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Evidence from pandemics suggests that influenza is often associated with bacterial coinfection. Among patients hospitalized for influenza pneumonia, we report the rate of coinfection and distribution of pathogens, and we compare outcomes of patients with and without bacterial coinfection.
We included adults admitted with community-acquired pneumonia (CAP) and tested for influenza from 2010 to 2015 at 179 US hospitals participating in the Premier database. Pneumonia was identified using an International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) algorithm. We used multiple logistic and gamma-generalized linear mixed models to assess the relationships between coinfection and inpatient mortality, intensive care unit (ICU) admission, length of stay, and cost.
Among 38,665 patients hospitalized with CAP and tested for influenza, 4,313 (11.2%) were positive. In the first 3 hospital days, patients with influenza were less likely than those without to have a positive culture (10.3% vs 16.2%; P < .001), and cultures were more likely to contain Staphylococcus aureus (34.2% vs 28.2%; P = .007) and less likely to contain Streptococcus pneumoniae (24.9% vs 31.0%; P = .008). Of S. aureus isolates, 42.8% were methicillin resistant among influenza patients versus 53.2% among those without influenza (P = .01). After hospital day 3, pathogens for both groups were similar. Bacterial coinfection was associated with increased odds of in-hospital mortality (aOR, 3.00; 95% CI, 2.17–4.16), late ICU transfer (aOR, 2.83; 95% CI, 1.98–4.04), and higher cost (risk-adjusted mean multiplier, 1.77; 95% CI, 1.59–1.96).
In a large US inpatient sample hospitalized with influenza and CAP, S. aureus was the most frequent cause of bacterial coinfection. Coinfection was associated with worse outcomes and higher costs.
ABSTRACT IMPACT: Indiana CTSI Team Science to maximize rapid collection, analyses and dissemination of biosamples collected from patients with Covid-19 to provide preliminary data for grant applications on the pathogenesis and outcomes of patients with Covid-19. OBJECTIVES/GOALS: When Covid-19 hit Indiana in April, there was an immediate need to respond rapidly to coordinate research across our healthcare systems. The CTSI became a point of contact for coordinating research endeavors including activation of clinical trials and use of precious samples from patients with Covid-19 to maximize preliminary data for grants. METHODS/STUDY POPULATION: The Indiana CTSI coordinated collection of biospecimens at multiple hospitals using in person and remote consenting via telephone or on a smartphone utilizing a QR code. We also retrieved existing samples from the Indiana Biobank previously collected for future research and from subject positive for Covid-19 by search of the linked electronic health record (EHR). A total of 224 subject samples (7 children, 36 previously collected, and 6 with both acute and recovered specimens) were obtained over a four month period. Our CTSI cores ran varied analyses collated to a single database, linked to the EMR for use as preliminary data for grant applications to avoid redundancy of measures on limited samples. RESULTS/ANTICIPATED RESULTS: The 224 subject samples were used for whole exome DNA sequencing, RNA seq, analyses of 48 plasma cytokine/chemokines by multiplex analyses, and PBMC isolated for culture and assessment of secreted cytokines. The clinical data were linked and included demographics, hospitalization length of stay and need for mechanical ventilation, max and min oxygen levels, liver function tests, IL-6, D-dimer, CRP, LDH, and ferritin, need for dialysis, and echocardiography. Additional clinical data were available upon request. A survey was sent to our CTSI email to query for potential interest in the data with 87 inquiries, and to date 46 investigators have requested data and/or additional samples. DISCUSSION/SIGNIFICANCE OF FINDINGS: During the first surge of Covid-19, the CTSI coordinated analyses for the dissemination of results for use by CTSI investigators to minimize duplication of assays and increase availability. The collaboration of research coordinators, biobank, research cores, and informatics demonstrates the power and agility of team science in the Indiana CTSI.
