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This study involves an in-depth examination of Canadian elementary teachers’ cognitive processes and metacognitive strategies they used during a self-directed online learning experience. The virtual revisit think aloud, a methodology that combines a retrospective procedure with screen recording technology, was used to capture verbalisations from 13 elementary teachers as they used an online database. Resulting think aloud protocols and post-task interviews were analysed using qualitative methods. An inductive approach to analysis led to six themes related to the types of cognitive processes and metacognitive strategies teachers use during self-directed online learning: connecting to practice, tweaking and adapting, narrowing the focus, skimming through, reading for depth, and source credibility. The teachers in this study demonstrated a non-linear iterative process in which they continuously planned, monitored, and evaluated their learning during the self-directed online learning experience. Implications for teacher learning and research are discussed.

Male fin whales sing by producing 20 Hz pulses in regular patterns of inter-note intervals. While singing, fin whales may also alternate the frequency ranges of their notes. Different song patterns have been observed in different regions of the world's oceans. New song patterns suddenly emerging in an area have been hypothesized to either be indicators of new groups of whales in the area or signs of cultural transmission between groups. Since the status of fin whales around Hawaii is unknown and visual surveys are expensive and difficult to conduct in offshore areas, passive acoustic monitoring has been proposed as a way to monitor these whales. We used passive acoustic recordings from an array of 14 hydrophones to analyze the song patterns of 115 fin whale encounters made up of 50,034 unique notes off Kauai, Hawaii from 2011 to 2017. Fin whale singing patterns were more complicated than previously described. Fin whales off Hawaii sang in five different patterns made of two 20 Hz note types and both singlet and doublet inter-note interval patterns. The inter-note intervals present in their songs were 28/33 s for the lower frequency doublet, 30 s for the lower frequency singlet, 17/24 s for the higher frequency doublet, 17 s for the higher frequency singlet, and 12/20 s for the doublet that alternated between both note types. Some of these song patterns were unique to these fin whales in Hawaiian waters, while others were similar to song patterns recorded from fin whales off the U.S. west coast. Individual fin whales often utilized several different song patterns which suggests that multiple song patterns are not necessarily indicators of different individuals or groups. The dominant song pattern also changed over these years. Cultural transmission may have occurred between fin whales in Hawaiian waters and off the U.S. west coast, which has resulted in similar songs being present at both locations but on lagged timescales. Alternatively, groups occupying the Hawaiian waters could shift over time resulting in different song patterns becoming dominant. This work has implications for the population structure and behavior of Hawaii fin whales.

Suicide is the 10th leading cause of death in the United States and is a significant public health problem. Suicide has also become a major concern among career American firefighters with rates for suicidal ideation and attempts in firefighters two to three times higher than rates in the general population. Firefighter suicide and mental health are major issues facing fire service leaders, mental health professionals, and most recently suicide experts. Despite an increased focus on understanding suicide in the fire service, there is little empirical evidence on the effectiveness of prevention in this population. The juxtaposition of elevated suicide rates with a dearth of empirical prevention data specific to firefighters warrants new approaches and conceptualizations of suicide prevention in this population. Grounded in the framework of the interpersonal-psychological theory of suicide (IPTS), this narrative review integrates select relevant firefighter specific suicide risk/protective factors and multi-level intervention/prevention literature to provide a structured approach to identifying current suicide intervention/prevention efforts with promising transportability to firefighters. Several recommendations for future intervention research specific to firefighters are also proposed.

Since the Global Polio Eradication Initiative (GPEI) was launched in 1988, the number of polio cases worldwide has declined approximately 99.99%; only two countries (Afghanistan and Pakistan) have never interrupted wild poliovirus (WPV) transmission (1). The primary means of detecting poliovirus circulation is through surveillance for acute flaccid paralysis (AFP) among children aged

Tax incentives encourage Canadian families to save for their children’s post-secondary education. In recent years, the federal government has created and enhanced incentives aimed specifically at low- to middle-income families. To access these incentives, families must open a ‘registered education savings plan’ (RESP). Approximately one-quarter of RESPs are invested in group plan RESPs. Group plan providers are regulated by securities laws. Group RESPs have a unique and complicated structure, which generates a high number of consumer complaints, particularly about the high, upfront fees. Group plan providers also have a long history of non-compliance with securities laws, including selling group plans to investors for whom they are not suitable. The combination of high, upfront fees and the lack of suitability is particularly harmful to low-income investors. A bad experience with a group RESP may lead the investor to avoid education savings altogether, thereby undermining the government’s policy goals in establishing incentives for low-income families and, ultimately, affecting the future path that may be taken by the potential beneficiaries of such savings. This article examines government incentives for education savings, the terms of group plans and their history of non-compliance, and puts forward three possible avenues for reform, including decoupling incentives aimed specifically at low- and middle-income families from having to open a RESP.

