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Evidence supporting collection of follow-up blood cultures for Gram-negative bacteremia is mixed. We sought to understand why providers order follow-up blood cultures when managing P. aeruginosa bacteremia and whether follow-up blood cultures in this context are associated with short- and long-term survival.
We conducted a retrospective cohort study of adult inpatients with P. aeruginosa bacteremia at the University of Maryland Medical Center in 2015–2020. Kaplan-Meier survival curves and Cox regression with time-varying covariates were used to evaluate the association between follow-up blood cultures and time to mortality within 30 days of first positive blood culture. Provider justifications for follow-up blood cultures were identified through chart review.
Of 159 eligible patients, 127 (80%) had follow-up blood cultures, including 9 (7%) that were positive for P. aeruginosa and 10 (8%) that were positive for other organisms. Follow-up blood cultures were typically collected “to ensure clearance” or “to guide antibiotic therapy.” Overall, 30-day mortality was 25.2%. After risk adjustment for patient characteristics, follow-up blood cultures were associated with a nonsignificant reduction in mortality risk (hazard ratio, 0.43; 95% confidence interval, 1.08; P = .071). In exploratory analyses, the potential mortality reduction from follow-up blood cultures was driven by their use in patients with Pitt bacteremia scores >0.
Follow-up blood cultures are commonly collected for P. aeruginosa bacteremia but infrequently identify persistent bacteremia. Targeted use of follow-up blood cultures based on severity of illness may reduce unnecessary culturing.
Research was conducted to evaluate acetyl-Coenzyme A carboxylase (ACCase) enzyme activity using a functional malachite green colorimetric assay previously identified as resistant to sethoxydim, and select aryloxyphenoxypropionate (FOPs) herbicides, fenoxaprop, and fluazifop. Two resistant southern crabgrass [Digitaria ciliaris (Retz.) Koeler] biotypes, R1 and R2, containing an Ile-1781-Leu amino acid substitution and previously identified as resistant to sethoxydim, pinoxaden, and fluazifop but not clethodim was utilized as the resistant chloroplastic ACCase source compared to known susceptible (S) ACCase. Dose-response studies with sethoxydim, clethodim, fluazifop-p-butyl, and pinoxaden (0.6 to 40 µM) were conducted to compare the ACCase enzyme-herbicides interaction of R1, R2, and S using the malachite green functional assay. Assay results indicated that R biotypes required more ACCase-targeting herbicides to inhibit ACCase activity compared to S. IC50 values of all four herbicides for R biotypes were consistently an order of magnitude greater than S. No sequencing differences in the carboxyltransferase domain was observed for R1 and R2, however, R2 IC50 values were greater across all herbicides. These results indicate the malachite green functional assay is effective in evaluating ACCase enzyme activity of R and S biotypes in the presence of ACCase-targeting herbicides, which can be used as a replacement for the 14C-based radiometric functional assay.
A goosegrass [Eleusine indica (L.) Gaertn.] population uncontrolled by paraquat (R) in a vegetable production field in St. Clair County, AL, was collected in summer 2019. Research was conducted to assess the level of resistance of the suspected resistant population compared with three populations with no suspected paraquat resistance (S1, S2, and S3). Visual injury at all rating dates and biomass reduction at 28 d after treatment (DAT) of S populations occurred exponentially to increasing paraquat rates. S biotypes were injured more than R at 3 DAT, with biomass recovery at 28 DAT only occurring at rates <0.28 kg ha−1. Plant death or biomass reduction did not occur for any rate at any date for R. Paraquat rates that induced 50% or 90% injury or reduced biomass 50% or 90% compared with the non-treated (I50 or I90, respectively) ranged from 10 to 124 times higher I50 for R compared with S and 54 to 116 times higher I90 for R compared with S biotypes. These data confirm a paraquat-resistant E. indica biotype in Alabama, providing additional germplasm for study of resistance to photosystem I electron-diverting (PSI-ED) resistance mechanisms.
To identify intramuscular rapid tranquilisation (IMRT) events in all >65 years inpatients in Sussex Partnership NHS Foundation Trust (SPFT) and to establish whether accompanying documentation meets SPFT guidelines. This is a re-audit, initial data were collected in 2016. Multimodal intervention has been implemented since initial data collection. In psychiatric inpatients IMRT should be administered as a last resort to calm acutely disturbed patients after verbal de-escalation and an offer of oral medication has failed. IMRT can cause physical health complications and impact therapeutic relationships. Quality improvements made since initial data collection were: an IMRT treatment algorithm for >65s, a teaching package for staff, IMRT prescription area on medicine cards and post IMRT physical monitoring forms – in line with updates to trust IMRT policy.
Retrospective case note audit cycle of 119 patients. Electronic and paper records were reviewed for inpatients >65 years on 1/9/2019. Records were examined for instances of IMRT– the following features were noted: diagnosis; verbal de-escalation; oral medication offered prior to IMRT; IMRT prescription location; and post-IMRT monitoring. Descriptive statistics were performed. This audit was approved by the trust audit committee.