ABSTRACT IMPACT: Given the association between lower time to treatment and better clinical outcomes in stroke patients, identifying factors correlated with reduced proximity and thus greater time to stroke care can aid efforts to reduce disparities in stroke outcomes. OBJECTIVES/GOALS: The objective of this study is to quantify the relationship between distance to the nearest certified stroke hospital and census-derived demographics of age, race/ethnicity, income, and insurance status. METHODS/STUDY POPULATION: This is a cross-sectional study. Population data for all census tracts in the contiguous United States were obtained from the US Census Bureau’s 2014-2018 American Community Survey. Stroke hospitals were identified from national or state level certification databases and were required to offer at least IV tPA. The main outcome is driving distance in kilometers from each census tract to the nearest certified stroke center, which was calculated using OSMnx, a Python package to retrieve, model and analyze real-world street networks. Quantile regression analysis was used to compare relationships between distances and tract-level demographics of age, race/ethnicity, income, and insurance status. RESULTS/ANTICIPATED RESULTS: 2,423 stroke centers and 71,929 census tracts containing 316,995,649 individuals were included. 49,918 (69%) tracts were urban. Demographic disparities in proximity to certified stroke care were greater in non-urban areas than in urban areas. Higher representation of individuals with age ≤65 years were associated with increased median distance to a certified stroke center in non-urban areas, but not urban areas. Median distance was greater with greater representation of American Indian or uninsured populations in urban and non-urban census tracts. Higher median income was associated with decreased median distance in non-urban census tracts and greater median distance in urban census tracts. DISCUSSION/SIGNIFICANCE OF FINDINGS: Reduced proximity to stroke care exists in areas with greater representation of elderly, American Indian, or uninsured persons; and low median income. These disparities are magnified in non-urban settings. Such knowledge can aid efforts to address and reduce disparities in stroke outcomes.
Striking an appropriate balance in the intellectual property system has been the subject of a perennial scholarly and policy debate. Article 7 of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement) states explicitly that ‘[t]he protection and enforcement of intellectual property rights should contribute to … a balance of rights and obligations’. The preamble of the WIPO Copyright Treaty (WCT) also recognises ‘the need to maintain a balance between the rights of authors and the larger public interest, particularly education, research and access to information’.2
Viruses are more common than bacteria in patients hospitalized with community-acquired pneumonia. Little is known, however, about the frequency of respiratory viral testing and its associations with antimicrobial utilization.
Retrospective cohort study.
The study included 179 US hospitals.
Adults admitted with pneumonia between July 2010 and June 2015.
We assessed the frequency of respiratory virus testing and compared antimicrobial utilization, mortality, length of stay, and costs between tested versus untested patients, and between virus-positive versus virus-negative patients.
Among 166,273 patients with pneumonia on admission, 40,787 patients (24.5%) were tested for respiratory viruses, 94.8% were tested for influenza, and 20.7% were tested for other viruses. Viral assays were positive in 5,133 of 40,787 tested patients (12.6%), typically for influenza and rhinovirus. Tested patients were younger and had fewer comorbidities than untested patients, but patients with positive viral assays were older and had more comorbidities than those with negative assays. Blood cultures were positive for bacterial pathogens in 2.7% of patients with positive viral assays versus 5.3% of patients with negative viral tests (P < .001). Antibacterial courses were shorter for virus-positive versus -negative patients overall (mean 5.5 vs 6.4 days; P < .001) but varied by bacterial testing: 8.1 versus 8.0 days (P = .60) if bacterial tests were positive; 5.3 versus 6.1 days (P < .001) if bacterial tests were negative; and 3.3 versus 5.2 days (P < .001) if bacterial tests were not obtained (interaction P < .001).
A minority of patients hospitalized with pneumonia were tested for respiratory viruses; only a fraction of potential viral pathogens were assayed; and patients with positive viral tests often received long antibacterial courses.
During the COVID-19 pandemic, the use of telemedicine as a way to reduce COVID-19 infections was noted and consequently deregulated. However, the degree of telemedicine regulation varies from country to country, which may alter the widespread use of telemedicine. This study aimed to clarify the telepsychiatry regulations for each collaborating country/region before and during the COVID-19 pandemic.
