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Background: Despite focused initiatives to reduce device-associated infection among hospitalised patients, the practices US hospitals are currently using are unknown. We thus used a national survey to ascertain the use of several established and novel practices to prevent device-associated infections., Methods: We mailed surveys to infection preventionists in a random sample of nearly 900 US acute care hospitals in 2017. Our survey asked about the use of practices to prevent three common device-associated infections: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). Using sample weights, we estimated the percentage of hospitals reporting regular use of each practice. We also conducted multivariable regression to determine associations between selected hospital characteristics (eg, perceived support from leadership) and use of CAUTI, CLABSI and VAP prevention practices., Results: The response rate was 59%. Several practices are reportedly used in over 90% of US hospitals: aseptic technique during indwelling urethral catheter insertion and maintenance (to prevent CAUTI); maximum sterile barrier precautions during central catheter insertion and alcohol-containing chlorhexidine gluconate for insertion site antisepsis (to prevent CLABSI); and semirecumbent positioning of the patient (to prevent VAP). Antimicrobial devices are used in the minority of hospitals for these three device-associated infections., Conclusions: We provide an updated snapshot of the practices US hospitals are currently using to prevent device-associated infections. Compared with previous studies using a similar design and questions, we found that the use of recommended practices increased in US hospitals, especially for CAUTI prevention., Competing Interests: Competing interests: SS reports receiving honoraria for lectures and teaching related to the prevention of hospital-acquired infection and serving on the medical advisory boards for Doximity (a social networking site for physicians) and Jvion (a health care technology company). JM reports receiving honoraria for lectures and teaching related to prevention and value-based policies involving catheter-associated urinary tract infection and hospital-acquired pressure ulcers. SS and JM hold a provisional US patent on a technology to improve aseptic placement of urinary catheters, which was not part of this study., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: In preparation for a multisite antibiotic stewardship intervention, we assessed knowledge and attitudes toward management of asymptomatic bacteriuria (ASB) plus teamwork and safety climate among providers, nurses, and clinical nurse assistants (CNAs)., Design: Prospective surveys during January-June 2018., Setting: All acute and long-term care units of 4 Veterans' Affairs facilities., Methods: The survey instrument included 2 previously tested subcomponents: the Kicking CAUTI survey (ASB knowledge and attitudes) and the Safety Attitudes Questionnaire (SAQ)., Results: A total of 534 surveys were completed, with an overall response rate of 65%. Cognitive biases impacting management of ASB were identified. For example, providers presented with a case scenario of an asymptomatic patient with a positive urine culture were more likely to give antibiotics if the organism was resistant to antibiotics. Additionally, more than 80% of both nurses and CNAs indicated that foul smell is an appropriate indication for a urine culture. We found significant interprofessional differences in teamwork and safety climate (defined as attitudes about issues relevant to patient safety), with CNAs having highest scores and resident physicians having the lowest scores on self-reported perceptions of teamwork and safety climates (P < .001). Among providers, higher safety-climate scores were significantly associated with appropriate risk perceptions related to ASB, whereas social norms concerning ASB management were correlated with higher teamwork climate ratings., Conclusions: Our survey revealed substantial misunderstanding regarding management of ASB among providers, nurses, and CNAs. Educating and empowering these professionals to discourage unnecessary urine culturing and inappropriate antibiotic use will be key components of antibiotic stewardship efforts.

Single nucleotide polymorphisms (SNPs) in TLR genes may serve as a crucial marker for early susceptibility of various cancers including cervical cancer. The present study was therefore designed to ascertain the role of TLR4 and TLR9 SNPs and haplotypes to hrHPV infection and cervical cancer susceptibility. The study included 110 cervical cancer biopsies and 141 cervical smears from age-matched healthy controls of Gujarati ethnicity of Western India. hrHPV 16 and 18 were detected using Real-time PCR. Eight SNPs, four each in TLR4 and TLR9 were analyzed using Polymerase Chain Reaction-Restriction Fragment Length Polymorphism and Allele-Specific PCR. HPV 16 and 18 were detected in 68% cervical cancer cases. TLR4 rs4986790, rs1927911 and TLR9 rs187084 showed association with HPV 16/18 infection. CC and CT genotypes of TLR4 rs11536889 and rs1927911 respectively, and TC, CC genotypes of TLR9 rs187084, as well as minor alleles of TLR4 rs4986790 and TLR9 rs187084, were associated with the increased risk of cervical cancer. Stage-wise analysis revealed TLR9 rs187084 and rs352140 to be associated with early-stage cancer. TLR4 haplotype GTAC and TLR9 haplotype GATC were associated with the increased risk of cervical cancer while TLR4 haplotype GCAG was associated with the decreased risk. TLR4 haplotype GCAG and TLR9 haplotype GATC showed association with increased susceptibility to hrHPV infection. In conclusion, the present study revealed association of TLR4 and TLR9 polymorphisms and haplotypes with hrHPV infection and cervical cancer risk. Further evaluation of a larger sample size covering diverse ethnic populations globally is warranted.