There were 34 RT events in 17 patients, reduced from 83 RT events in 20 patients in 2016. De-escalation was attempted in 62% versus 34% in 2016, oral medication offered first in 71% versus 59% in 2016. Physical monitoring was fully completed in 50% of instances in 2019, an improvement from 23% in 2016.
Education, a new treatment algorithm, medicine card changes, and IMRT physical monitoring forms have improved adherence to trust standards. There was a 49% reduction in IMRT events in 2019 versus 2016. De-escalation is being performed more frequently, and oral sedation offered in more cases. The physical monitoring of patients has improved.
Chapter 2 explores the structure and evolution of federal, state, and international SORN policies. The chapter first outlines the history of federal legislation in the United States that has shaped the current SORN environment, beginning with the 1994 Jacob Wetterling Act and continuing through the 2006 Sex Offender Registration and Notification Act (SORNA) and its subsequent amendments. The chapter then explores the key points of variation in state SORN policies, underscoring the elusive nature of fulfilling SORNA’s vision of a uniform national system. This analysis examines two particularly prominent points of interstate variation: provisions for the registration of juveniles and mechanisms for registrant classification. The chapter concludes with a brief examination of SORN systems outside the United States, indicating that, although many countries have adopted provisions for requiring registration with law enforcement, the provision of public access to registrant information is far less common.
Epidemiological studies indicate that individuals with one type of mental disorder have an increased risk of subsequently developing other types of mental disorders. This study aimed to undertake a comprehensive analysis of pair-wise lifetime comorbidity across a range of common mental disorders based on a diverse range of population-based surveys.
The WHO World Mental Health (WMH) surveys assessed 145 990 adult respondents from 27 countries. Based on retrospectively-reported age-of-onset for 24 DSM-IV mental disorders, associations were examined between all 548 logically possible temporally-ordered disorder pairs. Overall and time-dependent hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models. Absolute risks were estimated using the product-limit method. Estimates were generated separately for men and women.
Each prior lifetime mental disorder was associated with an increased risk of subsequent first onset of each other disorder. The median HR was 12.1 (mean = 14.4; range 5.2–110.8, interquartile range = 6.0–19.4). The HRs were most prominent between closely-related mental disorder types and in the first 1–2 years after the onset of the prior disorder. Although HRs declined with time since prior disorder, significantly elevated risk of subsequent comorbidity persisted for at least 15 years. Appreciable absolute risks of secondary disorders were found over time for many pairs.
Survey data from a range of sites confirms that comorbidity between mental disorders is common. Understanding the risks of temporally secondary disorders may help design practical programs for primary prevention of secondary disorders.
This paper summarizes a multi-state, multi-year study assessing the potential for local agriculture in northern New England. While largely rural, this region's agricultural sector differs greatly from the rest of the United States, and demand for locally produced food has been increasing. To assess this unique economic landscape, researchers and Cooperative Extension at the Universities of Maine, New Hampshire, and Vermont investigated four key areas: (1) local food capacities, (2) constraints to agricultural expansion, (3) consumer preferences for local and organic produce, and (4) the role of intermediaries as alternative local food outlets. The project included input from local farmers, Extension members, restaurants, and the general public. We present the four research areas in a sequential, overlapping fashion. The timing of our research was such that each step in the process informed the next and can be used as a template for assessing a region's potential for local agricultural production.
Introduction: Emergency Department Overcrowding (EDOC) is a multifactorial issue that leads to Access Block for patients needing emergency care. Identified as a national problem, patients presenting to a Canadian Emergency Department (ED) at a time of overcrowding have higher rates of admission to hospital and increased seven-day mortality. Using the well accepted input-throughput-output model to study EDOC, current research has focused on throughput as a measure of patient flow, reported as ED length of stay (LOS). In fact, ED LOS and ED beds occupied by inpatients are two “extremely important indicators of EDOC identified by a 2005 survey of Canadian ED directors. One proposed solution to improve ED throughput is to utilize a physician at triage (PAT) to rapidly assess newly arriving patients. In 2017, a pilot PAT program was trialed at Kelowna General Hospital (KGH), a tertiary care hospital, as part of a PDSA cycle. The aim was to mitigate EDOC by improving ED throughput by the end of 2018, to meet the national targets for ED LOS suggested in the 2013 CAEP position statement. Methods: During the fiscal periods 1-6 (April 1 to September 7, 2017) a PAT shift occurred daily from 1000-2200, over four long weekends. ED LOS, time to inpatient bed, time to physician initial assessment (PIA), number of British Columbia Ambulance Service (BCAS) offload delays, and number of patients who left without being seen (LWBS) were extracted from an administrative database. Results were retrospectively analyzed and compared to data from 1000-2200 of non-PAT trial days during the trial periods. Results: Median ED LOS decreased from 3.8 to 3.4 hours for high-acuity patients (CTAS 1-3), from 2.1 to 1.8 hours for low-acuity patients (CTAS 4-5), and from 9.3 to 8.0 hours for all admitted patients. During PAT trial weekends, there was a decrease in the average time to PIA by 65% (from 73 to 26 minutes for CTAS 2-5), average number of daily BCAS offload delays by 39% (from 2.3 to 1.4 delays per day), and number of patients who LWBS from 2.4% to 1.7%. Conclusion: The implementation of PAT was associated with improvements in all five measures of ED throughput, providing a potential solution for EDOC at KGH. ED LOS was reduced compared to non-PAT control days, successfully meeting the suggested national targets. PAT could improve efficiency, resulting in the ability to see more patients in the ED, and increase the quality and safety of ED practice. Next, we hope to prospectively evaluate PAT, continuing to analyze these process measures, perform a cost-benefit analysis, and formally assess ED staff and patient perceptions of the program.
