Flow on a beta‐plane driven by a steady localised anticyclonic forcing of potential vorticity (or equivalently a mass source) is considered as a simple model of the Asian monsoon flow in the upper ...troposphere. Previous authors have noted that the response may be steady, or unsteady, according to the magnitude of the forcing, with the unsteadiness manifested as westward eddy shedding. A detailed study of the transition between steady and eddy‐shedding regimes reveals a third regime ('break up'), for intermediate forcing magnitude, where the flow is steady in the neighbourhood of the forcing, but the westward extending plume of low potential vorticity breaks up into isolated anticyclonic vortices some distance away from the forcing region. A related spatio‐temporal instability problem for flow on a beta plane is specified and analysed. The flow can be stable, convectively unstable or absolutely unstable. It is argued that these three stability regimes correspond to the steady, break‐up and eddy‐shedding regimes for the forced flow and good quantitative correspondence between the regimes is demonstrated by explicit solution of the spatio‐temporal stability problem.
Snapshots of the stream function and potential vorticity response in quasi‐geostrophic single‐layer experiments forced with a steady, localised mass source. The response transitions between different states (steady, break‐up and shedding), defined in terms of temporal and spatial variability, when varying the magnitude F0 or length‐scale r0 of the forcing. The different behaviours can be explained by the spatio‐temporal stability properties of the steady linear response and a transition of the system into an absolutely or convectively unstable regime.
On September 30, 2014, the first US patient with Ebola virus disease was diagnosed. Hospitals and healthcare systems identified many complex issues that needed to be addressed to prepare for possible ...future outbreaks. Here we summarize themes identified in free text responses from a query of infectious disease physicians from the Infectious Disease Society of America's (IDSA) Emerging Infections Network (EIN) early in the domestic Ebola response and place them into the context of biopreparedness for possible future events. We queried infectious disease physician members of the EIN from October 21-November 11, 2014, about their institutions' experience with Ebola preparedness at that time. Of 1,566 EIN physicians, 869 replied to this query, and 318 provided 448 write-in comments in response to the question, "What gaps have been identified in order for facilities to safely care for suspected Ebola patients?" or in a section for general comments. Six themes emerged from the responses: the unique challenges faced by small community hospitals (87 comments), the burden placed on infectious disease and infection control staff (61), ethical questions and planning for vulnerable populations (40), misinformation and stigma (29), financial issues faced by response staff (27), and long-term sustainability (16). This qualitative analysis provides insights into early thinking about challenges in preparing for Ebola and other emerging infections in the United States. The themes identified here should be considered during local, state, and national planning.
Background.
The first case of Ebola diagnosed in the United States and subsequent cases among 2 healthcare workers caring for that patient highlighted the importance of hospital preparedness in ...caring for Ebola patients.
Methods.
From October 21, 2014 to November 11, 2014, infectious disease physicians who are part of the Emerging Infections Network (EIN) were surveyed about current Ebola preparedness at their institutions.
Results.
Of 1566 EIN physician members, 869 (55.5%) responded to this survey. Almost all institutions represented in this survey showed a substantial degree of preparation for the management of patients with suspected and confirmed Ebola virus disease. Despite concerns regarding shortages of personal protective equipment, approximately two thirds of all respondents reported that their facilities had sufficient and ready availability of hoods, full body coveralls, and fluid-resistant or impermeable aprons. The majority of respondents indicated preference for transfer of Ebola patients to specialized treatment centers rather than caring for them locally. In general, we found that larger hospitals and teaching hospitals reported higher levels of preparedness.
Conclusions.
Prior to the Centers for Disease Control and Prevention's plan for a tiered approach that identified specific roles for frontline, assessment, and designated treatment facilities, our query of infectious disease physicians suggested that healthcare facilities across the United States were making preparations for screening, diagnosis, and treatment of Ebola patients. Nevertheless, respondents from some hospitals indicated that they were relatively unprepared.
