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In this retrospective cohort study, we evaluated the predictive value of methicillin-resistant Staphylococcus aureus (MRSA) nasal swabs for the development of MRSA infections in patients with left ventricular assist devices. In 106 patients, the MRSA nasal swab had a negative predictive value of 92.9% demonstrating a potential role in antibiotic de-escalation.
Background: Peritoneal dialysis is a type of dialysis performed by patients in their homes; patients receive training from dialysis clinic staff. Peritonitis is a serious complication of peritoneal dialysis, most commonly caused by gram-positive organisms. During March‒April 2019, a dialysis provider organization transitioned ~400 patients to a different manufacturer of peritoneal dialysis equipment and supplies (from product A to B). Shortly thereafter, patients experienced an increase in peritonitis episodes, caused predominantly by gram-negative organisms. In May 2019, we initiated an investigation to determine the source. Methods: We conducted case finding, reviewed medical records, observed peritoneal dialysis procedures and trainings, and performed patient home visits and interviews. A 1:1 matched case–control study was performed in 1 state. A case had ≥2 of the following: (1) positive peritoneal fluid culture, (2) high peritoneal fluid white cell count with ≥50% polymorphonuclear cells, or (3) cloudy peritoneal fluid and/or abdominal pain. Controls were matched to cases by week of clinic visit. Conditional logistic regression was used to estimate univariate matched odds ratios (mOR) and 95% confidence intervals (CIs). We conducted microbiological testing of peritoneal dialysis fluid bags to rule out product contamination. Results: During March‒September 2019, we identified 157 cases of peritonitis across 15 clinics in 2 states (attack rate≍39%). Staphylococcus spp (14%), Serratia spp (12%) and Klebsiella spp (6.3%) were the most common pathogens. Steps to perform peritoneal dialysis using product B differed from product A in several key areas; however, no common errors in practice were identified to explain the outbreak. Patient training on transitioning products was not standardized. Outcomes of the 73 cases in the case–control study included hospitalization (77%), peritoneal dialysis failure (40%), and death (7%). The median duration of training prior to product transition was 1 day for cases and controls (P = .86). Transitioning to product B (mOR, 18.00; 95% CI, 2.40‒134.83), using product B (mOR, 18.26; 95% CI, 3.86‒∞), drain-line reuse (mOR, 4.67; 95% CI, 1.34‒16.24) and performing daytime exchanges (mOR, 3.63; 95% CI, 1.71‒8.45) were associated with peritonitis. After several interventions, including transition of patients back to product A (Fig. 1), overall cases declined. Sterility testing of samples from 23 unopened product B peritoneal dialysis solution bags showed no contamination. Conclusions: Multiple factors may have contributed to this large outbreak, including a rapid transition in peritoneal dialysis products and potentially inadequate patient training. Efforts are needed to identify and incorporate best training practices, and product advances are desired to improve the safety of patient transitions between different types of peritoneal dialysis equipment.
Introduction: The emergency department (ED) is often the first point of health care contact for patients with mild traumatic brain injury (MTBI). Spontaneous resolution occurs in most patients within 7 days, yet 15-30% will develop post-concussion syndrome (PCS). Given the paucity of effective management strategies to prevent PCS and emerging evidence supporting exercise, the objective of this study was to evaluate the impact of prescribed early light exercise compared to standard discharge instructions for acute MTBI patients in the ED. Methods: This was a randomized controlled trial conducted in three Canadian EDs. Consecutive, adult (18-64 years) ED patients with a MTBI sustained within the preceding 48 hours were eligible for enrollment. The intervention group received discharge instructions prescribing 30 minutes of daily light exercise (e.g., walking), and the control group was given standard MTBI instructions advising gradual return to exercise following symptom resolution. Participants documented their daily physical activities and completed follow-up questionnaires at 7, 14, and 30 days. The primary outcome was the proportion of patients with PCS at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at 30 days. Results: 367 patients were enrolled (control n = 184; intervention n = 183). Median age was 32 years and 201 (57.6%) were female. There was no difference in the proportion of patients with PCS at 30 days (control 13.4 vs intervention 14.6; Δ1.2, 95% CI: -6.2 to 8.5). There were no differences in median change of RPQ scores (control 14 vs intervention 13; Δ1, 95% CI: -1 to 4), median number of return health care provider visits (control 1 vs intervention 1; Δ0, 95% CI: 0 to 0), or median number of missed school or work days (control 2 vs intervention 2; Δ0, 95% CI: 0 to 1) at 30 days. There was a nonsignificant difference in unplanned return ED visits within 30 days (control 9.9% vs intervention 5.6%; Δ1, 95% CI: -1.4 to 10.3). Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35; Δ5, 95% CI: 2 to 15). Conclusion: To our knowledge, this is the first randomized trial of prescribed early light exercise for adults with acute MTBI. There were no differences in recovery or healthcare utilization outcomes. Results suggest prescribed early light exercise should be encouraged as tolerated at ED discharge following MTBI, but exercise prescription alone is not sufficient to prevent PCS.