This journal is © The Royal Society of Chemistry 2019, Fueled by the therapeutic potential of the epigenetic machinery, BET bromodomains have seen high interest as drug targets. Herein, we introduce different linkers to a BET bromodomain benzodiazepine ligand (I-BET762) to gauge its implications in the development of hybrid drugs, imaging probes and small molecule drug conjugates. Biophysical studies confirmed minimal disruption to binding of the BRD4 cavity by the synthesized entities, which includes imaging probes. Target engagement was confirmed in a cellular context, but poor membrane diffusion was found despite efficient localization in the nuclei after membrane disruption. Our study highlights challenges and opportunities for the successful design of benzodiazepine-derived drug-delivery systems., We thank the Hovione Farmaciência (PhD studentship to R. T.) Royal Society (URF\R\180019 to G. J. L. B.), DFG (SI 2117/1-1 to F. S.), FCT Portugal (IF/00624/2015 to G. J. L. B., CEECIND/04518/2017 to P. M. S. D. C. and CEECIND/00887/2017 to T. R., and 02/SAICT/2017, Grant 28333 to T. R.) and the Medical Research Council (MRC grant MR/N010051/1 to P. F.) for funding.

Minke whales were acoustically detected, localized, and tracked on the U.S. Navy's Pacific Missile Range Facility from 2012 to 2017. Animal source levels (SLs) were estimated by adding transmission loss estimates to measured received levels of 42 159 individual minke whale boings. Minke whales off Hawaii exhibited the Lombard effect in that they increased their boing call intensity in increased background noise. Minke whales also decreased the variance of the boing call SL in higher background noise levels. Although the whales partially compensated for increasing background noise, they were unable or unwilling to increase their SLs by the same amount as the background noise. As oceans become louder, this reduction in communication space could negatively impact the health of minke whale populations. The findings in this study also have important implications for acoustic animal density studies, which may use SL to estimate probability of detection.

Aberrant isoform expression of chromatin-associated proteins can induce epigenetic programs related to disease. The MDS1 and EVI1 complex locus (MECOM) encodes PRDM3, a protein with an N-terminal PR-SET domain, as well as a shorter isoform, EVI1, lacking the N-terminus containing the PR-SET domain (ΔPR). Imbalanced expression of MECOM isoforms is observed in multiple malignancies, implicating EVI1 as an oncogene, while PRDM3 has been suggested to function as a tumor suppressor through an unknown mechanism. To elucidate functional characteristics of these N-terminal residues, we compared the protein interactomes of the full-length and ΔPR isoforms of PRDM3 and its closely related paralog, PRDM16. Unlike the ΔPR isoforms, both full-length isoforms exhibited a significantly enriched association with components of the NuRD chromatin remodeling complex, especially RBBP4. Typically, RBBP4 facilitates chromatin association of the NuRD complex by binding to histone H3 tails. We show that RBBP4 binds to the N-terminal amino acid residues of PRDM3 and PRDM16, with a dissociation constant of 3.0 μM, as measured by isothermal titration calorimetry. Furthermore, high-resolution X-ray crystal structures of PRDM3 and PRDM16 N-terminal peptides in complex with RBBP4 revealed binding to RBBP4 within the conserved histone H3-binding groove. These data support a mechanism of isoform-specific interaction of PRDM3 and PRDM16 with the NuRD chromatin remodeling complex.

This article highlights autoethnography as an arts-based methodology in early years research, giving consideration to its challenges and critics as well as the power of its application to elicit voices in a way that other methodologies do not. It embraces and models autoethnography through sharing a performative autoethnographic narrative of one practitioner’s experiences as she grapples with implementing child protection/safeguarding policies, exploring the embodiment of social policy and the consequent dissonance in emotions that lead to a disruption in identity. It asks, ‘What do policy imperatives actually feel like in practice and how might autoethnography, as an arts-based methodology, afford researchers a way to illustrate this?’ Challenging the perception of what it means to be an early years practitioner, through an evocative and provocative narrative, this article foregrounds the need to overcome the historical silencing of practitioner’s voices while illustrating the value of autoethnographic research in helping to reveal the multiple layers of power and dissonance in a pedagogical space such as a nursery. Adopting a critical stance, to avert challenges of solipsism and to further extend the debate around practitioner identity, the performative autoethnographic narrative is later reflected within the wider context of relevant literature. Finally, consideration is given to the question of why autoethnographic research is under-represented in the early years field, particularly at a time when it is prudent to create a wider epistemological base to extend the discourse around what support practitioners need to help them fulfil their vital role in children’s lives.