Background: Autologous bone grafts remain the gold standard for craniofacial reconstruction despite limitations of donor-site availability and morbidity. A myriad of commercial bone substitutes and allografts are available, yet no product has gained widespread use because of inferior clinical outcomes. The ideal bone substitute is both osteoconductive and osteoinductive. Craniofacial reconstruction often involves irregular three-dimensional defects, which may benefit from malleable or customizable substrates. "Hyperelastic Bone" is a three-dimensionally printed synthetic scaffold, composed of 90% by weight hydroxyapatite and 10% by weight poly(lactic-co-glycolic acid), with inherent bioactivity and porosity to allow for tissue integration. This study examines the capacity of Hyperelastic Bone for bone regeneration in a critical-size calvarial defect., Methods: Eight-millimeter calvarial defects in adult male Sprague-Dawley rats were treated with three-dimensionally printed Hyperelastic Bone, three-dimensionally printed Fluffy-poly(lactic-co-glycolic acid) without hydroxyapatite, autologous bone (positive control), or left untreated (negative control). Animals were euthanized at 8 or 12 weeks postoperatively and specimens were analyzed for new bone formation by cone beam computed tomography, micro-computed tomography, and histology., Results: The mineralized bone volume-to-total tissue volume fractions for the Hyperelastic Bone cohort at 8 and 12 weeks were 74.2 percent and 64.5 percent of positive control bone volume/total tissue, respectively (p = 0.04). Fluffy-poly(lactic-co-glycolic acid) demonstrated little bone formation, similar to the negative control. Histologic analysis of Hyperelastic Bone scaffolds revealed fibrous tissue at 8 weeks, and new bone formation surrounding the scaffold struts by 12 weeks., Conclusion: Findings from our study suggest that Hyperelastic Bone grafts are effective for bone regeneration, with significant potential for clinical translation.

The rapid heating of a thin titanium foil by a high intensity, subpicosecond laser is studied by using a 2D narrow-band x-ray imaging and x-ray spectroscopy. A novel monochromatic imaging diagnostic tuned to 4.51 keV Ti Kα was used to successfully visualize a significantly ionized area (⟨Z⟩>17±1) of the solid density plasma to be within a ∼35  μm diameter spot in the transverse direction and 2  μm in depth. The measurements and a 2D collisional particle-in-cell simulation reveal that, in the fast isochoric heating of solid foil by an intense laser light, such a high ionization state in solid titanium is achieved by thermal diffusion from the hot preplasma in a few picoseconds after the pulse ends. The shift of Kα and formation of a missing Kα cannot be explained with the present atomic physics model. The measured Kα image is reproduced only when a phenomenological model for the Kα shift with a threshold ionization of ⟨Z⟩=17 is included. This work reveals how the ionization state and electron temperature of the isochorically heated nonequilibrium plasma are independently increased.

Background: Urinary tract-related bloodstream infection (BSI) is associated with substantial morbidity, mortality, and financial costs. We examined the role of red blood cell (RBC) transfusions on developing this condition among US Veterans., Methods: We conducted a matched case-control study among adult inpatients admitted to 4 Veterans Affairs hospitals. Cases were patients with a positive urine culture result obtained 48hours or longer after admission and a blood culture obtained within 14days of the urine culture, which grew the same organism. Controls included patients with a positive urine culture result who were at risk for but did not develop BSI (control group 1) and patients without a positive urine culture result who were present in the facility at the time of case diagnosis (control group 2)., Results: Compared with the findings in control group 1, receipt of RBCs was not significantly associated with urinary tract-related BSI (odds ratio, 1.03; 95% confidence interval, 1.00-1.07; P = .07). However, we found increased odds of urinary tract-related BSI compared with the results in patients without infection (control group 2) (odds ratio, 1.11; 95% confidence interval, 1.06-1.17; P < .001)., Conclusions: Given the heightened risk of urinary tract-related BSI associated with receiving a greater number of RBC transfusions, adhering to recommendations to transfuse the minimum amount of blood products necessary may minimize the risk of this infection among Veterans., (Copyright © 2018. Published by Elsevier Inc.)