Introduction: The emergency department (ED) is the first point of health care contact for most head injured patients. Although early and spontaneous resolution occurs in most patients with mild traumatic brain injury (MTBI), between 15-30% develop post-concussion syndrome (PCS). To date, clinical prediction tools do not yet exist to accurately identify adult MTBI patients at risk of PCS. The objective of this study was to identify predictors of PCS within 30 days in adults with acute MTBI presenting to the ED. Methods: This was a secondary analysis of a randomized controlled trial conducted in three Canadian EDs evaluating prescribed light exercise compared to standard care. Adult (18-64 years) patients with a MTBI sustained within the preceding 48 hours were eligible for enrollment. Participants completed follow-up questionnaires at 7, 14, and 30 days. The primary outcome was the presence of PCS at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at 30 days. Backward, stepwise, multivariable logistic regression with a removal criterion probability of 0.05 was conducted to determine predictor variables independently associated with PCS at 30 days. Likelihood ratio tests were used to determine appropriate inclusion of variables in the multivariable model. Results are reported as odds ratios (OR) with 95% confidence intervals (CIs). Results: A total of 367 patients were enrolled, 18 (4.9%) withdrew, and 108 (29.4%) were lost to follow-up. Median (IQR) age was 32 (25 to 48) years, and 201 (57.6%) were female. Of the 241 patients who completed follow-up, 49 (20.3%) had PCS at 30 days. Headache at ED presentation (OR = 6.59; 95% CI: 1.31 to 33.11), being under the influence of drugs or alcohol at the time of injury (OR = 4.42; 95% CI: 1.31 to 14.88), the injury occurring via bike or motor vehicle collision (OR = 2.98; 95% CI: 1.39 to 6.40), history of anxiety or depression (OR = 2.49; 95% CI: 1.23 to 5.03), and the sensation of numbness or tingling at ED presentation (OR = 2.25; 95% CI: 1.04 to 4.88), were independently associated with PCS at 30 days. Conclusion: Five variables were found to be significant predictors of PCS. Although MTBI is a self-limited condition in the majority of patients, patients with these risk factors should be considered high risk and flagged for early follow-up. There continues to be an urgent need for a clinical prognostic tool that accurately identifies adult patients at risk for PCS early in their injury.
The role that vitamin D plays in pulmonary function remains uncertain. Epidemiological studies reported mixed findings for serum 25-hydroxyvitamin D (25(OH)D)–pulmonary function association. We conducted the largest cross-sectional meta-analysis of the 25(OH)D–pulmonary function association to date, based on nine European ancestry (EA) cohorts (n 22 838) and five African ancestry (AA) cohorts (n 4290) in the Cohorts for Heart and Aging Research in Genomic Epidemiology Consortium. Data were analysed using linear models by cohort and ancestry. Effect modification by smoking status (current/former/never) was tested. Results were combined using fixed-effects meta-analysis. Mean serum 25(OH)D was 68 (sd 29) nmol/l for EA and 49 (sd 21) nmol/l for AA. For each 1 nmol/l higher 25(OH)D, forced expiratory volume in the 1st second (FEV1) was higher by 1·1 ml in EA (95 % CI 0·9, 1·3; P<0·0001) and 1·8 ml (95 % CI 1·1, 2·5; P<0·0001) in AA (Prace difference=0·06), and forced vital capacity (FVC) was higher by 1·3 ml in EA (95 % CI 1·0, 1·6; P<0·0001) and 1·5 ml (95 % CI 0·8, 2·3; P=0·0001) in AA (Prace difference=0·56). Among EA, the 25(OH)D–FVC association was stronger in smokers: per 1 nmol/l higher 25(OH)D, FVC was higher by 1·7 ml (95 % CI 1·1, 2·3) for current smokers and 1·7 ml (95 % CI 1·2, 2·1) for former smokers, compared with 0·8 ml (95 % CI 0·4, 1·2) for never smokers. In summary, the 25(OH)D associations with FEV1 and FVC were positive in both ancestries. In EA, a stronger association was observed for smokers compared with never smokers, which supports the importance of vitamin D in vulnerable populations.