In 1988, the World Health Assembly launched the Global Polio Eradication Initiative (GPEI) (1). Among the three wild poliovirus (WPV) serotypes, only type 1 (WPV1) has been detected since 2012. Since 2014, detection of WPV1 has been limited to three countries, with 37 cases in 2016 and 11 cases in 2017 as of September 27. The99.99% decline worldwide in polio cases since the launch of the GPEI is attributable to the extensive use of the live, attenuated oral poliovirus vaccine (OPV) in mass vaccination campaigns and comprehensive national routine immunization programs. Despite its well-established safety record, OPV use can be associated with rare emergence of genetically divergent vaccine-derived polioviruses (VDPVs) whose genetic drift from the parental OPV strains indicates prolonged replication or circulation (2). VDPVs can also emerge among persons with primary immunodeficiencies (PIDs). Immunodeficiency-associated VDPVs (iVDPVs) can replicate for years in some persons with PIDs. In addition, circulating vaccine-derived polioviruses (cVDPVs) can emerge very rarely among immunologically normal vaccine recipients and their contacts in areas with inadequate OPV coverage and can cause outbreaks of paralytic polio. This report updates previous summaries regarding VDPVs (3). During January 2016-June 2017, new cVDPV outbreaks were identified, including two in the Democratic Republic of the Congo (DRC) (eight cases), and another in Syria (35 cases), whereas the circulation of cVDPV type 2 (cVDPV2) in Nigeria resulted in cVDPV2 detection linked to a previous emergence. The last confirmed case from the 2015-2016 cVDPV type 1 (cVDPV1) outbreak in Laos occurred in January 2016. Fourteen newly identified persons in 10 countries were found to excrete iVDPVs, and three previously reported patients in the United Kingdom and Iran (3) were still excreting type 2 iVDPV (iVDPV2) during the reporting period. Ambiguous VDPVs (aVDPVs), isolates that cannot be classified definitively, were found among immunocompetent persons and environmental samples in 10 countries. Cessation of all OPV use after certification of polio eradication will eliminate the risk for new VDPV infections.

Bromodomain and extra-terminal (BET) proteins orchestrate a multitude of transcriptional networks through their interactions with acetylated and nonacetylated binding partners. Their association with chromatin dictates important roles in development and cellular homeostasis in normal tissue. However, there is evidence showing their contribution to malignant phenotypes; combined with proof of principle already established for targeting these transcriptional coregulators, there is a strong rationale for the attenuation of their function in cancer. When BET bromodomains are targeted in cells, there are a myriad of responses between and within malignancies. While many of the responses overlap between cancers of varying origins, there are many inconsistencies. Equally, the mechanisms underpinning these downstream events have been uncovered with varying degrees of clarity. Here we highlight those that are common between malignancies, as well as determinants of responses to BET inhibitors. Lastly, there are several limitations to BET inhibitor use, and strategies to circumvent these problems will be discussed.

Background Clostridioides difficile infection (CDI) is one of the most common health care–associated infections. This study assessed the validity of a laboratory-based surveillance method as compared with a traditional, clinical surveillance method to identify hospital-acquired CDIs. Methods Retrospective analysis of positive C difficile laboratory records between April 2015 and March 2017 were compared with a clinical dataset of positive inpatient C difficile cases for all acute care facilities in Alberta, Canada. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using STATA/IC 13.0. Results The laboratory surveillance method had a sensitivity of 96.6% (95% confidence interval [CI], 95.7%-97.3%) and a specificity of 65.7% (95% CI, 63.6%-67.8%); positive predictive value and negative predictive value were 74.3% (95% CI, 73.2%-75.5%) and 94.9% (95% CI, 93.7%-95.9%), respectively. Discussion To date, the breadth of research on alternate CDI surveillance systems has focused on the use of International Statistical Classification of Diseases and Related Health Problems 9th and 10th Revision coding mechanisms. Our results expand on the published literature, as a laboratory approach may provide more timely information, with a smaller amount of misclassified cases. Conclusions Using a laboratory surveillance method to capture hospital-acquired CDI cases is highly sensitive but not overly specific. Changes to improve the specificity of this method are provided.