Intraoperative photography has the potential to raise costs and introduce possible contamination but is essential for documentation in plastic surgery. The authors evaluate their use of a waterproof camera immersed in povidone-iodine for taking intraoperative photographs in an efficient manner. A waterproof camera is immersed in povidone-iodine during surgery and photographs are taken as needed by the operating surgeon or assistant without a change of gloves. A retrospective chart review was performed, evaluating serious infections and the number of photographs taken per procedure in the years before and after the camera was used. Bacterial cultures were taken of three areas of the camera on 10 consecutive operating days and evaluated for growth. The number of serious infections did not change after the camera protocol was implemented. The mean number of photographs taken per case increased significantly with the use of this camera. All cultures of the camera were negative. The use of a waterproof camera immersed in povidone-iodine allows efficient and improved intraoperative photographic documentation by the surgeon. It does not appear to increase the risk of infection or introduce contamination.

Immunosuppression proved as a captivating therapy in several autoimmune disorders, asthma as well as in organ transplantation. Immunosuppressive peptides are specific for reducing efficacy of immune system with wide range of therapeutic implementations. `ImmunoSPdb' is a comprehensive, manually curated database of around 500 experimentally verified immunosuppressive peptides compiled from 79 research article and 32 patents. The current version comprises of 553 entries providing extensive information including peptide name, sequence, chirality, chemical modification, origin, nature of peptide, its target as well as mechanism of action, amino acid frequency and composition, etc. Data analysis revealed that most of the immunosuppressive peptides are linear (91%), are shorter in length i.e. up to 20 amino acids (62%) and have L form of amino acids (81%). About 30% peptide are either chemically modified or have end terminal modification. Most of the peptides either are derived from proteins (41%) or naturally (27%) exist. Blockage of potassium ion channel (24%) is one a major target for immunosuppressive peptides. In addition, we have annotated tertiary structure by using PEPstrMOD and I-TASSER. Many user-friendly, web-based tools have been integrated to facilitate searching, browsing and analyzing the data. We have developed a user-friendly responsive website to assist a wide range of users.

Importance: The extent of cognitive deterioration after schizophrenia (SZ) onset is poorly understood because prior longitudinal studies used small samples of older individuals with established illness., Objective: To examine the association of age at onset and subsequent longitudinal course of prefrontal activity during the first 2 years of illness in youths with SZ and healthy control participants (HCs)., Design, Setting, and Participants: This naturalistic, longitudinal, functional magnetic resonance imaging (fMRI) study included patients with recent-onset SZ and HCs aged 12 to 25 years enrolled in an ongoing study of cognition in recent-onset psychosis in the Sacramento, California, area from October 13, 2004, through June 25, 2013. Participants completed clinical assessments and an established measure of cognitive control, the AX Continuous Performance Task (AX-CPT), during fMRI at baseline and at 6-, 12-, and 24-month follow-up. Whole-brain, voxelwise, and an a priori dorsolateral prefrontal cortex (DLPFC) region of interest analyses were performed. Group differences in developmental trajectories were examined by focusing on behavioral performance (d'-context) and cognitive control-associated brain activity. The association of antipsychotic medication and clinical factors were also examined. Data were analyzed from April 15, 2015, through August 29, 2017., Main Outcomes and Measures: Primary outcomes included group differences (HC vs SZ) in behavioral performance (d'-context from AX-CPT) and brain activity for cue B-A trials of the AX-CPT in an a priori DLPFC region of interest at baseline and across the age span. Secondary analysis examined the influence of antipsychotics on behavioral performance and DLPFC activity., Results: Among the sample of 180 participants (66.1% male; mean [SD] age at baseline, 19.2 [3.2] years), 87 patients with SZ (mean [SD] age, 19.6 [3.0] years) showed impaired performance compared with 93 HCs (mean [SD] age, 18.8 [3.4] years) across the age span (estimated difference [SE], -0.571 [0.12], d'-context; P < .001). Patients with SZ showed reduced activation in the DLPFC and parietal cortex (false discovery rate cluster corrected to P < .05) compared with HCs under conditions of high cognitive control at baseline. Region-of-interest analysis showed reduced activation in the DLPFC bilaterally for patients with SZ, with a trajectory that paralleled that of HCs across the age span (left DLPFC β [SE] estimates, 0.409 [0.165] for the HC group and -0.285 [0.130] for the SZ group [main effect of group, P = .03]; right DLPFC β [SE] estimates, 0.350 [0.103] for the HC group and -0.469 [0.157] for the SZ group [P = .003]). Antipsychotic medication, clinical symptoms, and global functioning were associated with SZ performance., Conclusions and Relevance: During the initial 1 to 2 years after illness onset, young individuals with SZ showed deficits in DLPFC activation and cognitive control, with developmental trajectories comparable to those of HCs. Younger age at onset was not associated with reduced cognition or activation. For individuals contributing to longitudinal analysis, results suggest that young patients do not show deterioration or disruption of ongoing brain development in the initial years after illness onset.