The replacement of fish oil (FO) with vegetable oil (VO) in feed formulations reduces the availability of n-3 long-chain PUFA (LC-PUFA) to marine fish such as gilthead seabream. The aim of this study was to examine compositional and physiological responses to a dietary gradient of n-3 LC-PUFA. Six iso-energetic and iso-nitrogenous diets (D1–D6) were fed to seabream, with the added oil being a blend of FO and VO to achieve a dietary gradient of n-3 LC-PUFA. Fish were sampled after 4 months feeding, to determine biochemical composition, tissue fatty acid concentrations and lipid metabolic gene expression. The results indicated a disturbance to lipid metabolism, with fat in the liver increased and fat deposits in the viscera reduced. Tissue fatty acid profiles were altered towards the fatty acid compositions of the diets. There was evidence of endogenous modification of dietary PUFA in the liver which correlated with the expression of fatty acid desaturase 2 (fads2). Expression of sterol regulatory element binding protein 1 (srebp1), fads2 and fatty acid synthase increased in the liver, whereas PPARα1 pathways appeared to be supressed by dietary VO in a concentration-dependent manner. The effects in lipogenic genes appear to become measurable in D1–D3, which agrees with the weight gain data suggesting that disturbances to energy metabolism and lipogenesis may be related to performance differences. These findings suggested that suppression of β-oxidation and stimulation of srebp1-mediated lipogenesis may play a role in contributing toward steatosis in fish fed n-3 LC-PUFA deficient diets.
Prior research has typically found a negative relationship between chronic pain and memory, and we examined whether cognitive control processes (e.g. reflection and rumination) moderated this relationship in individuals with Chiari malformation Type I (CM). CM is a neurological condition in which the cerebellar tonsils descend into the medullary and upper cervical spine regions potentially resulting in severe headaches and neck pain.
CM patients who had (n = 341) and had not (n = 297) undergone decompression surgery completed the McGill Pain Questionnaire-Short Form-Revised (SF-MPQ-2), the Rey Auditory Verbal Learning Test (RAVLT), and the Rumination-Reflection Questionnaire (RRQ). Immediate recall scores were compared to those of 102 healthy controls, and delayed recall performance was compared across other variables within the CM group.
CM patients performed more poorly on immediate recall than did controls. Within CM patients, we observed main effects for reflection and age, and a pain x reflection x surgical status (surgery v. no surgery) interaction in which non-decompressed individuals with low levels of pain and high levels of reflection showed superior delayed recall relative to non-decompressed individuals with higher pain and all decompressed individuals.
CM patients show an immediate recall deficit relative to controls, regardless of surgical status. High levels of reflection were associated with better delayed recall performance in non-decompressed CM patients with lower pain levels. High levels of chronic pain may overwhelm increased focused attention abilities, but higher levels of reflection partially overcome the distracting effects of pain and this may represent a type of resilience.
Profitability of using alternative protein sources in broiler feed is investigated through the development of a two-stage mathematical program that optimizes broiler production. A case study of peanut meal vs. soybean meal is examined. Value of marginal product concepts incorporated in this model permit analysis of demand adjustments before decisions on the production process occur. Given reported input and output prices, results indicate that soybean meal is generally more profitable than peanut meal. Peanut meal can be more profitable at higher dietary protein levels fed to broilers processed into whole carcass or at relatively higher prices for soybean meal.
