Clostridium difficile infection is the most common hospital-acquired infection. Besides infected patients, carriers have emerged as a key player in C. difficile epidemiology. In this study, we ...evaluated the impact of identifying and isolating carriers upon hospital admission on the incidence of CDI incidence and hospital-acquired C. difficile colonization, as a single policy and as part of bundle approaches. We simulated C. difficile transmission using a stochastic mathematical approach, considering the contribution of carriers based on published literature. In the baseline scenario, CDI incidence was 6.18/1,000 admissions (95% CI, 5.72-6.65), simulating reported estimates from U.S. hospital discharges. The acquisition rate of C. difficile carriage was 9.72/1,000 admissions (95% CI, 9.15-10.31). Screening and isolation of colonized patients on admission to the hospital decreased CDI incidence to 4.99/1,000 admissions (95% CI, 4.59-5.42; relative reduction (RR) = 19.1%) and led to 36.2% reduction in the rate of hospital-acquired colonization. Simulating an antimicrobial stewardship program reduced CDI rate to 2.35/1,000 admissions (95% CI, 2.07-2.65). In sensitivity analysis, CDI incidence was less than 2.32/1,000 admissions (RR = 62.4%) in 95% of 1,000 simulations. The combined bundle, focusing on reducing C. difficile transmission from colonized patients and the individual risk of these patients to develop CDI, decreased significantly the incidence of both CDI and hospital-acquired colonization. Implementation of this bundle to current practice is expected to have an important impact in containing CDI.
The opioid epidemic is an escalating health crisis. We evaluated the impact of opioid prescription rates and socioeconomic determinants on opioid mortality rates, and identified potential differences ...in prescription patterns by categories of practitioners.
We combined the 2013 and 2014 Medicare Part D data and quantified the opioid prescription rate in a county level cross-sectional study with data from 2710 counties, 468,614 unique prescribers and 46,665,037 beneficiaries. We used the CDC WONDER database to obtain opioid-related mortality data. Socioeconomic characteristics for each county were acquired from the US Census Bureau.
The average national opioid prescription rate was 3.86 claims per beneficiary that received a prescription for opioids (95% CI 3.86-3.86). At a county level, overall opioid prescription rates (p < 0.001, Coeff = 0.27) and especially those provided by emergency medicine (p < 0.001, Coeff = 0.21), family medicine physicians (p = 0.11, Coeff = 0.008), internal medicine (p = 0.018, Coeff = 0.1) and physician assistants (p = 0.021, Coeff = 0.08) were associated with opioid-related mortality. Demographic factors, such as proportion of white (p
< 0.001, Coeff = 0.22), black (p
< 0.001, Coeff = - 0.19) and male population (p
< 0.001, Coeff = 0.13) were associated with opioid prescription rates, while poverty (p < 0.001, Coeff = 0.41) and proportion of white population (p
< 0.001, Coeff = 0.27) were risk factors for opioid-related mortality (p
< 0.001, R
= 0.35). Notably, the impact of prescribers in the upper quartile was associated with opioid mortality (p < 0.001, Coeff = 0.14) and was twice that of the remaining 75% of prescribers together (p < 0.001, Coeff = 0.07) (p
= 0.03, R
= 0.03).
The prescription opioid rate, and especially that by certain categories of prescribers, correlated with opioid-related mortality. Interventions should prioritize providers that have a disproportionate impact and those that care for populations with socioeconomic factors that place them at higher risk.
Since the ALICE experiment began data taking in early 2010, the amount of end user jobs on the AliEn Grid has increased significantly. Presently 1/3 of the 40K CPU cores available to ALICE are ...occupied by jobs submitted by about 400 distinct users, individually or in organized analysis trains. The overall stability of the AliEn middleware has been excellent throughout the 3 years of running, but the massive amount of end-user analysis and its specific requirements and load has revealed few components which can be improved. One of them is the interface between users and central AliEn services (catalogue, job submission system) which we are currently re-implementing in Java. The interface provides persistent connection with enhanced data and job submission authenticity. In this paper we will describe the architecture of the new interface, the ROOT binding which enables the use of a single interface in addition to the standard UNIX-like access shell and the new security-related features.