Background: Antimicrobial resistance is a major public health threat internationally but, particularly in India. A primary contributing factor to this rise in resistance includes unregulated access to antimicrobials. Implementing antimicrobial stewardship programs (ASPs) in the acute hospital setting will help curb inappropriate antibiotic use in India. Currently, ASPs are rare in India but are gaining momentum. This study describes ASP implementation in a large, academic, private, tertiary care center in India., Methods: An ASP was established in February 2016 consisting of an administrative champion, hospitalist, microbiologist, intensivist, and pharmacists. Antimicrobial stewardship program interventions included postprescriptive audit and establishment of institutional guidelines. The ASP tracked appropriate drug selection including loading dose, maintenance dose, frequency, route, duration of therapy, de-escalation, and compliance with ASP recommendations. Defined daily dose (DDD) of drugs and cost of antimicrobials were compared between the pre-implementation phase (February 2015-January 2016) and post-implementation phase (February 2016-January 2017)., Results: Of 48 555 patients admitted during the post-implementation phase, 1020 received 1326 prescriptions for restricted antibiotics. Antibiotic therapy was appropriate in 56% (742) of the total patient prescriptions. A total of 2776 instances of "inappropriate" antimicrobial prescriptions were intervened upon by the ASP. Duration (806, 29%) was the most common reason for inappropriate therapy. Compliance with ASP recommendations was 54% (318). For all major restricted drugs, the DDD/1000 patient days declined, and there was a significant reduction in mean monthly cost by 14.4% in the post-implementation phase., Conclusions: Implementation of a multidisciplinary antibiotic stewardship program in this academic, large, Indian hospital demonstrated feasibility and economic benefits.

Small changes in the pH gradient play a critical role in numerous biological and chemical pathways. Systems capable of monitoring and regulating these changes with high sensitivity and minimum photo-fatigue are in demand. Herein, we propose a visible light-triggered molecular system that allows for reversible regulation of acidity and fluorescence. This robust bi-functional system opens a new horizon towards novel studies that rely on small changes in acid-mediated controlled processes with high sensitivity. The two photosensitive compounds employed, a metastable-state photoacid (mPAH) and a boron-dipyrromethene (BODIPY) derivative, allow for consistent modulation of both fluorescence (based on the working principle of the inner filter effect) and pH (around a magnitude) over multiple cycles.

A new capability at the National Ignition Facility (NIF) has been implemented to measure the temperature of x-ray emitting sources. Although it is designed primarily for Inertial Confinement Fusion (ICF), it can be used for any hot emitting source that is well modeled. The electron temperature (T e ) of the hot spot within the core of imploded ICF capsules is an effective indicator of implosion performance. Currently, there are spatially and temporally integrated T e inferences using image plates. A temporally resolved measurement of T e will help elucidate the mechanisms for hot spot heating and cooling such as conduction to fuel, alpha-heating, mix, and radiative losses. To determine the temporally resolved T e of hot spots, specific filters are added to an existing x-ray streak camera "streaked polar instrumentation for diagnosing energetic radiation" to probe the emission spectrum during the x-ray burn history of implosions at the NIF. One of the difficulties in inferring the hot spot temperature is the attenuation of the emission due to opacity from the shell and fuel. Therefore, a series of increasingly thick titanium filters were implemented to isolate the emission in specific energy regions that are sensitive to temperatures above 3 keV while not significantly influenced by the shell/fuel attenuation. Additionally, a relatively thin zinc filter was used to measure the contribution of colder emission sources. Since the signal levels of the emission through the thicker filters are relatively poor, a dual slit (aperture) was designed to increase the detected signal at the higher end of the spectrum. Herein, the design of the filters and slit is described, an overview of the solving technique is provided, and the initial electron temperature results are reported.

