To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.
Substance use and psychiatric illness, particularly psychotic disorders, contribute to violence in emergency healthcare settings. However, there is limited research regarding the relationship between specific substances, psychotic symptoms and violent behaviour in such settings. We investigated the interaction between recent cannabinoid and stimulant use, and acute psychotic symptoms, in relation to violent behaviour in a British emergency healthcare setting.
We used electronic medical records from detentions of 1089 individuals under Section 136 of the UK Mental Health Act (1983 amended 2007), an emergency police power used to detain people for 24–36 h for psychiatric assessment. The relationship between recent cannabinoids and/or stimulant use, psychotic symptoms, and violent behaviour, was estimated using logistic regression.
There was evidence of recent alcohol or drug use in 64.5% of detentions. Violent incidents occurred in 12.6% of detentions. Psychotic symptoms increased the odds of violence by 4.0 [95% confidence intervals (CI) 2.2–7.4; p < 0.0001]. Cannabinoid use combined with psychotic symptoms increased the odds of violence further [odds ratios (OR) 7.1, 95% CI 3.7–13.6; p < 0.0001]. Recent use of cannabinoids with stimulants but without psychotic symptoms was also associated with increased odds of violence (OR 3.3, 95% CI 1.4–7.9; p < 0.0001).
In the emergency setting, patients who have recently used cannabinoids and exhibit psychotic symptoms are at higher risk of violent behaviour. Those who have used both stimulants and cannabinoids without psychotic symptoms may also be at increased risk. De-escalation protocols in emergency healthcare settings should account explicitly for substance use.
In Canada, recreational use of cannabis was legalized in October 2018. This policy change along with recent publications evaluating the efficacy of cannabis for the medical treatment of epilepsy and media awareness about its use have increased the public interest about this agent. The Canadian League Against Epilepsy Medical Therapeutics Committee, along with a multidisciplinary group of experts and Canadian Epilepsy Alliance representatives, has developed a position statement about the use of medical cannabis for epilepsy. This article addresses the current Canadian legal framework, recent publications about its efficacy and safety profile, and our understanding of the clinical issues that should be considered when contemplating cannabis use for medical purposes.
Introduction: Intravenous insertion (IVI) is identified by children as extremely painful and the resultant distress can have lasting negative consequences. There is an urgent need to effectively manage such procedures. Our primary objective was to compare the pain and distress of IVI with the addition of humanoid robot-based distraction to standard care, versus standard care alone. Methods: This two-armed randomized controlled trial (RCT) was conducted from April 2017 to May 2018 at the Stollery Children's Hospital emergency department (ED). Children aged 6 to 11 years who required IVI were included. Exclusion criteria included hearing or visual impairments, neurocognitive delays, sensory impairment to pain, previous enrolment, and discretion of the ED clinical staff. Primary outcomes were measured using the Observational Scale of Behavioural Distress-Revised (OSBD-R) (distress) and the Faces Pain Scale-Revised (FPS-R) (pain). A total of 426 pediatric patients were screened and 340 were excluded. Results: We recruited 86 children, of which 55% (47/86) were male; 9% (7/82) were premature at birth; 82% (67/82) had a previous ED visit; 30% (25/82) required previous hospitalization; 78% (64/82) had previous IV placement and 96% (78/81) received topical anesthesia. The mean total OSBD-R score was 1.49 ± 2.36 (standard care) compared to 0.78 ± 1.32 (robot group) (p = 0.047). The median FPS-R during the IV procedure was 4 (IQR 2,6) in the standard care group alone, compared to 2 (IQR 0,4) with the addition of humanoid robot-based distraction (p = 0.10). Change in parental state anxiety pre-procedure versus post-procedure was not significantly different between groups (p = 0.49). Parental satisfaction with the IV start was 93% (39/42) in the robot arm compared to 74% (29/39) in the standard care arm (p = 0.03). Parents were also more satisfied with management of their child's pain in the robot group (95% very satisfied) compared with standard care (72% very satisfied) (p = 0.002). Conclusion: A statistically significant reduction in distress was observed with the addition of robot-based distraction to standard care. Humanoid robot-based distraction therapy reduces distress and to a lesser extent, pain, in children undergoing IVI in the ED. Further trials are required to confirm utility in other age groups and settings.
