Objectives To describe and compare the incidence of late-onset sepsis (LOS) and demographic and clinical characteristics associated with LOS in very low birth weight (VLBW) infants from singleton and ...multiple births, and to examine the heritability of susceptibility to LOS among VLBW twins by comparing same-sex and unlike-sex twin pairs. Study design The study group comprised infants with birth weight 401-1500 g seen at clinical centers of the Eunice Kennedy Shriver National Institute of Child and Human Development Neonatal Research Network between 2002 and 2008. Only the first episode of LOS was included in our analysis. Stepwise logistic regression models were fitted separately for singleton and multiple pregnancies to examine the maternal and neonatal factors associated with LOS. LOS due solely to gram-negative bacteria in singleton and multiple pregnancies was also examined in separate models. The heritability of LOS was estimated by examining the concordance of LOS in twins from same-sex and unlike-sex pairs. Results LOS occurred in 25.0% (3797 of 15 178) of singleton and 22.6% (1196 of 5294) of multiple-birth VLBW infants. Coagulase-negative staphylococci were the most common infecting organisms, accounting for 53.2% of all LOS episodes in singletons and 49.2% in multiples. Escherichia coli and Klebsiella species were the most commonly isolated gram-negative organisms, and Candida albicans was the most commonly isolated fungus. Concordance of LOS did not differ significantly between same-sex and unlike-sex twin pairs. Conclusion LOS remains a common problem in VLBW infants. The incidence of LOS is similar for singleton and multiple-birth infants. The similar concordance of LOS in same-sex and unlike-sex twin pairs provides no evidence that susceptibility to LOS among VLBW infants is genetically determined.
Heat-induced weight loss (WL) and chemical and dimensional changes of small specimens of beech (
Fagus sylvatica L.), Scots pine (
Pinus sylvestris L.) and Norway spruce (
Picea abies L.) wood were ...examined after thermal modification in the 190–245 °C temperature range. Treated specimens exhibited reductions in their oven-dry weight in line with the severity of the treatment, with the effect of increasing the temperature of exposure being greater than extending the period of treatment. Wood polysaccharides were found to be distinctly more labile than the lignin constituent; the latter increased possibly as a result of repolymerisation reactions trapping some degradation products in the process. Specimens shrank in the transversal plane in a tangential to radial ratio of 2:1 regardless of the treatment regime, while their length increased marginally for WL < 10–12%. It is proposed that the thermal modification leaves the cell wall material in a permanent strained state.
US residents make 60 million international trips annually. Family practice providers need to be aware of travel-associated diseases affecting this growing mobile population.
To describe demographics, ...travel characteristics and clinical diagnoses of US residents who present ill after international travel.
Descriptive analysis of travel-associated morbidity and mortality among US travellers seeking care at 1 of the 22 US practices and clinics participating in the GeoSentinel Global Surveillance Network from January 2000 to December 2012.
Of the 9624 ill US travellers included in the analysis, 3656 (38%) were tourist travellers, 2379 (25%) missionary/volunteer/research/aid workers (MVRA), 1580 (16%) travellers visiting friends and relatives (VFRs), 1394 (15%) business travellers and 593 (6%) student travellers. Median (interquartile range) travel duration was 20 days (10-60 days). Pre-travel advice was sought by 45%. Hospitalization was required by 7%. Compared with other groups of travellers, ill MVRA travellers returned from longer trips (median duration 61 days), while VFR travellers disproportionately required higher rates of inpatient care (24%) and less frequently had received pre-travel medical advice (20%). Illnesses of the gastrointestinal tract were the most common (58%), followed by systemic febrile illnesses (18%) and dermatologic disorders (17%). Three deaths were reported. Diagnoses varied according to the purpose of travel and region of exposure.
Returning ill US international travellers present with a broad spectrum of travel-associated diseases. Destination and reason for travel may help primary health care providers to generate an accurate differential diagnosis for the most common disorders and for those that may be life-threatening.