A needs assessment survey of infectious diseases (ID) training program directors identified gaps in educational resources for training and evaluating ID fellows in antimicrobial stewardship. An Infectious Diseases Society of America-sponsored core curriculum was developed to address that need.

To reach the pressures and densities required for ignition, it may be necessary to develop an approach to design that makes it easier for simulations to guide experiments. Here, we report on a new short-pulse inertial confinement fusion platform that is specifically designed to be more predictable. The platform has demonstrated 99%+0.5% laser coupling into the hohlraum, high implosion velocity (411  km/s), high hotspot pressure (220+60  Gbar), and high cold fuel areal density compression ratio (>400), while maintaining controlled implosion symmetry, providing a promising new physics platform to study ignition physics.

Background: Most nursing facilities (NFs) lack methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) surveillance programs due to limited resources and high costs. We investigated the utility of environmental screening of high-touch surfaces in patient rooms as a way to circumvent these challenges., Methods: We compared MRSA and VRE culture data from high-touch surfaces in patients' rooms (14450 samples from 6 NFs) and ranked each site's performance in predicting patient colonization (7413 samples). The best-performing sites were included in a MRSA- and a VRE-specific panel that functioned as a proxy for patient colonization. Molecular typing was performed to confirm available concordant patient-environment pairs., Results: We identified and validated a MRSA panel that consisted of the bed controls, nurse call button, bed rail, and TV remote control. The VRE panel included the toilet seat, bed controls, bed rail, TV remote control, and top of the side table. Panel colonization data tracked patient colonization. Negative predictive values were 89%-92% for MRSA and 82%-84% for VRE. Molecular typing confirmed a strong clonal type relationship in available concordant patient-environment pairs (98% for MRSA, 91% for VRE), pointing to common epidemiological patterns for environmental and patient isolates., Conclusions: Environmental panels used as a proxy for patient colonization and incorporated into facility surveillance protocols can guide decolonization strategies, improve awareness of MRSA and VRE burden, and inform efforts to reduce transmission. Targeted environmental screening may be a viable surveillance strategy for MRSA and VRE detection in NFs.

Accurate measurement of the thermal temperature in inertially confined fusion plasmas is essential for characterizing ignition performance and validating the basic physics understanding of the stagnation conditions. We present experimental results from cryogenic deuterium-tritium implosions on the National Ignition Facility using a differential filter spectrometer designed to measure the thermal electron temperature from x-ray continuum emission from the stagnated plasma. Furthermore, electron temperature measurements, used in conjunction with the Doppler-broadened DT neutron spectra, allow one to infer the partition of energy in the hot spot between internal energy and unconverted kinetic energy.

Background: Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to predict the chance of successful vaginal birth after cesarean (VBAC) based on the patient's preexisting demographic and clinical factors., Objective: To assess the rate of successful TOLAC using two calculators: FLAMM and the Grobman calculator, and to compare the performance of the two calculators in the successful prediction of VBAC., Methods: Prospective cohort study in subjects with previous one caesarean section using well-defined inclusion and exclusion criteria., Results: A total of 280 subjects with previous one cesarean section were enrolled. One hundred thirty-nine subjects consented for TOLAC, 90 (67%) underwent successful trial of vaginal birth, and 49 (32.8) required cesarean section. Cervical dilatation (p < 0.0001) and effacement (p < 0.0001), and any prior vaginal delivery (p < 0.02) were significantly associated with a successful outcome. At a cutoff score of 5, the sensitivity of the FLAMM score was 72% and specificity was 76%. For the Grobman calculator, the best sensitivity (69%) and specificity (67%) were seen at a cutoff score of 85%., Conclusion: Both prediction models, the FLAMM and the "close to delivery" nomogram, recommended by Grobman et al. are easy to use and could successfully estimate the chances of vaginal birth in previous caesarean, in this small cohort. The decision for women opting for TOLAC can be individualized, and patient-specific chances of success can be predicted by the use of these prediction models., Competing Interests: Compliance with Ethical StandardsThe authors declare that they have no conflict of interest.All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki declaration of 1975 as revised in 2008.Informed consent was obtained from all patents for being included in the study.