Current methods of control recruitment for case-control studies can be slow (a particular issue for outbreak investigations), resource-intensive and subject to a range of biases. Commercial market panels are a potential source of rapidly recruited controls. Our study evaluated food exposure data from these panel controls, compared with an established reference dataset. Market panel data were collected from two companies using retrospective internet-based surveys; these were compared with reference data from the National Diet and Nutrition Survey (NDNS). We used logistic regression to calculate adjusted odds ratios to compare exposure to each of the 71 food items between the market panel and NDNS participants. We compared 2103 panel controls with 2696 reference participants. Adjusted for socio-demographic factors, exposure to 90% of foods was statistically different between both panels and the reference data. However, these differences were likely to be of limited practical importance for 89% of Panel A foods and 79% of Panel B foods. Market panel food exposures were comparable with reference data for common food exposures but more likely to be different for uncommon exposures. This approach should be considered for outbreak investigation, in conjunction with other considerations such as population at risk, timeliness of response and study resources.
The opioid epidemic has claimed the lives of more than 183,000 individuals since 1999 and is now the leading cause of accidental death in the United States. Meanwhile, rates of incarceration have quadrupled in recent decades, and drug use is the leading cause of incarceration. Medication-assisted treatment or MAT (i.e. methadone, buprenorphine) is the gold standard for treatment of opioid use disorder. Incarcerated individuals with opioid use disorder treated with methadone or buprenorphine have a lower risk of overdose, lower rates of hepatitis C transmission, and lower rates of re-incarceration. Despite evidence of improved outcomes, many jails and prisons do not offer MAT to individuals with opioid use disorder. This seems partly due to a scientifically unjustified preference for an abstinence-only treatment approach. The absence of MAT in prisons and jails results in poor outcomes for individuals and poses a public health threat to communities. Furthermore, it disproportionately harms poor communities and communities of color. Health care providers in prisons and jails have an ethical obligation to offer MAT to individuals with opioid use disorder to mitigate risk of infectious diseases, opioid overdose and health disparities associated with incarceration.
This article argues that correctional institutions violate the Eighth Amendment when they refuse to establish MAT programs and prevent doctors from exercising medical judgment to properly treat incarcerated people with OUD.
To determine whether antimicrobial (AM) courses ordered with an antimicrobial computer decision support system (CDSS) were more likely to be appropriate than courses ordered without the CDSS.
Retrospective cohort study. Blinded expert reviewers judged whether AM courses were appropriate, considering drug selection, route, dose, and duration.
A 279-bed university-affiliated Department of Veterans Affairs (VA) hospital.
A 500-patient random sample of inpatients who received a therapeutic AM course between October 2007 and September 2008.
An optional CDSS, available at the point of order entry in the VA computerized patient record system.
CDSS courses were significantly more likely to be appropriate (111/254, 44%) compared with non-CDSS courses (81/246, 33%, P = .013). Courses were more likely to be appropriate when the initial provider diagnosis of the condition being treated was correct (168/273, 62%) than when it was incorrect, uncertain, or a sign or symptom rather than a disease (24/227, 11%, P< .001). In multivariable analysis, CDSS-ordered courses were more likely to be appropriate than non-CDSS-ordered courses (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.13–2.98). Courses were also more likely to be judged appropriate when the initial provider diagnosis of the condition being treated was correct than when it was incorrect, uncertain, or a sign or symptom rather than a disease (OR, 3.56; 95% CI, 1.4-9.0).
Use of the CDSS was associated with more appropriate AM use. To achieve greater improvements, strategies are needed to improve provider diagnoses of syndromes that are infectious or possibly infectious.