We used snowball sampling within a global network of international telepsychiatry experts. Thirty collaborators from 17 different countries/regions responded to a questionnaire on barriers to the use and implementation of telepsychiatric care, including policy factors such as regulations and reimbursement at the end of 2019 and as of May 2020.
Thirteen of 17 regions reported a relaxation of regulations due to the pandemic; consequently, all regions surveyed stated that telepsychiatry was now possible within their public healthcare systems. In some regions, restrictions on prescription medications allowed via telepsychiatry were eased, but in 11 of the 17 regions, there were still restrictions on prescribing medications via telepsychiatry. Lower insurance reimbursement amounts for telepsychiatry consultations v. in-person consultations were reevaluated in four regions, and consequently, in 15 regions telepsychiatry services were reimbursed at the same rate (or higher) than in-person consultations during the COVID-19 pandemic.
Our results confirm that, due to COVID-19, the majority of countries surveyed are altering telemedicine regulations that had previously restricted the spread of telemedicine. These findings provide information that could guide future policy and regulatory decisions, which facilitate greater scale and spread of telepsychiatry globally.
Our workplace has changed so dramatically that a new term for this chapter was created to describe it, electronicized. This chapter will focus on the associated issues of distraction due to personal electronic devices (PEDs), electronic medical records (EMRs), EMR’s OR equivalent, anesthesia information management systems (AIMS), and alarms. The digital distraction due to the combination of these devices will be described. Specific concerns will be raised regarding PED’s ubiquity as a distinct threat to vigilance that has the potential to be significantly disruptive and potentially injurious. Alarm fatigue due to the quantity and large number of false alarms will also be reviewed in detail
We investigate the phased evolution and variation of the South Asian monsoon and resulting weathering intensity and physical erosion in the Himalaya–Karakoram Mountains since late Pliocene time (c. 3.4 Ma) using a comprehensive approach. Neodymium and strontium isotopic compositions and single-grain zircon U–Pb age spectra reveal the sources of the deposits in the east Arabian Sea, and show a combination of sources from the Himalaya and the Karakoram–Kohistan–Ladakh Mountains, with sediments from the Indian Peninsula such as the Deccan Traps or Craton. We interpret shifts in the sediment sources to have been forced by sea-level changes that correlate with South Asian monsoon rainfall variation since late Pliocene time. We collected 908 samples from the International Ocean Discovery Program Hole U1456A, which was drilled in the east Arabian Sea. Time series of hematite content and grain size of the sediments were examined downcore. We found South Asian monsoon precipitation and weathering intensity experienced three phases from late Pliocene time. Lower monsoon precipitation, with a lower variability and strong weathering intensity, occurred during 3.4–2.4 Ma; an increased and more variable South Asian monsoon rainfall, along with strengthened but fluctuating weathering intensity, occurred at 1.8–1.1 Ma; and a reduced rainfall with lower South Asian monsoon precipitation variability and moderate weathering intensity marked the period 1.1–0.1 Ma. Maximum entropy spectral analysis and wavelet transform show that there were orbital-dominated cycles of periods c. 100 and c. 41 ka in these proxy-based time series. We propose that the monsoon, sea level, global temperature and insolation together forced the weathering and erosion in SW Asia.
At the forefront of developments in synchrotron x-ray microscopy, nanoscale-resolution high-dimensional spectrotomography under controlled sample environments has been demonstrated. Such cutting-edge experimental capability has been broadly applied to scientific studies in the field of energy materials science, where the dynamically evolving structural and chemical defects play a vital role in the functionality. In this article, we review novel developments of this technique from both experimental and data/information mining perspectives. Using studies on lithium-ion battery electrode materials as examples, we highlight the rich information in the high-dimensional and high-resolution x-ray tomographic data, which can be used to interpret the complicated thermal-electro-chemo-mechanical interplay that occurs under the operating conditions and collectively determines battery performance. We also discuss the frontier challenges in this field and our perspectives of the future directions in the context of projected major developments in the landscape of large-scale x-ray facilities across the globe.
Women are more likely to be admitted to nursing home after stroke than men. Differences in patient characteristics and outcomes by sex after institutionalization are less understood. We examined sex differences in the characteristics and care needs of patients admitted to nursing home following stroke and their subsequent survival.