While hands-on therapy is the most commonly used technique for upper limb rehabilitation after stroke, it requires a therapist and residual activity and is best suited for active-assisted exercises. ...Robotic therapy on the other hand, can provide intention driven training in a motivating environment. We compared a robotic and standard therapy group, allowing intention driven finger flexion/extention respectively active-assisted exercises and a standard therapy only group. A total of 25 patients, 2 to 6 months post-stroke, with moderate motor deficit (Fugl-Meyer Assessment or FMA between 15 and 50), were randomly assigned in one of the groups. Patients practiced 30 minutes of hands-on therapy each day for 2 weeks with a supplementary 30 minutes of robotic therapy each day for patients in the experimental group. Subjects were evaluated using the FMA, Box and Blocks test (BBT) and Stroke Impact Scale (SIS) before and after the treatment. Patients in the experimental group showed higher average gain in all tests than those in the control group but only the SIS average gain was on the limit of statistical significance. This study shows the potential efficacy of robotic therapy for hand rehabilitation in subacute stroke patients. Index Terms--electrical stimulation, mechatronic hand, neuromuscular stimulation, rehabilitation robotics, robot control.
Many people suffer from anxiety and panic attacks, statistics showing that 1 in 3 people have their lives affected because of these worrying and annoying symptoms. One of the most common anxiety ...disorders observed in general medical practice and in the general population is the generalized anxiety disorder. In about 85% of cases, generalized anxiety does not appear alone, but is accompanied by other psychological problems, of which the most common are: depression, other anxiety disorders, substance abuse, digestive problems, etc. The patient diagnosed with Generalized Anxiety Disorder (GAD) usually has suffered from severe anxiety and worries about several different areas of their life for at least six months. It occurs in 5-9% of the population, and the incidence is twice as high in women as in men. Generalized anxiety usually begins in adolescence or early adulthood. GAG is caused by several factors: 30%-50% of it can be genetic in nature, but it also can be caused by experiences during childhood, recent stressful life events, unrealistic expectations about others and oneself, conflicts in relationships, alcohol consumption, coping skills and other factors (Ciubara et al., 2018). Studies show that the anxiety levels in the general population have risen over the past 50 years - probably due to declining social cohesion affecting communities, unrealistic expectations for quality of life, excessive focus on negative news, and other factors, social and cultural aspects.
Medication shortages are frequent and have clinical and financial ramifications; however, their effect on drug prices remains unknown.
To examine price progression of medications affected by a ...shortage.
We collected prices of medications covered under Medicare Part B, reflective of general market prices, and data on clinically relevant shortages for the period 2005-16. We used linear mixed-effects models to examine the price growth of affected medications.
Shortage medications demonstrated a quarterly price growth of -0.5 % (95 % confidence interval CI -1.6, 0.6) in the period preceding a shortage, 4.3 % (95 % CI 3.6, 4.5) during a shortage, and 4.1 % (95 % CI 2.6, 5.5) in the post-shortage period. Medications not affected by a shortage had a quarterly price growth of 0.2 % (95 % CI -0.3, 0.6).
Medication shortages are associated with price increases, and these increases are likely reactive to the low profitability of the affected medications and thus, proactive collaboration between the US Food and Drug Administration and industry can serve to identify low-profit drugs and evaluate measures to ensure continued production.
Breast cancer surgery is associated with a high incidence of persistent postsurgical pain (PPSP). The aim of this study was to evaluate the impact of intravenous (IV) lidocaine on acute and PPSP, ...analgesic requirements, and sensation abnormalities in patients undergoing surgery for breast cancer.
Thirty-six patients participated in this randomized, double-blinded study. Before induction of general anesthesia, patients received a bolus of intravenous lidocaine 1.5 mg/kg followed by a continuous infusion of lidocaine 1.5 mg/kgh (lidocaine group) or an equal volume of saline (control group). The infusion was stopped 1 hour after the skin closure. Pain scores and analgesic consumption were recorded at 2, 4, 24 hours, and then daily for 1 week postoperatively. Three months later, patients were assessed for PPSP and secondary hyperalgesia.
Two (11.8%) patients in the lidocaine group and 9 (47.4%) patients in the control group reported PPSP at 3 months follow-up (P=0.031). McGill Pain Questionnaire revealed greater present pain intensity-visual analog scale in the control group (14.6 ± 22.5 vs. 2.6 ± 7.5; P=0.025). Secondary hyperalgesia (area of hyperalgesia/length of surgical incision) was significantly less in the lidocaine group compared with control group (0.2 ± 0.8 vs. 3.2 ± 4.5 cm; P=0.002). The 2 groups were similar in terms of analgesic consumption during the early postoperative period.
Intravenous perioperative lidocaine decreases the incidence and severity of PPSP after breast cancer surgery. Prevention of the induction of central hyperalgesia is a potential mechanism.
Autophagy and regulation of IL-23 signaling pathways have been implicated in the pathogenesis of Crohn's disease (CD). We studied the mode of inheritance and reviewed the association of 2 polymorphic ...variants of ATG16L1 and IL23R with CD.