We previously showed that developmental 3,4-methylenedioxymethamphetamine (MDMA) treatment induces long-term spatial and egocentric learning and memory deficits and serotonin (5-HT) reductions. During brain development, 5-HT is a neurotrophic factor influencing neurogenesis, synaptogenesis, migration, and target field organization. MDMA (10 mg/kg × 4/d at 2 h intervals) given on post-natal day (PD) 11–20 in rats (a period of limbic system development that approximates human third trimester brain development) induces 50% reductions in 5-HT during treatment and 20% reductions when assessed as adults. To determine whether the 5-HT reduction is responsible for the cognitive deficits, we used citalopram (Cit) pretreatment to inhibit the effects of MDMA on 5-HT reuptake in a companion study. Cit attenuated MDMA-induced 5-HT reductions by 50% (Schaefer et al., 2012). Here we tested whether Cit (5 or 7.5 mg/kg × 2/d) pretreatment attenuates the cognitive effects of MDMA. Within each litter, different offspring were treated on PD11–20 with saline (Sal) + MDMA, Cit + MDMA, Cit + Sal or Sal + Sal. Neither spatial nor egocentric learning/memory was improved by Cit pretreatment. Unexpectedly, Cit + Sal (at both doses) produced spatial and egocentric learning deficits as severe as those caused by Sal + MDMA. These are the first data showing cognitive deficits resulting from developmental exposure to a selective serotonin reuptake inhibitor. These data indicate the need for further research on the long-term safety of antidepressants during pregnancy.
Neonatal exposure to (+)-methamphetamine (Meth) results in long-term behavioural abnormalities but its developmental mechanisms are unknown. In a series of experiments, rats were treated from post-natal days (PD) 11–20 (stage that approximates human development from the second to third trimester) with Meth or saline and assessed using locomotor activity as the readout following pharmacological challenge doses with dopamine, serotonin and glutamate agonists or antagonists during adulthood. Exposure to Meth early in life resulted in an exaggerated adult locomotor hyperactivity response to the dopamine D1 agonist SKF-82958 at multiple doses, a high dose only under-response activating effect of the D2 agonist quinpirole, and an exaggerated under-response to the activating effect of the N-methyl-d-aspartic acid (NMDA) receptor antagonist, MK-801. No change in locomotor response was seen following challenge with the 5-HT releaser p-chloroamphetamine or the 5-HT2/3 receptor agonist, quipazine. These are the first data to show that PD 11-20 Meth exposure induces long-lasting alterations to dopamine D1, D2 and glutamate NMDA receptor function and may suggest how developmental Meth exposure leads to many of its long-term adverse effects.
Previous findings showed allocentric and egocentric learning deficits in rats after MDMA treatment from postnatal days (PD) 11–20 but not after treatment from PD 1–10. Shorter treatment periods (PD 1–5, 6–10, 11–15, or 16–20) resulted in allocentric learning deficits averaged across intervals but not for any interval individually and no egocentric learning deficits individually or collectively. Whether this difference was attributable to treatment length or age at the start of treatment was unclear. In the present experiment rat litters were treated on PD 1–10, 6–15, or 11–20 with 0, 10, or 15 mg/kg MDMA q.i.d. at 2-h intervals. Two male/female pairs/litter received each treatment. One pair/litter received acoustic startle with prepulse inhibition, straight channel swimming, Cincinnati water maze (CWM), and conditioned fear in a latent inhibition paradigm. The other pair/litter received locomotor activity, straight channel swimming, Morris water maze (MWM), and locomotor activity retest with MK-801 challenge. MDMA impaired CWM learning following PD 6–15 or 11–20 exposure. In MWM acquisition, all MDMA-treated groups showed impairment. During reversal and shift, the PD 6–15 and PD 11–20 MDMA-treated groups were significantly impaired. Reductions in locomotor activity were most evident after PD 6–15 treatment while increases in acoustic startle were most evident after PD 1–10 treatment. After MK-801 challenge, MDMA-treated offspring showed less locomotion compared to controls. Region-specific changes in brain monoamines were also observed but were not significantly correlated with behavioural changes. The results show that PD 11–20 exposure to MDMA caused the largest long-term cognitive deficits followed by PD 6–15 exposure with PD 1–10 exposure least affected. Other effects, such as those upon MK-801-stimulated locomotion showed greatest effects after PD 1–10 MDMA exposure. Hence, each effect has a different window of developmental susceptibility.