We identified patients with stroke newly admitted to nursing home between April 2011 and March 2016 in Ontario, Canada, with follow-up until March 2018 using linked administrative data. We calculated prevalence ratios and 95% confidence intervals (CIs) for the primary outcomes of dependence for activities of daily living, cognitive impairment, frailty, health instability, and symptoms of depression or pain, comparing women to men. The secondary outcome was all-cause mortality.
Among 4831 patients, 60.9% were women. Compared to men, women were older (median age [interquartile range, IQR]: 84 [78, 89] vs. 80 [71, 86]), more likely to be frail (prevalence ratio 1.14, 95% CI [1.08, 1.19]), have unstable health (1.45 [1.28, 1.66]), and experience symptoms of depression (1.25 [1.11, 1.40]) or pain (1.21 [1.13, 1.30]), and less likely to have aggressive behaviors (0.87 [0.80, 0.94]). Overall median survival was 2.9 years. In a propensity-score-matched cohort, women had lower mortality than men (hazard ratio 0.85, 95% CI [0.77, 0.94]), but in the age-stratified survival analysis, the survival advantage in women was limited to those aged 75 years and older.
Despite lower subsequent mortality, women admitted to nursing home after stroke required more care than men. Pain and depression are two treatable symptoms that disproportionately affect women.
Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada.
We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers.
Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT).
Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.
For a large part of the past century, the cold war between the Soviet Union and the United States and Russia’s continued refusal to join the Berne Convention for the Protection of Literary and Artistic Works (Berne Convention), the predominant international copyright agreement, have raised complicated questions concerning the protection of Russian authors in the United States.1 The case that has received considerable attention in intellectual property literature is Itar-Tass Russian News Agency v. Russian Kurier, Inc (Itar-Tass).2 Filed in the mid-1990s, shortly after Russia’s accession to the Berne Convention but before its admission to the World Trade Organization (WTO), this case covered not only choice-of-law questions in the intellectual property field but also the interrelationship between domestic law and international treaties. Less frequently explored, however, are the rich comparative lessons that the case has provided on the development of intellectual property law and policy in Central and Eastern Europe.
The intensity of turbidite sedimentation over long timescales is driven by sea-level change, tectonically driven rock uplift and climatically modulated sediment delivery rates. This study focuses on understanding the effect of sea-level fluctuations and climatic variability on grain-size variations. The grain size and environmental magnetic parameters of Arabian Sea sediments have been documented using 203 samples, spanning the last 200 ka, obtained from International Ocean Discovery Program (IODP) Site U1457. Grain-size end-member modelling suggests that between ~200 and 130 ka there was an increase in the coarse silt fraction caused by sediment transport following reworking of the Indus Fan and development of deep-sea canyons. The sediment size and enhanced magnetic susceptibility indicate a dominant flux of terrestrial sediments. Sedimentation in the distal Indus Fan at c. 200–130 ka was driven by a drop in sea level that lowered the base level in the Indus and Narmada river systems. The low sea-stand caused incision in the Indus delta, canyons and fan area, which resulted in the transportation of coarser sediment at the drilling site. Magnetic susceptibility and other associated magnetic parameters suggest a large fraction of the sediment was supplied by the Narmada River during ~200–130 ka. Since ~130 ka, clay-dominated sedimentation is attributed to the rise in sea level due to warm and wet climate.