Healthcare provider hands are an important source of intraoperative bacterial transmission events associated with postoperative infection development.
To explore the efficacy of a novel hand hygiene improvement system leveraging provider proximity and individual and group performance feedback in reducing 30-day postoperative healthcare-associated infections via increased provider hourly hand decontamination events.
Randomized, prospective study.
Dartmouth-Hitchcock Medical Center in New Hampshire and UMass Memorial Medical Center in Massachusetts.
Patients undergoing surgery.
Operating room environments were randomly assigned to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. Anesthesia and circulating nurse provider hourly hand decontamination events were continuously monitored and reported. All patients were followed prospectively for the development of 30-day postoperative healthcare-associated infections.
A total of 3,256 operating room environments and patients (1,620 control and 1,636 treatment) were enrolled. The mean (SD) provider hand decontamination event rate achieved was 4.3 (2.9) events per hour, an approximate 8-fold increase in hand decontamination events above that of conventional wall-mounted devices (0.57 events/hour); P<.001. Use of the hand hygiene system was not associated with a reduction in healthcare-associated infections (odds ratio, 1.07 [95% CI, 0.82–1.40], P=.626).
The hand hygiene system evaluated in this study increased the frequency of hand decontamination events without reducing 30-day postoperative healthcare-associated infections. Future work is indicated to optimize the efficacy of this hand hygiene improvement strategy.
Both empirically and interpretively, extant histories of psychiatry reveal a vastly greater degree of difference among themselves than historical accounts of any other field. Scholarship focuses on the period after 1800 and the same is true of historiographical reviews; those of early modern British psychiatry are often brief literature studies. This article sets out in depth the development of this rich and varied branch of history since the 1950s, exploring the many different approaches that have contributed to understanding the mad and how they were treated. Social, cultural, philosophical, religious, and intellectual historians have contributed as much as historians of science and medicine to understanding an enduring topic of fascination: ‘disorders of consciousness and conduct’ and their context. Appreciating the sometimes unacknowledged lineages of the subject and the personal histories of scholars (roots and routes) makes it easier to understand the past, present, and future of the history of psychiatry. The article explores European and North American influences as well as British traditions, looking at both the main currents of historiographical change and developments particular to the history of psychiatry.
The workshop Variational Problems in Differential Geometry was held at the University of Leeds from March 30 to April 2nd, 2009.
The aim of the meeting was to bring together researchers working on disparate geometric problems, all of which admit a variational formulation. Among the topics discussed were recent developments in harmonic maps and morphisms, minimal and CMC surfaces, extremal Kähler metrics, the Yamabe functional, Hamiltonian variational problems, and topics related to gauge theory and to the Ricci flow.
The meeting incorporated a special session in honour of John C. Wood, on the occasion of his 60th birthday, to celebrate his seminal contributions to the theory of harmonic maps and morphisms.
The following mathematicians gave one-hour talks: Bernd Ammann, Claudio Arezzo, Paul Baird, Olivier Biquard, Christoph Boehm, Francis Burstall, Josef Dorfmeister, Akito Futaki, Mark Haskins, Frederic Helein, Nicolaos Kapouleas, Mario Micallef, Frank Pacard, Simon Salamon, Lorenz Schwachhoefer, Peter Topping, Richard Wentworth, and Jon Wolfson.
There were about 50 participants from the UK, US, Japan and several European countries. The schedule allowed plenty of opportunities for discussion and interaction between official talks and made for a successful and stimulating meeting.
The workshop was financially supported by the London Mathematical Society, the Engineering and Physical Sciences Research Council of Great Britain and the School of Mathematics, University of Leeds.
The articles presented in this volume represent the whole spectrum of the subject.