We searched the PubMed and ISI Web of Science databases (up to May 2014) for pertinent articles. We included all studies that had a case-control design, with cases having CD and controls being healthy and reported full genotype frequencies for the ATG16L1 and/or IL23R variant of interest. We quantified the relative genetic risk using the model-free approach of the generalized odds ratio metric (ORG) and reported 95% precision estimates. Also, we explored the mode of inheritance using the degree of dominance h-index.
Fifty-one studies fulfilled these requirements and were included in the analysis. These studies involved 12,762 patients and 16,735 controls evaluating the association of ATG16L1 (rs2241880 p.Thr300Ala) and 8110 patients and 11,900 controls evaluating the association of IL23R (rs11209026 p.Arg381Gln) with CD. The ATG16L1 variant rs2241880 was associated with increased susceptibility to CD (combined ORG = 1.38; 95% confidence interval, 1.29-1.48) and a nondominant mode of inheritance (suggesting that the effect of heterozygosity lies exactly in the middle of extreme homozygotes, h = 0). The IL23R variant rs11209026 was associated with significant protection (ORG = 0.46; 95% confidence interval, 0.41-0.53) and a recessive mode of inheritance, indicating that the effect of a heterozygous genotype would lie close to the wild-type homozygous genotype. In subgroup analysis, the significant effects persisted across Caucasian ancestry studies and pediatric populations but were lacking across studies in Asian populations.
The ATG16L1 variant rs2241880 was associated with 38% increase in the risk for CD for higher mutational load, whereas IL23R variant rs11209026 decreased the risk by 54% for higher mutational load. The mode of inheritance for ATG16L1 variant demonstrated perfect additivity for genetic risk, whereas it showed recessiveness for the IL23R variant. This analysis permits risk stratification for CD based on the mutational status and highlight the need for additional studies in certain populations.
Clinical guidelines play a central role in day-to-day practice. We assessed the degree of incorporation of cost analyses to guidelines and identified modifiable characteristics that could affect the ...level of incorporation.We selected the 100 most cited guidelines listed on the National Guideline Clearinghouse (http://www.guideline.gov) and determined the number of guidelines that used cost analyses in their reasoning and the overall percentage of incorporation of relevant cost analyses available in PubMed. Differences between medical specialties were also studied. Then, we performed a case-control study using incorporated and not incorporated cost analyses after 1:1 matching by study subject and compared them by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement requirements and other criteria.We found that 57% of guidelines do not use any cost justification. Guidelines incorporate a weighted average of 6.0% (95% confidence interval CI 4.3-7.9) among 3396 available cost analyses, with cardiology and infectious diseases guidelines incorporating 10.8% (95% CI 5.3-18.1) and 9.9% (95% CI 3.9- 18.2), respectively, and hematology/oncology and urology guidelines incorporating 4.5% (95% CI 1.6-8.6) and 1.6% (95% CI 0.4-3.5), respectively. Based on the CHEERS requirements, the mean number of items reported by the 148 incorporated cost analyses was 18.6 (SD = 3.7), a small but significant difference over controls (17.8 items; P = 0.02). Included analyses were also more likely to directly relate cost reductions to healthcare outcomes (92.6% vs 81.1%, P = 0.004) and declare the funding source (72.3% vs 53.4%, P < 0.001), while similar number of cases and controls reported a noncommercial funding source (71% vs 72.7%; P = 0.8).Guidelines remain an underused mechanism for the cost-effective allocation of available resources and a minority of practice guidelines incorporates cost analyses utilizing only 6% of the available cost analyses. Fulfilling the CHEERS requirements, directly relating costs with healthcare outcomes and transparently declaring the funding source seem to be valued by guideline-writing committees.
With the startup of LHC, the ALICE detector will collect data at a rate that, after two years, will reach 4PB per year. To process such a large amount of data, ALICE has developed AliEn, a ...distributed computing environment, integrated with the WLCG environment. The ALICE environment presents several original solutions, which have shown their viability in a number of large exercises of increasing complexity called ALICE Data Challenges. Within the ALICE distributed computing environment, the AliEn Workload Management Structure was created to submit to the WLCG infrastructure, and has played a crucial role to achieve the mentioned results. ALICE has more than 80 sites distributed all over the world and this WMS together with the operations management structure defined by the experiment has demonstrated a reliability and performance level ready to begin the data taking at the end of the year. In this talk we will focus on the description and current status of the AliEn WMS, emphasizing the last functionalities that have been included to handle from a single entry point the different matchmaking services of WLCG (lcg-RB, gLite WMS) and also the CREAM Computing Element; the latter has been extensively tested by the experiment during summer 2008.
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