We present a new set of clay mineral and grain-size data for the siliciclastic sediment fraction from International Ocean Discovery Program (IODP) Site U1456 located in the eastern Arabian Sea to reconstruct the variabilities in the continental erosion and weathering intensity in the western Himalaya, elucidate the sediment source-to-sink processes and discuss the potential controls underlying these changes since 3.7 Ma. The clay minerals mainly consist of smectite (0–90%, average 44%) and illite (3–90%, average 44%), with chlorite (1–26%, average 7%) and kaolinite (0–19%, average 5%) as minor components. The compositional variations in the clay minerals at IODP Site U1456 suggest four phases of sediment provenance: the Indus River (phase 1, 3.7–3.2 Ma), the Indus River and Deccan Traps (phase 2, 3.2–2.6 Ma), the Indus River (phase 3, 2.6–1.2 Ma) and the Indus River and Deccan Traps (phase 4, 1.2–0 Ma). These provenance changes since 3.7 Ma can be correlated with variations in the Indian summer monsoon intensity. The siliciclastic sediments in the eastern Arabian Sea were mainly derived from the Indus River when the Indian summer monsoon was generally weak. In contrast, when the Indian summer monsoon intensified, the siliciclastic sediment supply from the Deccan Traps increased. In particular, this study shows that the smectite/(illite+chlorite) ratio is a sensitive tool for reconstructing the history of the variation in the Indian summer monsoon intensity over the continents surrounding the Arabian Sea since 3.7 Ma.
In his essay of 1983, ‘Towards a Critical Regionalism’, Kenneth Frampton referred to the Bagsværd Church as a primary exemplar, briefly citing the architect's representation of ‘the Chinese pagoda roof’ in this project, to emphasise the importance of crosscultural inspiration in the creation of ‘critical regionalism’. Peter Myers followed Frampton in his 1993 ‘Une histoire inachevée’, arguing for the significant role that Chinese architecture played as a source for Utzon's Bagsværd Church design and further variations on the theme of Chinese and Japanese exemplars on Utzon's work follows. Françoise Fromonot established the importance of the 1925 edition of the Yingzao-fashi (State Building Standard, first published in 1103 ad) and Johannes Prip-Møller's 1937 Chinese Buddhist Monasteries for Utzon; Philip Drew pointed out the significance of the work of Chinese writer Lin Yutang (1895–1976) and historian Osvald Sirén (1879–1966) as important channels through which Utzon perceived East Asian art and architecture; while in 2002, Richard Weston suggested Das Japanische Wohnhaus (1935), written by Japanese architect Tetsuro Yoshida (1894–1956), as a formational influence in Utzon's early perception of Japanese building culture. However, none of these works attempt to clarify the precise role that Chinese and Japanese precedents play in Utzon's architectural career. Two more recent studies, by Philip Goad and Michael Asgaard Andersen, have confirmed the role of Chinese architecture in Utzon's church design and have introduced new evidence and details, but there are still unanswered questions about the exact nature of these influences. This article attempts to address the detailed process of Utzon's cross-cultural practices for his design of the Bagsværd Church in order to reveal how Utzon interpreted specific ideas, ideals, and artefacts from East Asian building culture.
This chapter focuses on the roles and responsibilities of intellectual property-related public-private partnerships (PPPs) in the international human rights regime. It begins by debunking two key claims transnational corporations have advanced in the area intersecting intellectual property and human rights. The chapter examines the "protect, respect, and remedy" framework and the Guiding Principles on Business and Human Rights, which John Ruggie presented to the United Nations Human Rights Council in his capacity as the United Nations Secretary-General's Special Representative on the Issue of Human Rights and Transnational Corporations and Other Business Enterprises. It further explains why these partnerships should assume greater human rights responsibilities than transnational corporations. This chapter concludes with three specific examples illustrating how PPPs can be utilized to foster a more appropriate balance between intellectual property and human rights. It also underscores the need to proactively develop PPPs for human rights in the intellectual property arena.
The basic principle of high-entropy alloys (HEAs) is that high mixing entropies of solid-solution phases enhance the phase stability, which renders us a new strategy on alloy design. The current research of HEAs mostly emphasizes mechanical behavior at room and higher temperatures. Relatively fewer papers are focused on low-temperature behaviors, below room temperature. However, based on the published papers, we can find that the low-temperature properties of HEAs are generally excellent. The great potential for cryogenic applications could be expected on HEAs. In this article, we summarized and discussed the mechanical behaviors and deformation mechanisms, as well as stacking-fault energies, of HEAs at low temperatures. The comparison of low-temperature properties of HEAs and conventional alloys will be provided. Future research directions will be suggested at the end.