BACKGROUND: Acute flaccid myelitis (AFM) is a neurologic condition characterized by flaccid limb weakness. After a large number of reports of AFM in 2014, the Centers for Disease Control and Prevention began standardized surveillance in the United States to characterize the disease burden and explore potential etiologies and epidemiologic associations. METHODS: Persons meeting the clinical case criteria of acute flaccid limb weakness from January 1, 2015, through December 31, 2017, were classified as confirmed (spinal cord gray matter lesions on MRI) or probable (white blood cell count >5 cells per mm3 in cerebrospinal fluid [CSF]). We describe clinical, radiologic, laboratory, and epidemiologic findings of pediatric patients (age ≤21 years) confirmed with AFM. RESULTS: Of 305 children reported from 43 states, 193 were confirmed and 25 were probable. Of confirmed patients, 61% were male, with a median age of 6 years (range: 3 months to 21 years; interquartile range: 3 to 10 years). An antecedent respiratory or febrile illness was reported in 79% with a median of 5 days (interquartile range: 2 to 7 days) before limb weakness. Among 153 sterile-site specimens (CSF and serum) submitted to the Centers for Disease Control and Prevention, coxsackievirus A16 was detected in CSF and serum of one case patient and enterovirus D68 was detected in serum of another. Of 167 nonsterile site (respiratory and stool) specimens, 28% tested positive for enterovirus or rhinovirus. CONCLUSIONS: AFM surveillance data suggest a viral etiology, including enteroviruses. Further study is ongoing to better characterize the etiology, pathogenesis, and risk factors of this rare condition.

Chikungunya, a mosquito-borne viral, acute febrile illness (AFI) is associated with polyarthralgia and polyarthritis. Differentiation from other AFI is difficult due to the non-specific presentation and limited availability of diagnostics. This 3-year study identified independent clinical predictors by day post-illness onset (DPO) at presentation and age-group that distinguish chikungunya cases from two groups: other AFI and dengue. Specimens collected from participants with fever ≤7 days were tested for chikungunya, dengue viruses 1–4, and 20 other pathogens. Of 8,996 participants, 18.2% had chikungunya, and 10.8% had dengue. Chikungunya cases were more likely than other groups to be older, report a chronic condition, and present, Author summary Chikungunya is an acute febrile illness (AFI), caused by the chikungunya virus (CHIKV), that is transmitted by mosquitoes. Patients with chikungunya exhibit joint, muscle, or bone pain, and may also have skin rash, red eyes (conjunctiva), and red swollen joints (arthritis). Up to 20% of cases develop long lasting arthritis, fatigue or psychiatric conditions. We used data from our prospective study to identify signs and symptoms that predict chikungunya. We enrolled 8,996 AFI patients and tested for CHIKV, dengue viruses 1–4 (DENV 1–4), and other pathogens. A pathogen was detected in 55% of participants; 18.2% had CHIKV and 10.8% had DENV 1–4 infections. This study compared the clinical presentation of chikungunya with that of all other AFI and dengue alone. Regardless of timing of presentation, significant predictors of chikungunya were joint pain, muscle, bone or back pain, and red conjunctiva when compared to other AFI, and arthritis, joint pain, skin rash, any bleeding, and irritability, when dengue was the comparator group. Chikungunya patients were less likely than AFI and dengue patients to have low platelets, signs of poor circulation, diarrhea, headache, and cough. By enrolling febrile patients at presentation, we identified unbiased predictors of chikungunya. These findings can assist physicians to clinically diagnose chikungunya and initiate proper patient management.

Neurofibromatosis Type 1 (NF1) is an autosomal dominant genetic disorder with an incidence of approximately 1 in 4,000 live births [1]. Pulmonary arterial hypertension (PAH) is a rare but extremely life-threatening complication associated with NF1. Timely recognition of this unusual and severe association between NF1 and PAH is imperative in prolonging the survival in this specific patient population. We present the clinical outcomes of a 47-year old female previously diagnosed with NF1, who presented with progressively worsening dyspnea. Keywords: NF1, PAH, PH

BACKGROUNDHip and knee arthroplasty infections are associated with considerable healthcare costs. The merits of reducing the postoperative surveillance period from 1 year to 90 days have been debated.OBJECTIVESTo report the first pan-Canadian hip and knee periprosthetic joint infection (PJI) rates and to describe the implications of a shorter (90-day) postoperative surveillance period.METHODSProspective surveillance for infection following hip and knee arthroplasty was conducted by hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) using standard surveillance definitions.RESULTSOverall hip and knee PJI rates were 1.64 and 1.52 per 100 procedures, respectively. Deep incisional and organ-space hip and knee PJI rates were 0.96 and 0.71, respectively. In total, 93% of hip PJIs and 92% of knee PJIs were identified within 90 days, with a median time to detection of 21 days. However, 11%–16% of deep incisional and organ-space infections were not detected within 90 days. This rate was reduced to 3%–4% at 180 days post procedure. Anaerobic and polymicrobial infections had the shortest median time from procedure to detection (17 and 18 days, respectively) compared with infections due to other microorganisms, including Staphylococcus aureus.CONCLUSIONSPJI rates were similar to those reported elsewhere, although differences in national surveillance systems limit direct comparisons. Our results suggest that a postoperative surveillance period of 90 days will detect the majority of PJIs; however, up to 16% of deep incisional and organ-space infections may be missed. Extending the surveillance period to 180 days could allow for a better estimate of disease burden.Infect Control Hosp Epidemiol 2017;38:147–153