Background: Hospital-acquired urinary tract-related bloodstream infections are rare but often lethal. Recent epidemiology of this condition among the United States veteran population is poorly described., Methods: We conducted a retrospective review of hospital-acquired urinary tract-related bloodstream infections of adult inpatients admitted to 4 Veterans Affairs hospitals over 15 years. Electronic medical records were used to obtain clinical, demographic, and microbiologic information. Descriptive statistical analyses were conducted using chi-square tests of association. Test for trend was performed by genus of organism and for case fatality rate over time., Results: While the most commonly isolated organisms were Staphylococcus spp. (36.5%), the incidence of infections caused by Escherichia and Klebsiella increased over time (P = .02 and P = .03, respectively). The overall in-hospital case fatality rate was 24.2% in 499 patients. The case fatality rate was 25.8% for patients with Staphylococcus infections and 20.7% for patients with enterococcal infections., Conclusions: Hospital-acquired urinary tract-related bloodstream infection is commonly due to Staphylococcus spp. and is related to the high fatality among United States veterans. Focused infection control efforts could decrease the incidence of this fatal infection., (Published by Elsevier Inc.)

Background: In 1996, Oman launched its surveillance programme for adverse events following immunization (AEFI) to address vaccine safety concerns. In 2010, an analysis of surveillance activities for AEFI was done for 10 years (1996-2005)., Objectives: The main objective of the study was to describe the trend of AEFI over the 10-year period, 2006-2015, and compare the findings with a previous report in Oman and reports from other countries., Methods: A descriptive record-based review of AEFI was carried out using the national AEFI surveillance database for the study period, 2006-2015., Results: A total of 890 adverse event reports were received, giving an annual rate during the review period of 21.4 per 100 000 population or 8.3 per 100 000 doses administered. The most frequently reported AEFI were BCG adenitis and local reactions - 31.1 and 4.1 per 100 000 doses respectively. There were no reported deaths. Pentavalent vaccine was responsible for the greatest proportion of adverse events (30%). Local reaction was the most common adverse event among all vaccines administered. The Hexa vaccine caused fewer adverse events compared with the pentavalent vaccine, probably due to the acellular pertussis component - 0.8 versus 1.5 per 100 000 doses administered respectively., Conclusion: The overall rate of AEFI (8.3 per 100 000 doses administered) is comparable to the rate (10.8/100 000 doses) in the previous decade (1996-2005) in Oman. The reported rates for individual vaccines are similar to or below international rates., (Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Atypical craniofacial clefts of the upper facial region have been well documented; however, the mandibular clefts remain rare and reported as isolated case reports. We report a case of a median mandibular cleft within the context of a Tessier 0-14 axis that we have followed over a 5-year period without surgical/orthodontic intervention. The mandibular symphysis cleft remained open without evidence of the fusion, in contrast to ossification of the metopic dysraphism. Within this context, we present a review of the median mandibular cleft cases from 1819 to 2015.

Central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are costly and morbid. Despite evidence-based guidelines, Some intensive care units (ICUs) continue to have elevated infection rates. In October 2015, we performed a systematic search of the peer-reviewed literature within the PubMed and Cochrane databases for interventions to reduce CLABSI and/or CAUTI in adult ICUs and synthesized findings using a narrative review process. The interventions were categorized using a conceptual model, with stages applicable to both CAUTI and CLABSI prevention: (stage 0) avoid catheter if possible, (stage 1) ensure aseptic placement, (stage 2) maintain awareness and proper care of catheters in place, and (stage 3) promptly remove unnecessary catheters. We also looked for effective components that the 5 most successful (by reduction in infection rates) studies of each infection shared. Interventions that addressed multiple stages within the conceptual model were common in these successful studies. Assuring compliance with infection prevention efforts via auditing and timely feedback were also common. Hospitalists with patient safety interests may find this review informative for formulating quality improvement interventions to reduce these infections., (© 2017 Society of Hospital Medicine.)