Molecular phylogenetic analyses of 113 taxa representing Ascaridida, Rhigonematida, Spirurida and Oxyurida were used to infer a more comprehensive phylogenetic hypothesis for representatives of ‘clade III’. The posterior probability of multiple alignment sites was used to exclude or weight characters, yielding datasets that were analysed using maximum parsimony, likelihood, and Bayesian inference methods. Phylogenetic results were robust to differences among inference methods for most high-level taxonomic groups, but some clades were sensitive to treatments of characters reflecting differences in alignment ambiguity. Taxa representing Camallanoidea, Oxyurida, Physalopteroidea, Raphidascarididae, and Skrjabillanidae were monophyletic in all 9 analyses whereas Ascaridida, Ascarididae, Anisakidae, Cosmocercoidea, Habronematoidea, Heterocheilidae, Philometridae, Rhigonematida and Thelazioidea were never monophyletic. Some clades recovered in all trees such as Dracunculoidea and Spirurina included the vast majority of their sampled species, but were non-monophyletic due to the consistent behaviour of one or few ‘rogue’ taxa. Similarly, 102 of 103 clade III taxa were strongly supported as monophyletic, yet clade III was paraphyletic due to the grouping of Truttaedacnitis truttae with the outgroups. Mapping of host ‘habitat’ revealed that tissue-dwelling localization of nematode adults has evolved independently at least 3 times, and relationships among Spirurina and Camallanina often reflected tissue predilection rather than taxonomy.
Using the Orr-Sommerfeld equation with the wavenumber as the eigenvalue, a search for higher eigenstates in the stability theory of the Blasius boundary layer has revealed the existence of a number of viscous states in addition to the long established fundamental state. The viscous states are discrete, belong to two series, and are all heavily damped in space. Within the limits of the investigation the number of viscous states existing in the layer increases as the Reynolds number and the angular frequency of the perturbation increase. It is suggested that the viscous eigenstates may be responsible for the excitation of some boundary-layer disturbances by disturbances in the free stream.
Recent studies have reported cognitive asymmetries in patients with
Alzheimer's disease (AD) and in individuals with apolipoprotein E
ε4 (APOE ε4) genotype who are in the preclinical phase of AD.
This increased frequency of cognitive asymmetry, typically defined as a
significant discrepancy (in either direction) between verbal and spatial
abilities, often occurs despite an absence of differences on traditional
measures of central tendency (i.e., mean test scores). We prospectively
studied the relationship between APOE genotype and two modality-specific
executive-function tasks: The Verbal Fluency and Design Fluency tests of
the Delis-Kaplan Executive Function System (D-KEFS) in 52 normal
functioning older adult participants who were grouped according to the
presence (n = 24) or absence (n = 28) of the APOE
ε4 allele. Nondemented older adults with the APOE ε4 allele
demonstrated a greater frequency of cognitive asymmetric profile on the
new switching conditions of the Verbal and Design Fluency measures than
the APOE non-ε4 individuals. This study further supports the utility
of assessing cognitive asymmetry for the detection of subtle cognitive
differences in individuals at-risk for AD, and suggests that dual-task
executive function tests (i.e., fluency plus switching) may serve as a
useful preclinical marker of AD. (JINS, 2005, 11,
The longevity of filarial nematodes is dependent on secreted immunomodulatory products. Previous investigation of one such product, ES-62, has suggested a critical role for post-translationally attached phosphorylcholine (PC) moieties. In order to further investigate this, ES-62 lacking PC was produced, using the Pichia pastoris recombinant gene expression system. Unlike parasite-derived ES-62, which is tetrameric the recombinant material was found to consist of a mixture of apparently stable tetramers, dimers and monomers. Nevertheless, the recombinant protein was considered to be an adequate PC-free ES-62 as it was recognized by existing antisera against the parasite-derived protein. However, subsequent to this, recognition of parasite-derived ES-62 by antibodies produced against the recombinant protein was found to be absent. In an attempt to explain this, recombinant ES-62 was subjected to structural analysis and was found to (i) contain 3 changes in amino acid composition; (ii) demonstrate significant alterations in glycosylation; (iii) show major differences in protein secondary structure. The effects of these alterations in relation to the observed change in immunogenicity were investigated and are discussed. The data presented clearly show that recognition by existing antibodies is insufficient proof that recombinant proteins can be used to mimic parasite-derived material in studies on nematode immunology and vaccination.