OBJECTIVETo evaluate hospital administrative data to identify potential surgical site infections (SSIs) following primary elective total hip or knee arthroplasty.DESIGNRetrospective cohort study.SETTINGAll acute care facilities in Alberta, Canada.METHODSDiagnosis and procedure codes for 6 months following total hip or knee arthroplasty were used to identify potential SSI cases. Medical charts of patients with potential SSIs were reviewed by an infection control professional at the acute care facility where the patient was identified with a diagnosis or procedure code. For SSI decision, infection control professionals used the National Healthcare Safety Network SSI definition. The performance of traditional surveillance methods and administrative data–triggered medical chart review was assessed.RESULTSOf the 162 patients identified by diagnosis or procedure code, 46 (28%) were confirmed as an SSI by an infection control professional. More SSIs were identified following total hip vs total knee arthroplasty (42% vs16%). Of 46 confirmed SSI cases, 20 (43%) were identified at an acute care facility different than their procedure facility. Administrative data–triggered medical chart review with infection control professional confirmation resulted in a 1.1- to 1.7-fold increase in SSI rate compared with traditional surveillance. SSIs identified by administrative data resulted in sensitivity of 90% and specificity of 99%.CONCLUSIONMedical chart review for cases identified through administrative data is an efficient supplemental SSI surveillance strategy. It improves case-finding by increasing SSI identification and making identification consistent across facilities, and in a provincial surveillance network it identifies SSIs presenting at nonprocedure facilities.Infect Control Hosp Epidemiol 2016;37:699–703

SUMMARYPatients with methicillin-resistant Staphylococcus aureus (MRSA) clones, which were traditionally seen in the community setting (USA400/CMRSA7 and USA300/CMRSA10), are often identified as hospital-acquired (HA) infections using Infection Prevention and Control (IPC) surveillance definitions. This study examined the demographics and healthcare risk factors of patients with HA-MRSA to help understand if community MRSA clones are from a source internal or external to the hospital setting. Despite USA300/CMRSA10 being the predominant clone in Alberta, hospital clones (USA100/CMRSA2) still dominated in the acute care setting. In the Alberta hospitalized population, patients with USA400/CMRSA7 and USA300/CMRSA10 clones were significantly younger, had fewer comorbidities, and a greater proportion had none or ambulatory care-only healthcare exposure. These findings suggest that there are two distinct populations of HA-MRSA patients, and the patients with USA400/CMRSA7 and USA300/CMRSA10 clones identified in hospital more greatly resemble patients affected by those clones in the community. It is possible that epidemiological assessment overidentifies HA acquisition of MRSA in patients unscreened for MRSA on admission to acute care.

Purpose: A proposed mechanism for the enhanced effectiveness of hyperthermia and doxorubicin (Dox) combinations is increased intracellular Dox concentrations resulting from heat-induced cell stress. The purpose of this study was to determine whether specific varied Dox and heat combinations produce measurable effects greater than the additive combination, and whether these effects can be attributed to heat-induced increases in intracellular Dox concentrations. Methods: HCT116, HT29 and CT26 cells were exposed to Dox and water bath heating independently. A clonogenic survival assay was used to determine cell killing and intracellular Dox concentrations were measured in HCT116 cells with mass spectrometry. Cells were exposed to heating at 42 °C (60 min) and 0.5 µg/ml of Dox at varying intervals. Synergy was determined by curve-fitting and isobologram analysis. Results: All cell lines displayed synergistic effects of combined heating and Dox. A maximum synergistic effect was achieved with simultaneous cell exposure to Dox and heat. For exposures at 42 °C, the synergistic effect was most pronounced at Dox concentrations Conclusions: Simultaneous exposure of HCT116 cells to heating and Dox is more effective than sequential exposure. Heat-induced cell responses are accompanied by increased intracellular Dox concentrations; however, clonogenic survival data do not support this as the cause for synergistic cytotoxicity.