Dairy cow undergoes tremendous physiological challenges during the transition period leading to negative energy balance (NEBAL), impaired immunity and oxidative stress that ultimately compromises the postpartum fertility. Accordingly, we investigated the effects of antioxidant supplementation and increased energy allowance on transition stress and fertility of crossbred cow. Advanced pregnant crossbred cows (n = 26) of 2-4 parity and lactation potential of >10 L/day were divided into two equal groups (n = 13 cows/group). Cows were fed diets either (i) supplemented with vitamin E (80 IU/kg DM), Selenium (Se; 0.3 mg/kg DM) and increased energy allowance in the form of 20% additional concentrate (TRT) or (ii) basal diet without any supplementation as control (CON). Vitamin E and Se were supplemented with wheat flour bolus from -4 to 8 week of calving whereas energy allowance was increased from 2 to 8 week of calving on daily basis to individual animal (where 0 is day of calving). Blood samples were collected on weekly interval from -4 to 8 week of calving. Oxidative stress was assessed by estimation of malondialdehyde (MDA), total antioxidant capacity (TAC), superoxide dismutase (SOD) and catalase (CAT). Immunity level was assessed via estimation of phagocytic activity (PA) of granulocytes and lymphocyte proliferation assay (LPA). Postpartum fertility was assessed by interval to first postpartum estrus (day) and pregnancy rate. Cows in TRT had a significantly lower MDA, higher TAC and decreased activity of SOD and CAT than that of CON (P < 0.05). Phagocytic activity increased at -1, 0 and 3-8 weeks postpartum (P < 0.05) while LPA showed difference (P < 0.05) at parturition, week 4 and 8 postpartum. Marked improvement in the fertility was recorded in terms of early resumption of postpartum estrus (P < 0.001) and higher pregnancy rate (P < 0.05)., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Pharmaceuticals are beginning to receive attention as a source of pollution in aquatic environments. Yet the impact of physician prescription patterns on water resources is not often discussed in clinical decision making. Here, we comment on a case in which empiric antibiotic treatment might benefit a patient while simultaneously being detrimental to the aquatic environment. We first highlight the potential harm caused by this prescription from its production to its disposal. We then suggest that Van Rensselaer Potter's original conceptualization of bioethics can be used to balance clinicians' obligations to protect individual, public, and environmental health., (© 2017 American Medical Association. All Rights Reserved.)

Background: Anastomosis in gastrointestinal (GI) surgery is a commonly performed procedure. Irrelevant various methods of intestinal anastomosis were followed - recent advance is the use of a stapler as a device for GI anastomosis. Due to the use of staplers, technical failures are a rarity, anastomosis is more consistent and can be used at difficult locations., Materials and Methods: : Between 2008 and August 2016, 75 patients with esophagus or gastroesophageal junction carcinoma underwent curative intent resection either via a right posterolateral thoracotomy (TTE) or transhiatal esophagectomy or video-assisted thoracoscopic surgery with linear stapler anastomosis., Results: The average follow-up was approximately 9 months. Anastomotic leakage was observed in three patients. On follow-up, two patients presented with difficulty in swallowing, and on upper GI endoscopy, they were found to have anastomotic site stricture. There was no perioperative mortality., Conclusion: The linear-stapled esophagogastric anastomosis is a safe and effective anastomotic technique, which can decrease the rate of leak, postoperative dysphagia, and anastomotic stricture. As in this technique only two linear staplers are used in comparison to other techniques where three or more staplers are used, it is also cost-effective. The procedure deserves more attention and further application., Competing Interests: There are no conflicts of interest

We assessed multidrug-resistant organism (MDRO) patient hand colonization in relation to the environment in post-acute care to determine risk factors for MDRO hand colonization. Patient hand colonization was significantly associated with environmental contamination. Risk factors for hand colonization included disability, urinary catheter, recent antibiotic use, and prolonged hospital stay. Infect Control Hosp Epidemiol 2017;38:1110-1113.

Dorsal lateral striatum (DLS) is a highly associative structure that encodes relationships among environmental stimuli, behavioral responses, and predicted outcomes. DLS is known to be disrupted after chronic drug abuse; however, it remains unclear what neural signals in DLS are altered. Current theory suggests that drug use enhances stimulus-response processing at the expense of response-outcome encoding, but this has mostly been tested in simple behavioral tasks. Here, we investigated what neural correlates in DLS are affected by previous cocaine exposure as rats performed a complex reward-guided decision-making task in which predicted reward value was independently manipulated by changing the delay to or size of reward associated with a response direction across a series of trial blocks. After cocaine self-administration, rats exhibited stronger biases toward higher-value reward and firing in DLS more strongly represented action-outcome contingencies independent from actions subsequently taken rather than outcomes predicted by selected actions (chosen-outcome contingencies) and associations between stimuli and actions (stimulus-response contingencies). These results suggest that cocaine self-administration strengthens action-outcome encoding in rats (as opposed to chosen-outcome or stimulus-response encoding), which abnormally biases behavior toward valued reward when there is a choice between two options during reward-guided decision-making. SIGNIFICANCE STATEMENT Current theories suggest that the impaired decision-making observed in individuals who chronically abuse drugs reflects a decrease in goal-directed behaviors and an increase in habitual behaviors governed by neural representations of response-outcome (R-O) and stimulus-response associations, respectively. We examined the impact that prior cocaine self-administration had on firing in dorsal lateral striatum (DLS), a brain area known to be involved in habit formation and affected by drugs of abuse, during performance of a complex reward-guided decision-making task. Surprisingly, we found that previous cocaine exposure enhanced R-O associations in DLS. This suggests that there may be more complex consequences of drug abuse than current theories have explored, especially when examining brain and behavior in the context of a complex two-choice decision-making task., (Copyright © 2017 the authors 0270-6474/17/377737-11$15.00/0.)

