation of Interventional and Therapeutic Neuroradiology in October 2017 in Budapest, Hungary. This multi-society meeting was dedicated to establish standards of practice in acute ischemic stroke intervention aiming for a consensus on the minimum requirements for centers providing such treatment. In an ideal situation, all patients would be treated at a center offering a full spectrum of neuroendovascular care (a level 1 center). However, for geographical reasons, some patients are unable to reach such a center in a reasonable period of time. With this in mind, the group paid special attention to define recommendations on the prerequisites of organizing stroke centers providing medical thrombectomy for acute ischemic stroke, but not for other neurovascular diseases (level 2 centers). Finally, some centers will have a stroke unit and offer intravenous thrombolysis, but not any endovascular stroke therapy (level 3 centers). Together, these level 1, 2, and 3 centers form a complete stroke system of care. The multi-society group provides recommendations and a framework for the development of medical thrombectomy services worldwide.
Lithium sulfur (Li–S) batteries have the potential to provide higher energy storage density at lower cost than conventional lithium ion batteries. A key challenge for Li–S batteries is the loss of sulfur to the electrolyte during cycling. This loss can be mitigated by sequestering the sulfur in nanostructured carbon–sulfur composites. The nanoscale characterization of the sulfur distribution within these complex nanostructured electrodes is normally performed by electron microscopy, but sulfur sublimates and redistributes in the high-vacuum conditions of conventional electron microscopes. The resulting sublimation artifacts render characterization of sulfur in conventional electron microscopes problematic and unreliable. Here, we demonstrate two techniques, cryogenic transmission electron microscopy (cryo-TEM) and scanning electron microscopy in air (airSEM), that enable the reliable characterization of sulfur across multiple length scales by suppressing sulfur sublimation. We use cryo-TEM and airSEM to examine carbon–sulfur composites synthesized for use as Li–S battery cathodes, noting several cases where the commonly employed sulfur melt infusion method is highly inefficient at infiltrating sulfur into porous carbon hosts.
We aimed to study the fate of fat during digestion. For this purpose, we validated and investigated the non-invasive quantification of gastric and duodenal fat emptying and emulsion processing (creaming and phase separation) using the MRI method iterative decomposition with echo asymmetry and least squares estimation (IDEAL). In total, twelve healthy subjects were studied on two separate visits in a single-blind, randomised, cross-over design study. IDEAL was utilised to repeatedly acquire quantitative fat fraction maps of the gastrointestinal tract after infusion of one of two fat emulsions: E1 (acid stable, droplet size 0·33 mm) and E4 (acid unstable, 0·38 mm). In vitro and in vivo validation was carried out using diluted emulsion and gastric content samples, respectively, and resulted in Lin’s concordance correlation coefficients of 1·00 (95 % CI 0·98, 1·00) and 0·91 (95 % CI 0·87, 0·94), respectively. Fat fraction maps and intragastric emulsion profiles enabled the identification of features of intraluminal phase separation and creaming that were not visible in conventional MRI. Gastric fat emptying was faster for E4 compared with E1 with a difference of 2·5 (95 % CI 1·9, 3·1) ml/h. Duodenal content volumes were larger for E1 than for E4 with a difference of 4·9 (95 % CI 3·9, 8·5) ml. This study demonstrated that with IDEAL it was possible (1) to visualise the intragastric and duodenal fat distribution and (2) to quantify the differences in emptying, phase separation and creaming of an acid-stable and an acid-unstable emulsion. This method has potential to bridge the gap between current in vitro digestive models and in vivo behaviour and to be applied in the development of effective functional foods.
NiAl, YCu and TiAl polycrystals with B2 and L10 structure, respectively, have been deformed by high pressure torsion (HPT) at temperatures between 20°C and 500°C at a hydrostatic pressure of 8 GPa to high shear strains. Local texture measurements were done by diffraction of high-energy synchrotron radiation and X-ray microdiffraction. In addition, the microstructure was analyzed by electron backscatter diffraction (EBSD). Besides typical shear components an oblique cube component is observed with quite large rotations about the transverse direction. Based on the temperature dependence of this component as well as on microstructure investigations it is concluded that it is formed by discontinuous dynamic recrystallization. The influence of high pressure on recrystallization of intermetallics at low temperatures is discussed.