Since the World Health Assembly's 1988 resolution to eradicate poliomyelitis, one of the main tools of the World Health Organization (WHO) Global Polio Eradication Initiative (GPEI) has been the live, attenuated oral poliovirus vaccine (OPV). OPV might require several doses to induce immunity but provides long-term protection against paralytic disease. Through effective use of OPV, GPEI has brought polio to the threshold of eradication. Wild poliovirus type 2 (WPV2) was eliminated in 1999, WPV3 has not been detected since November 2012, and WPV1 circulation appears to be restricted to parts of Pakistan and Afghanistan. However, continued use of OPV carries two key risks. The first, vaccine-associated paralytic poliomyelitis (VAPP) has been recognized since the early 1960s. VAPP is a very rare event that occurs sporadically when an administered dose of OPV reverts to neurovirulence and causes paralysis in the vaccine recipient or a nonimmune contact. VAPP can occur among immunologically normal vaccine recipients and their contacts as well as among persons who have primary immunodeficiencies (PIDs) manifested by defects in antibody production; it is not associated with outbreaks. The second, the emergence of genetically divergent, neurovirulent vaccine-derived polioviruses (VDPVs) was recognized more recently. Circulating VDPVs (cVDPVs) resemble WPVs and, in areas with low OPV coverage, can cause polio outbreaks. Immunodeficiency-associated VDPVs (iVDPVs) can replicate and be excreted for years in some persons with PIDs; GPEI maintains a registry of iVDPV cases. Ambiguous VDPVs (aVDPVs) are isolates that cannot be classified definitively. This report updates previous surveillance summaries and describes VDPVs detected worldwide during January 2014-March 2015. Those include new cVDPV outbreaks in Madagascar and South Sudan, and sharply reduced type 2 cVDPV (cVDPV2) circulation in Nigeria and Pakistan during the latter half of 2014. Eight newly identified persons in six countries were found to excrete iVDPVs, and a patient in the United Kingdom was still excreting iVDPV2 in 2014 after more than 28 years. Ambiguous VDPVs were found among immunocompetent persons and environmental samples in 16 countries. Because the large majority of VDPV case-isolates are type 2, WHO has developed a plan for coordinated worldwide withdrawal of trivalent (types 1, 2, and 3) OPV (tOPV) and replacement with bivalent (types 1 and 3) OPV (bOPV) in April 2016, preceded by introduction of at least 1 dose of injectable inactivated poliovirus vaccine (IPV) into routine immunization schedules worldwide to maintain immunity to type 2 viruses.

ObjectiveNearly 800,000 primary hip and knee arthroplasty procedures are performed annually in North America. Approximately 1% of these are complicated by a complex surgical site infection (SSI), leading to very high healthcare costs. However, population-based studies to properly estimate the economic burden are lacking. We aimed to address this knowledge gap.DesignEconomic burden study.MethodsUsing administrative health and clinical databases, we created a cohort of all patients in Alberta, Canada, who received a primary hip or knee arthroplasty between April 1, 2012, and March 31, 2015. All patients who developed a complex SSI postoperatively were identified through a provincial infection prevention and control database. A combination of corporate microcosting data and gross costing methods were used to determine total mean 12- and 24-month costs, enabling comparison of costs between the infected and noninfected patients.ResultsMean 12-month total costs were significantly greater in patients who developed a complex SSI compared to those who did not (CAD$95,321 [US$68,150] vs CAD$19,893 [US$14,223];P< .001). The magnitude of the cost difference persisted even after controlling for underlying patient factors. The most commonly identified causative pathogen (38%) wasStaphylococcus aureus(95% MSSA).ConclusionsComplex SSIs following hip and knee arthroplasty lead to high healthcare costs, which are expected to rise as the yearly number of surgeries increases. Using our costing estimates, the cost-effectiveness of different strategies to prevent SSIs should be investigated.

We followed the dynamics of capsid amino acid replacement among 403 Nigerian outbreak isolates of type 2 circulating vaccine-derived poliovirus (cVDPV2) from 2005 through 2011. Four different functional domains were analyzed: (i) neutralizing antigenic (NAg) sites, (ii) residues binding the poliovirus receptor (PVR), (iii) VP1 residues 1 to 32, and (iv) the capsid structural core. Amino acid replacements mapped to 37 of 43 positions across all 4 NAg sites; the most variable and polymorphic residues were in NAg sites 2 and 3b. The most divergent of the 120 NAg variants had no more than 5 replacements in all NAg sites and were still neutralized at titers similar to those of Sabin 2. PVR-binding residues were less variable (25 different variants; 0 to 2 replacements per isolate; 30/44 invariant positions), with the most variable residues also forming parts of NAg sites 2 and 3a. Residues 1 to 32 of VP1 were highly variable (133 different variants; 0 to 6 replacements per isolate; 5/32 invariant positions), with residues 1 to 18 predicted to form a well-conserved amphipathic helix. Replacement events were dated by mapping them onto the branches of time-scaled phylogenies. Rates of amino acid replacement varied widely across positions and followed no simple substitution model. Replacements in the structural core were the most conservative and were fixed at an overall rate ∼20-fold lower than the rates for the NAg sites and VP1 1 to 32 and ∼5-fold lower than the rate for the PVR-binding sites. Only VP1 143-Ile, a non-NAg site surface residue and known attenuation site, appeared to be under strong negative selection. IMPORTANCE The high rate of poliovirus evolution is offset by strong selection against amino acid replacement at most positions of the capsid. Consequently, poliovirus vaccines developed from strains isolated decades ago have been used worldwide to bring wild polioviruses almost to extinction. The apparent antigenic stability of poliovirus obscures a dynamic of continuous change within the neutralizing antigenic (NAg) sites. During 7 years of a large outbreak in Nigeria, the circulating type 2 vaccine-derived polioviruses generated 120 different NAg site variants via multiple independent pathways. Nonetheless, overall antigenic evolution was constrained, as no isolate had fixed more than 5 amino acid differences from the Sabin 2 NAg sites, and the most divergent isolates were efficiently neutralized by human immune sera. Evolution elsewhere in the capsid was also constrained. Amino acids binding the poliovirus receptor were strongly conserved, and extensive variation in the VP1 amino terminus still conserved a predicted amphipathic helix.