Laboratory testing confirmed AKI associated with anemia, lymphocytopenia, and monocytosis as well as elevated CRP and LDH values (Table 2). Because the clinical presentation pointed to Hantavirus ...infection but urinalysis suggested acute glomerular dysfunction, a kidney biopsy was performed, revealing acute TIN and ATN. Based on small randomized trials, therapy for mild disease with penicillin or doxycyline shortens the duration of the illness and prevents shedding of the organisms. Because of high mortality of patients with severe leptospirosis, antiinfective therapy is recommended and should include doxycycline or a third-generation cephalosporin 21. Because symptoms may be attributed to other diseases, a leptospiral infection may often remain undiagnosed. Because of its global importance, serologic testing for leptospirosis should be considered in any patient with nondistinctive AKI due to acute tubulointerstial nephritis and fever.
The purpose of this report was to update previous estimates of the association between mental disorders and earnings. Current estimates for 2002 are based on data from the National Comorbidity Survey ...Replication (NCS-R).
The NCS-R is a nationally representative survey of the U.S. household population that was administered from 2001 to 2003. Following the same basic approach as prior studies, with some modifications to improve model fitting, the authors predicted personal earnings in the 12 months before interview from information about 12-month and lifetime DSM-IV mental disorders among respondents ages 18-64, controlling for sociodemographic variables and substance use disorders. The authors used conventional demographic rate standardization methods to distinguish predictive effects of mental disorders on amount earned by persons with earnings from predictive effects on probability of having any earnings.
A DSM-IV serious mental illness in the preceding 12 months significantly predicted reduced earnings. Other 12-month and lifetime DSM-IV/CIDI mental disorders did not. Respondents with serious mental illness had 12-month earnings averaging $16,306 less than other respondents with the same values for control variables ($26,435 among men, $9,302 among women), for a societal-level total of $193.2 billion. Of this total, 75.4% was due to reduced earnings among mentally ill persons with any earnings (79.6% men, 69.6% women). The remaining 24.6% was due to reduced probability of having any earnings.
These results add to a growing body of evidence that mental disorders are associated with substantial societal-level impairments that should be taken into consideration when making decisions about the allocation of treatment and research resources.
The prevalence of serious infections caused by multidrug-resistant pathogens transmitted in the hospital setting has reached alarming levels, despite intensified interventions. In the context of ...mandates that hospitals ensure compliance with disinfection procedures of surfaces in the environment surrounding the patient, we implemented a multihospital project to both evaluate and improve current cleaning practices.
Prospective quasi-experimental, before-after, study.
Thirty-six acute care hospitals in the United States ranging in size from 25 to 721 beds.
We used a fluorescent targeting method to objectively evaluate the thoroughness of terminal room disinfection cleaning before and after structured educational and procedural interventions.
Of 20,646 standardized environmental surfaces (14 types of objects), only 9,910 (48%) were cleaned at baseline (95% confidence interval, 43.4-51.8). Thoroughness of cleaning at baseline correlated only with hospital expenditures for environmental services personnel (P = .02). After implementation of interventions and provision of objective performance feedback to the environmental services staff, it was determined that 7,287 (77%) of 9,464 standardized environmental surfaces were cleaned (P < .001). Improvement was unrelated to any demographic, fiscal, or staffing parameter but was related to the degree to which cleaning was suboptimal at baseline (P < .001).
Significant improvements in disinfection cleaning can be achieved in most hospitals, without a substantial added fiscal commitment, by the use of a structured approach that incorporates a simple, highly objective surface targeting method, repeated performance feedback to environmental services personnel, and administrative interventions. However, administrative leadership and institutional flexibility are necessary to achieve success, and sustainability requires an ongoing programmatic commitment from each institution.
Stroke is a leading cause of mortality and disability, and its sequelae are associated with inadequate food intake which can lead to sarcopenia. The aim of this study is to verify the effectiveness ...of creatine supplementation on functional capacity, strength, and changes in muscle mass during hospitalization for stroke compared to usual care. An exploratory subanalysis will be performed to assess the inflammatory profiles of all participants, in addition to a follow-up 90 days after stroke, to verify functional capacity, muscle strength, mortality, and quality of life.