Characterisation, quality assessment and property prediction are several of the major industrial challenges for widespread acceptance of thermally modified wood (TMW). This study shows the potential ...of the multivariate analysis of mid-infrared (MIR) spectral data for the prediction of impact strength, five mechanical parameters in bending, moisture content, weight loss, density and chemical composition of small specimens of thermally modified beech, Norway spruce and Scots pine woods. Anti-swelling efficiency was also studied using DRIFT spectroscopy for spruce wood only. Calibrations were successfully accomplished by partial least-squares regression, with R Y ² and Q CUM ² values >0.96 for 64 out of 67 models. Predictions were also successful, with relative prediction values >0 and RMSEP:SD ratios <1 in most cases. Changes in the MIR spectra of TMW show that bands arising from the lignin environment and new bands appearing due to the degradation of carbohydrates, giving negative loadings, were related to strength loss, while those bands arising from the polysaccharides were associated with property retention. It is concluded that this approach is a powerful tool to characterise a number of properties of TMW with a single after-treatment measurement.
Colour evolution and colour changes were analysed from surface images of small specimens of three thermally-modified timber species using the CIEL*a*b* colour space. Upon heat exposure, the wood ...substance became orange and then approached grey irrespective of species; this was accompanied by a steady reduction in lightness. Colour changes were similar in the three woods at any given level of heat-induced weight loss (WL), whilst changes in the three coordinates of the CIEL*a*b* space in function of WL were different regardless of the wood species. For ΔL*, the profile was curvilinear and monotonous, while Δa* and Δb* bear a complex, non-linear profile. In turn, ΔE* was found to be highly influenced by the behaviour of ΔL*. It is proposed that ΔE* in thermally modified wood originates from chemical changes in the main wood polymers, more so in lignin than in polysaccharides, due to the darkening of the lignin itself. This was associated with the generation of chromophoric groups, mainly the increase in carbonyl groups appearing in the Fourier transform infrared spectra of lignin between 1710 and 1600 cm-1, particularly the emergence of quinone species.
Background. Mexico and Central America are important travel destinations for North American and European travelers. There is limited information on regional differences in travel related morbidity. ...Methods. We describe the morbidity among 4779 ill travelers returned from Mexico and Central America who were evaluated at GeoSentinel network clinics during December 1996 to February 2010. Results. The most frequent presenting syndromes included acute and chronic diarrhea, dermatologic diseases, febrile systemic illness, and respiratory disease. A higher proportion of ill travelers from the United States had acute diarrhea, compared with their Canadian and European counterparts (odds ratio, 1.9; P <.0001). During the 2009 H1N1 influenza outbreak from March 2009 through February 2010, the proportionate morbidity (PM) associated with respiratory illnesses in ill travelers increased among those returned from Mexico, compared with prior years (196.0 cases per 1000 ill returned travelers vs 53.7 cases per 1000 ill returned travelers; P <.0001); the PM remained constant in the rest of Central America (57.3 cases per 1000 ill returned travelers). We identified 50 travelers returned from Mexico and Central America who developed influenza, including infection due to 2009 H1N1 strains and influenza-like illness. The overall risk of malaria was low; only 4 cases of malaria were acquired in Mexico (PM, 2.2 cases per 1000 ill returned travelers) in 13 years, compared with 18 from Honduras (PM, 79.6 cases per 1000 ill returned travelers) and 14 from Guatemala (PM, 34.4 cases per 1000 ill returned travelers) during the same period. Plasmodium vivax malaria was the most frequent malaria diagnosis. Conclusions. Travel medicine practitioners advising and treating travelers visiting these regions should dedicate special attention to vaccine-preventable illnesses and should consider the uncommon occurrence of acute hepatitis A, leptospirosis, neurocysticercosis, acute Chagas disease, onchocerciasis, mucocutaneous leishmaniasis, neurocysticercosis, HIV, malaria, and brucellosis.