Since 2002, passive acoustic monitoring at the Pacific Missile Range Facility off Kauai, HI has yielded minimum density estimates and disturbance analyses for various whale species, but the ability to do so for sperm whales (Physeter macrocephalus) has been limited. Such efforts have traditionally suffered from false positives and decreased localization accuracy with increased click density. Recent software developments have aimed to address these issues and attempts were made to quantitatively and qualitatively assess improvement using archived 2014 data (n = 1063 hours of recording). Algorithm changes generated 2.4 times more detections (SD = 3.9x) and 1.4 times more localizations (SD = 2.4x) on average. Metrics indicating localization accuracy also improved. The number of detections per localization increased from a median of 5.5 (IQR = 5.2–5.8) to 7.0 (IQR = 6.0–8.3) and the percent of localizations theoretically capable of being tracked increased from 5.9% (IQR = 1.4%–11.6%) to 31.2% (IQR = 8.0%–46.9%). Visual comparison of localizations indicates much lower false positive rates, while other software developments have enabled tracking slow clickers and identifying foraging groups. Ultimately, track-level analyses should permit a more stable metric for minimum density estimates and disturbance tests and help establish baseline kinematics and behavior.Since 2002, passive acoustic monitoring at the Pacific Missile Range Facility off Kauai, HI has yielded minimum density estimates and disturbance analyses for various whale species, but the ability to do so for sperm whales (Physeter macrocephalus) has been limited. Such efforts have traditionally suffered from false positives and decreased localization accuracy with increased click density. Recent software developments have aimed to address these issues and attempts were made to quantitatively and qualitatively assess improvement using archived 2014 data (n = 1063 hours of recording). Algorithm changes generated 2.4 times more detections (SD = 3.9x) and 1.4 times more localizations (SD = 2.4x) on average. Metrics indicating localization accuracy also improved. The number of detections per localization increased from a median of 5.5 (IQR = 5.2–5.8) to 7.0 (IQR = 6.0–8.3) and the percent of localizations theoretically capable of being tracked increased from 5.9% (IQR = 1.4%–11.6%) to 31.2% (IQR = 8.0%–46.9...

Background Nocardia species are thin, aerobic, filamentous, gram-positive bacilli that are ubiquitous in soil worldwide. Nocardia infections are divided into three main categories: pulmonary nocardiosis, disseminated nocardiosis, and cutaneous nocardiosis. Methods We present a case of cerebral nocardiosis in an immunocompetent patient caused by Nocardia beijingensis (NB). Results A 60-year-old Caucasian lady from Florida with type 2 diabetes mellitus, hypertension, hyperlipidemia, presented to the emergency room with complaints of altered mentation. Per husband, she was having episodes of emesis and diarrhea 3 days prior to admission that resolved however, her mentation significantly deteriorated to where she was unable to perform simple chores around the house. Pertinently she had resection of lung mass 2 months prior to admission which found to be benign. Vital sign at admission was stable and on examination, the patient was alert and oriented, however, lethargic appearing. Neurological examination was pertinent for expressive aphasia; however, cranial nerves II-XII were grossly intact. The patient was also found to have a 3 cm by 4 cm, tender, cystic lesion on the left-sided occipital scalp. The remainder of the physical examination was unremarkable. Admission laboratories were remarkable for leukocytosis and hyperglycemia. MRI of the brain was completed that showed multiple areas of vasogenic edema and multiple nodules with the largest being 1.8 cm suggestive of abscesses. She was started empirically on vancomycin, ceftriaxone, metronidazole, and ampicillin. Cerebral spinal fluid showed neutrophilic pleocytosis, low glucose, and high protein. Initial cultures including CSF were negative. Left-sided occipital scalp lesion was excised and sent for pathology and culture. Initial cultures showed gram-positive bacilli, so antibiotics were de-escalated to sulfamethoxazole/trimethoprim and ceftriaxone. Repeat imaging showed improving abscess, and final cultures resulted in NB. Conclusion NB is believed to have originated in Southeast Asia. NB has been associated mainly with infections in immunocompromised. In the United States, the two only other cases of NB described in immunocompetent hosts were interestingly from Florida as well. Disclosures All authors: No reported disclosures.