In January 2009, the IAEA EMRAS II (Environmental Modelling for Radiation Safety II) program was launched. The goal of the program is to develop, compare and test models for the assessment of radiological impacts to the public and the environment due to radionuclides being released or already existing in the environment; to help countries build and harmonize their capabilities; and to model the movement of radionuclides in the environment. Within EMRAS II, nine working groups are active; this paper will focus on the activities of Working Group 1: Reference Methodologies for Controlling Discharges of Routine Releases. Within this working group environmental transfer and dose assessment models are tested under different scenarios by participating countries and the results compared. This process allows each participating country to identify characteristics of their models that need to be refined. The goal of this working group is to identify reference methodologies for the assessment of exposures to the public due to routine discharges of radionuclides to the terrestrial and aquatic environments. Several different models are being applied to estimate the transfer of radionuclides in the environment for various scenarios. The first phase of the project involves a scenario of nuclear power reactor with a coastal location which routinely (continuously) discharges 60Co, 85Kr, 131I, and 137Cs to the atmosphere and 60Co, 137Cs, and 90Sr to the marine environment. In this scenario many of the parameters and characteristics of the representative group were given to the modellers and cannot be altered. Various models have been used by the different participants in this inter-comparison (PC-CREAM, CROM, IMPACT, CLRP POSEIDON, SYMBIOSE and others). This first scenario is to enable a comparison of the radionuclide transport and dose modelling. These scenarios will facilitate the development of reference methodologies for controlled discharges.
Assessments of infectious disease spread in hospitals seldom account for interfacility patient sharing. This is particularly important for pathogens with prolonged incubation periods or carrier states.
We quantified patient sharing among all 32 hospitals in Orange County (OC), California, using hospital discharge data. Same-day transfers between hospitals were considered “direct” transfers, and events in which patients were shared between hospitals after an intervening stay at home or elsewhere were considered “indirect” patient-sharing events. We assessed the frequency of readmissions to another OC hospital within various time points from discharge and examined interhospital sharing of patients with Clostridium difficile infection.
In 2005, OC hospitals had 319,918 admissions. Twenty-nine percent of patients were admitted at least twice, with a median interval between discharge and readmission of 53 days. Of the patients with 2 or more admissions, 75% were admitted to more than 1 hospital. Ninety-four percent of interhospital patient sharing occurred indirectly. When we used 10 shared patients as a measure of potential interhospital exposure, 6 (19%) of 32 hospitals “exposed” more than 50% of all OC hospitals within 6 months, and 17 (53%) exposed more than 50% within 12 months. Hospitals shared 1 or more patient with a median of 28 other hospitals. When we evaluated patients with C. difficile infection, 25% were readmitted within 12 weeks; 41% were readmitted to different hospitals, and less than 30% of these readmissions were direct transfers.
In a large metropolitan county, interhospital patient sharing was a potential avenue for transmission of infectious agents. Indirect sharing with an intervening stay at home or elsewhere composed the bulk of potential exposures and occurred unbeknownst to hospitals.
Numerical models used to simulate the lofting mechanisms of runway stones were developed to assess the threat to aircraft structures from runway debris impacts. An inflated aircraft tyre model, which was validated by comparison with experimental indentation tests, showed that over-rolling of stones under typical take-off conditions led to only modest vertical loft velocities of less than 5 m/s. Experiments using a drop weight impactor simulated a section of aircraft tyre descending upon stones. These tests demonstrated that lofting was achieved for impacts with low rubber thickness. However, for impacts with greater rubber thickness, lofting was suppressed. Using more realistic tyre geometries resulted in launches with backspin, but only horizontally along the ground in the direction of the tyre axis. The speed at which launches occurred was proportional to the rate of descent of the tyre section and would consequently determine the loft speeds due to potential asperity lofting.