Here, we report reproducible and accurate measurement of crystallographic parameters using scanning transmission electron microscopy. This is made possible by removing drift and residual scan distortion. We demonstrate real-space lattice parameter measurements with <0.1% error for complex-layered chalcogenides Bi2Te3, Bi2Se3, and a Bi2Te2.7Se0.3 nanostructured alloy. Pairing the technique with atomic resolution spectroscopy, we connect local structure with chemistry and bonding. Combining these results with density functional theory, we show that the incorporation of Se into Bi2Te3 causes charge redistribution that anomalously increases the van der Waals gap between building blocks of the layered structure. The results show that atomic resolution imaging with electrons can accurately and robustly quantify crystallography at the nanoscale.
The gut microbiota and its metabolic products interact with the host in many different ways, influencing gut homoeostasis and health outcomes. The species composition of the gut microbiota has been shown to respond to dietary change, determined by competition for substrates and by tolerance of gut conditions. Meanwhile, the metabolic outputs of the microbiota, such as SCFA, are influenced both by the supply of dietary components and via diet-mediated changes in microbiota composition. There has been significant progress in identifying the phylogenetic distribution of pathways responsible for formation of particular metabolites among human colonic bacteria, based on combining cultural microbiology and sequence-based approaches. Formation of butyrate and propionate from hexose sugars, for example, can be ascribed to different bacterial groups, although propionate can be formed via alternative pathways from deoxy-sugars and from lactate by a few species. Lactate, which is produced by many gut bacteria in pure culture, can also be utilised by certain Firmicutes to form butyrate, and its consumption may be important for maintaining a stable community. Predicting the impact of diet upon such a complex and interactive system as the human gut microbiota not only requires more information on the component groups involved but, increasingly, the integration of such information through modelling approaches.
The RepRap 3D printer development project is a fast growing, open-hardware initiative relying on the input of hobbyist designers. One of its key components is the printer nozzle. The performance and reliability deficiencies of currently available nozzle designs are common topics in the RepRap community, and our own experience with a RepRap 3D printer has identified a need for improvement in a few particular areas. We set out to eliminate melt leakage, improve thermal isolation, and develop a more effective method of nozzle assembly attachment. Here, we review the issues, describe design efforts, and report results.
Recently there have been reports of hot carrier thermoelectric response in nanostructured materials like graphene and MoS. We report observing that thermoelectric nanowire junctions detect light. In these experiments we employed devices composed of bismuth nanowire arrays which are capped with a transparent indium tin oxide electrode. The incident surface features very low optical reflectivity and enhanced light trapping. The unique attributes of the thermoelectric arrays are the combination of strong temporal and optical wavelength dependences of the photocurrent. Under infrared illumination, the signal can be completely described by “quasi-equilibrium” thermoelectric effects considering cooling rates given by heat diffusion through the array. The thermal diffusivity is found to be less (by a factor of 3.5) than in the bulk, a result that we discuss in terms of phonon confinement effects. In addition to a thermoelectric response, under visible illumination, we observe a photovoltaic response.
The present study investigated the relationship between the milk protein content of a rehydration solution and fluid balance after exercise-induced dehydration. On three occasions, eight healthy males were dehydrated to an identical degree of body mass loss (BML, approximately 1·8 %) by intermittent cycling in the heat, rehydrating with 150 % of their BML over 1 h with either a 60 g/l carbohydrate solution (C), a 40 g/l carbohydrate, 20 g/l milk protein solution (CP20) or a 20 g/l carbohydrate, 40 g/l milk protein solution (CP40). Urine samples were collected pre-exercise, post-exercise, post-rehydration and for a further 4 h. Subjects produced less urine after ingesting the CP20 or CP40 drink compared with the C drink (P< 0·01), and at the end of the study, more of the CP20 (59 (sd 12) %) and CP40 (64 (sd 6) %) drinks had been retained compared with the C drink (46 (sd 9) %) (P< 0·01). At the end of the study, whole-body net fluid balance was more negative for trial C ( − 470 (sd 154) ml) compared with both trials CP20 ( − 181 (sd 280) ml) and CP40 ( − 107 (sd 126) ml) (P< 0·01). At 2 and 3 h after drink ingestion, urine osmolality was greater for trials CP20 and CP40 compared with trial C (P< 0·05). The present study further demonstrates that after exercise-induced dehydration, a carbohydrate–milk protein solution is better retained than a carbohydrate solution. The results also suggest that high concentrations of milk protein are not more beneficial in terms of fluid retention than low concentrations of milk protein following exercise-induced dehydration.