Tonal vocalizations or whistles produced by many species of delphinids range from simple tones to complex frequency contours. Whistle structure varies in duration, frequency, and composition between delphinid species, as well as between populations and individuals. Categorization of whistles may be improved by decomposition of complex calls into simpler subunits, much like the use of phonemes in classification of human speech. We identify a potential whistle decomposition scheme and normalization process to facilitate comparison of whistle subunits derived from tonal vocalizations of bottlenose dolphins (Tursiops truncatus), spinner dolphins (Stenella longirostris), and short-beaked common dolphins (Delphinus delphis). Network analysis is then used to compare subunits within the vocal corpus of each species. By processing whistles through a series of steps including segmentation, normalization, and dynamic time warping, we are able to automatically cluster selected subunits by shape, regardless of differences in absolute frequency or moderate differences in duration. Using the clustered subunits, we demonstrate a preliminary species classification scheme based on rates of subunit occurrence in vocal repertoires. This provides a potential mechanism for comparing the structure of complex vocalizations within and between species.

This article examines the role played by the ‘public interest directors' appointed to the Irish credit institutions in the wake of the Irish Government's blanket deposit guarantee in 2008. Based on private interviews, it explores their experiences in interpreting the term ‘public interest’ and fulfilling their perceived responsibilities. Their experiences are also examined through the prism of the public interest scholarship in order to confirm or debunk existing hypotheses as to their likely reception and effectiveness. The article also analyses the nature of the duty imposed on all directors pursuant to section 48 of the Credit Institutions (Stabilisation) Act 2010 to have regard to a wide range of public interest factors in the performance of their functions. A unique feature of this duty and by contrast to section 172 of the UK Companies Act 2006, it is expressly stated to take priority over any other duty of the directors to the extent of any inconsistency. As the Irish experience demonstrate...

Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The χ, Fisher's exact, and Cochran-Mantel-Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association-supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.

I want to bring an error in a recent article to your attention. I was reading the article Potentially Dangerous Patients: A Review of the Duty to Warn by Elizabeth Henderson, and a major error jumped out at me. The article states that Texas recognizes “...Tarasoff as a legitimate piece of legislation, allowing but not mandating named professionals to warn potential victims.” This statement is completely false. Some of the other states mentioned are not exactly as portrayed either, but I ammost familiar with Texas because I am a licensed psychologist here and teach the doctoral classes in ethics at Southern Methodist University. In Thapar v Zezulka (1999), the Supreme Court of Texas found that there is no duty to warn and that mental health professionals cannot warn a potential victim. The Texas Supreme Court found that mental health professionals may contact the police or other health experts in cases of dangerousness but that our statutes (611.004) are permissive, not required reporting, and as such, it is possible that a civil case could be brought against a health practitioner for breaking confidentiality even when reportidentified specific professional groups as having an obligation to warn others. According the National Conference of State Legislatures, New Mexico does have a law regarding the duty to warn, but the specifics of this law are unclear. Finally, Oklahoma’s Title 59 § 1376, enacted in 2004, requires reporting of imminent threat but is more restrictive when permitted to breach patient confidentiality. Because of the legal implications and potential for physical harm to individuals that may result from using erroneous and/ or out-of-date information, having correct data regarding duty to warn is paramount.—Deanna Settelmeyer, MSN, RN, CEN, Doctor of Nursing Practice Candidate, University of Virginia, North Garden, VA; E-mail: drs5eq@virginia.edu

The purpose of this study is to review our experience with platinum fiducials in terms of feasibility of placement and detectability by both MRI and orthogonal x-ray images used in robotic SABR.Materials and Methods: 29 consecutive SABR patients (30 tumors) treated using fiducial tracking between January 2011 and February 2012 were reviewed. A total of 108 fiducials implanted in or around various tumor sites were identified. The pixel value contrast (PVC) of fiducials seen on MRI mages and treatment unit x-ray images of patients and phantoms were analysed.Migration rates were similar for PS versus GS and GC (6.2%). No difference was noted between the mean PVC in cirrhotic versus non-cirrhotic liver (60.4 vs. 47.9; p = 0.074). MRI sequences for tumors in the liver and other organs revealed a mean PVC for platinum superior to that of gold (p0.001). No PVC difference was seen between gold and platinum on analysis of the treatment unit x-rays.Platinum seeds provide a superior detectability in comparison to gold seeds or coils on MRI images and are detected equally well by an image guidance system using orthogonal x-rays, making them a better choice for fiducial-based CT-MRI registration.