Randomized, double-blind, unicenter, parallel-group trial including individuals with ischemic stroke in the acute phase. The duration of the trial for the individual subject will be approximately 90 days, and each subject will attend a maximum of three visits. Clinical, biochemical, anthropometric, body composition, muscle strength, functional capacity, degree of dependence, and quality of life assessments will be performed. Thirty participants will be divided into two groups: intervention (patients will intake one sachet containing 10g of creatine twice a day) and control (patients will intake one sachet containing 10g of placebo maltodextrin twice a day). Both groups will receive supplementation with powdered milk protein serum isolate to achieve the goal of 1.5g of protein/kg of body weight/day and daily physiotherapy according to the current rehabilitation guidelines for patients with stroke. Supplementation will be offered during the 7-day hospitalization. The primary outcomes will be functional capacity, strength, and changes in muscle mass after the intervention as assessed by the Modified Rankin Scale, Timed Up and Go test, handgrip strength, 30-s chair stand test, muscle ultrasonography, electrical bioimpedance, and identification of muscle degradation markers by D3-methylhistidine. Follow-up will be performed 90 days after stroke to verify functional capacity, muscle strength, mortality, and quality of life.
The older population has specific nutrient needs, especially for muscle mass and function maintenance. Considering that stroke is a potentially disabling event that can lead the affected individual to present with numerous sequelae, it is crucial to study the mechanisms of muscle mass loss and understand how adequate supplementation can help these patients to better recover.
The Brazilian Clinical Trials Registry (ReBEC) RBR-9q7gg4 . Registered on 21 January 2019.
Background. Little is known about viral hepatitis testing and infection prevalence among persons in private healthcare organizations (HCOs) in the United States. Methods. To determine the frequency ...of and characteristics associated with viral hepatitis testing and infection prevalence among adults with access to care, we conducted an observational cohort study among 1.25 million adults from 4 US HCOs and included persons with ≥1 clinical encounter during 2006–2008 and ≥12 months of continuous follow-up before 2009. We compared the number of infections identified with the number expected based on adjusted data from the National Health and Nutrition Examination Survey (NHANES). Results. Of 866 886 persons without a previous hepatitis B virus (HBV) diagnosis, 18.8% were tested for HBV infection, of whom 1.4% tested positive; among 865 659 without a previous hepatitis C virus (HCV) diagnosis, 12.7% were tested, of whom 5.5% tested positive. Less than half of those with ≥2 abnormal alanine aminotransferase (ALT) levels were subsequently tested for HBV or HCV. When tested, Asians (adjusted odds ratio aOR 6.33 relative to whites) were most likely HBV infected, whereas those aged 50–59 years were most likely HCV infected (aOR 6.04, relative to age <30 years). Based on estimates from NHANES, nearly one-half of HCV and one-fifth of HBV infections in this population were not identified. Conclusions. Even in this population with access to care and lengthy follow-up, only a fraction of expected viral hepatitis infections were identified. Abnormal ALT levels often but not consistently triggered testing. These findings have implications for the identification and care of 4–5 million US residents with HBV and HCV infection.
Background. The number of deaths in hepatitis C virus (HCV)–infected persons recorded on US death certificates has been increasing, but actual rates and causes of death in these individuals have not ...been well elucidated. Methods. Disease-specific, liver-related, and non-liver-related mortality data for HCV-infected patients in an observational cohort study, the Chronic Hepatitis Cohort Study (CHeCS) at 4 US healthcare systems, were compared with multiple cause of death (MCOD) data in 12 million death certificates in 2006–2010. Premortem diagnoses, liver biopsies, and FIB-4 scores (a noninvasive measure of liver damage) were examined. Results. Of 2 143 369 adult patients seen at CHeCS sites in 2006–2010, 11 703 (0.5%) had diagnosed chronic HCV infection, and 1590 (14%) died. The majority of CHeCS decedents were born from 1945 to 1965 (75%), white (50%), and male (68%); mean age of death was 59 years, 15 years younger than MCOD deaths. The age-adjusted mortality rate for liver disease in CHeCS was 12 times higher than the MCOD rate. Before death, 63% of decedents had medical record evidence of chronic liver disease, 76% had elevated FIB-4 scores, and, among those biopsied, 70% had moderate or worse liver fibrosis. However, only 19% of all CHeCS decedents and only 30% of those with recorded liver disease had HCV listed on their death certificates. Conclusions. HCV infection is greatly underdocumented on death certificates. The 16 622 persons with HCV listed in 2010 may represent only one-fifth of about 80 000 HCV-infected persons dying that year, at least two-thirds of whom (53 000 patients) would have had premortem indications of chronic liver disease.
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