Jurassic dykes of western Dronning Maud Land (Antarctica) form a minor component of the Karoo large igneous province. An extensive local dyke swarm intrudes Neoproterozoic gneisses and Jurassic syenite plutons on the margins of the Jutulstraumen palaeo rift in the Svedrupfjella region. The dykes were intruded in three distinct episodes (~204, ~176 and ~170 Ma). The 204 Ma dykes are overwhelminglylow-Ti, olivine tholeiites including some primitive (picritic) compositions (MgO >12 wt.%; Fe2O3 >12 wt.%; Cr >1000 ppm; Ni >600 ppm). This 204 Ma event precedes the main Karoo volcanic event by~25 Ma, so anycorrelations to the wider province are difficult to make. However, it mayrecord the earliest phase of rift activity along the Jutulstraumen. The 176 Ma dyke event is more intimately associated with the two syenite plutons. The dykes are alkaline (basanite/ tephrite) and were small-degree melts from an enriched, locallyderived source and underwent at least some degree of interaction with a syenitic contaminant. This ~176 Ma dyke event is widespread elsewhere in the Karoo (southern Africa and Dronning Maud Land). Later-stage (170 Ma) felsic (phonolite–comendite) dykes intrude the 176 Ma basanite–tephrite suite and represent the last phase of magmatic activityin the region.
This study involves an investigation of the mechanism underlying activating effects of inorganic additives on the oxidation of aluminum. The oxidation of nano aluminum powders in air was characterized by variable temperature x-ray powder diffraction and thermogravimetric analysis. For a 33-nm aluminum powder the aluminum oxide produced by air oxidation was poorly crystallized until the sample was heated to above 1050°C, where the alpha-alumina phase crystallized. For a mixture of the aluminum with cryolite, crystallization of oxide phases is enhanced, with Na-Al-O phases evident at 550°C and above. Fluorine is lost from the sample between 550 and 850°C, presumably due to reaction with moisture to produce HF. In a similar experiment with aluminum and silver molybdate, the only crystalline product was alpha-alumina, which was observed at 550°C and higher. The general result is that alpha-alumina, the ultimate product in most cases, crystallized at a lower temperature when activating agents were present.
Direct-write technologies offer the potential for low-cost materials-efficient deposition of contact metallizations for photovoltaics. We report on the inkjet printing of metal organic decomposition (MOD) inks with and without nanoparticle additions. Near-bulk conductivity of printed and sprayed metal films has been achieved for Ag and Ag nanocomposites. Good adhesion and ohmic contacts with a measured contact resistance of 400μΩ•cm2 have been observed between the sprayed silver films and a heavily doped n-type layer of Si. Silver deposited using the MOD ink burns through the Si3N4 antireflection coating when annealed at 850°C to form an ohmic contact to the n-Si underneath. An active solar cell device was fabricated using a top contact that was spray printed using the Ag MOD ink. Inkjet printed films show adhesion differences as a function of the process temperature and solvent. Silver lines with good adhesion and conductivity have been printed on glass with 100 μm resolution.
Metal-organic and hybrid metal-organic/metal nanoparticle inkswere evaluated for use in the inkjet printing of copper and silver conducting lines. Pure, smooth, dense, highly conductive coatings were produced by spray printing with (hexafluoroacetylacetonato)copper(I)-vinyltrimethylsilane Cu(hfa)·VTMS) and (hexafluoroacetylacetonato)silver(I)(1,5-cyclooctadiene) (Ag(hfa)COD) metal-organic precursors on heated substrates. Good adhesion to the substrates tested, glass, Kapton tape and Si, has been achieved without use of adhesion promoters. The silver metal-organic ink has also beenused to print metal lines and patterns with a commercial inkjet printer. Hybrid inks comprised of metal nanoparticles mixed with the metal-organic complexes above have also been used to deposit Cu and Ag films by spray printing.This approach gives dense, adherent films that are much thicker than those obtained using the metal-organic inks alone. The conductivities of the silvercoatings obtained by both approaches are near that of bulk silver (2 μΩ·cm). The copper coatings had conductivities at least an order ofmagnitude less than bulk.