In the woodworking industry, image analysis is routinely used for quality control and for matching and classification during various processes. An extension of these automated systems for the ...prediction of physical properties of thermally modified wood (TMW) is enticing, because to date there is no generalised procedure for the quality assurance of TMW. In this work, the feasibility of predicting 13 physical parameters from the analysis of colour changes is demonstrated using small thermally modified specimens of three wood species. Simple linear regression models for anti-swelling efficiency, nominal density, heat-induced weight loss and 10 strength parameters in six forms of stress were all very or highly significant, with R2 statistics for the best predictor from 0.24 to 0.94. ΔE* was found to be a better predictor than ΔL* for most properties. Multiple linear regression with 11 colour variables increased the prediction ability of most models in terms of R2, although these improvements varied with the property and species concerned. The best models altogether were obtained by partial least squares regression, with relative prediction error values >0 in all cases. Our results demonstrate that physical properties of small specimens of TMW can be efficiently predicted with only one after treatment measurement of colour in the CIEL*a*b* colour space by means of image analysis of TMW surfaces. We anticipate that our approach would be a starting point for more refined modelling of physical properties of larger wood members and other properties of interest in TMW (e.g., decay resistance).
Abstract Objective To determine the accuracy of do-not-resuscitate/do-not-intubate (DNR/DNI) orders in representing patient preferences regarding cardiopulmonary resuscitation (CPR) and intubation. ...Patients and Methods We conducted a prospective survey study of patients with documented DNR/DNI code status at an urban academic tertiary care center that serves approximately 250,000 patients per year. From October 1, 2010, to October 1, 2011, research staff enrolled a convenience sample of patients from the inpatient medical service, providing them with a series of emergency scenarios for which they related their treatment preference. We used the Kendall τ rank correlation coefficient to examine correlation between degree of illness reversibility and willingness to be resuscitated. Using bivariate statistical analysis and multivariate logistic regression analysis, we examined predictors of discrepancies between code status and patient preferences. Our main outcome measure was the percentage of patients with DNR/DNI orders wanting CPR and/or intubation in each scenario. We hypothesized that patients with DNR/DNI orders would frequently want CPR and/or intubation. Results We enrolled 100 patients (mean ± SD age, 78±13.7 years). A total of 58% (95% CI, 48%-67%) wanted intubation for angioedema, 28% (95% CI, 20%-3.07%) wanted intubation for severe pneumonia, and 20% (95% CI, 13%-29%) wanted a trial resuscitation for cardiac arrest. The desire for intubation decreased as potential reversibility of the acute disease process decreased (Kendall τ correlation coefficient, 0.45; P <.0002). Conclusion Most patients with DNR/DNI orders want CPR and/or intubation in hypothetical clinical scenarios, directly conflicting with their documented DNR/DNI status. Further research is needed to better understand the discrepancy and limitations of DNR/DNI orders.
Objectives To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates. Study design ...This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network's Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 240/7 to 276/7 weeks' gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation. Results Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/ bronchopulmonary dysplasia (OR 3.27). Conclusions Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities. Trial registration ClinicalTrials.gov : NCT00233324.
Manolio et al. (Am J Epidemiol. 2012;175:859-866) proposed that large cohort studies adopt novel models using "temporary assessment centers" to enroll up to a million participants to answer research ...questions about rare diseases and "harmonize" clinical endpoints collected from administrative records. Extreme selection bias, we are told, will not harm internal validity, and "process expertise to maximize efficiency of high-throughput operations is as important as scientific rigor" (p. 861). In this article, we describe serious deficiencies in this model as applied to the United States. Key points include: 1) the need for more, not less, specification of disease endpoints; 2) the limited utility of data collected from existing administrative and clinical databases; and 3) the value of university-based centers in providing scientific expertise and achieving high recruitment and retention rates through community and healthcare provider engagement. Careful definition of sampling frames and high response rates are crucial to avoid bias and ensure inclusion of important subpopulations, especially the medically underserved. Prospective hypotheses are essential to refine study design, determine sample size, develop pertinent data collection protocols, and achieve alliances with participants and communities. It is premature to reject the strengths of large national cohort studies in favor of a new model for which evidence of efficiency is insufficient.
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