Background: Breast cancer is the most common cancer in women and second most common type of cancer overall. The prime objectives of axillary surgery in the management of breast cancer are 1) accurate staging, 2) treatment to cure and 3) quantitative information of metastatic lymph nodes for prognostic purposes and allocation to adjuvant protocols. During axillary dissection, all 3 level lymphnodes are removed, while the important axillary structures (axillary vein, long thoracic and thoracodorsal nerves) are preserved. The latter two structures are particularly vulnerable to injury when dissecting the tissue between them (the interneural tissue)., Methods: This prospective non-randomized study, conducted on 125 female patients, who underwent axillary lymphadenectomy for breast cancer has evaluated the importance of dissection of the Interneural tissue during axillary dissection in breast cancer surgery by reviewing the lymph node yield and metastasis rate. The interneural tissue was excised separately after a routine axillary dissection., Results: Lymph nodes were found in the interneural tissue of 70 out of 125 patients (56%). The average number of interneural lymph nodes recovered per specimen was 1.3. The interneural tissue lymph nodes were positive for metastasis in 10 (8%) patients. There was no incidence of isolated metastasis in the internerve tissue nodes., Conclusions: There is a significant incidence of lymph nodes (56%) and axillary node metastases (8%) in the tissue lying between the long thoracic and thoracodorsal nerves. Therefore, meticulous dissection and excision of this interneural tissue is strongly recommended to optimize decision making regarding adjuvant treatment and outcome., Competing Interests: There are no conflicts of interest

Simultaneous monochromatic crystal imaging at 4.5 and 8.0 keV with x-rays produced by a single short-pulse laser is presented. A layered target consisting of thin foils of titanium and copper glued together is irradiated by the 50 TW Leopard short-pulse laser housed at the Nevada Terawatt Facility. Laser-accelerated MeV fast electrons transmitting through the target induce Kα fluorescence from both foils. Two energy-selective curved crystals in the imaging diagnostic form separate monochromatic images on a single imaging detector. The experiment demonstrates simultaneous two-color monochromatic imaging of the foils on a single detector as well as Kα x-ray production at two different photon energies with a single laser beam. Application of the diagnostic technique to x-ray radiography of a high density plasma is also presented.

Background: We evaluated the extent to which hospital characteristics, infection control practices, and compliance with prevention bundles impacted multidrug-resistant organism (MDRO) infections in Thai hospitals., Methods: From 1 January 2014 to 30 November 2014, we surveyed all Thai hospitals with an intensive care unit and ≥250 beds. Infection control practices for methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant Acinetobacter baumannii (MDR-AB) were assessed. Linear regression was used to examine associations between hospital characteristics and prevention bundle compliance and changes in MDRO infection rates., Results: A total of 212 of 245 (86.5%) eligible hospitals responded. Most hospitals regularly used several fundamental infection control practices for MRSA and MDR-AB (ie, contact precautions, private room/cohorting, hand hygiene, environmental cleaning, and antibiotic stewardship); advanced infection control practices (ie, active surveillance, chlorhexidine bathing, decolonization for MRSA, and hydrogen peroxide vaporizer for MDR-AB) were used less commonly. Facilities with ≥75% compliance with the MRSA prevention bundle experienced a 17.4% reduction in MRSA rates (P = .03). Although the presence of environmental cleaning services (41.3% reduction, P = .01) and a microbiology laboratory (82.8% reduction, P = .02) were among characteristics associated with decreases in MDR-AB rates, greater compliance with the MDR-AB prevention bundle did not lead to reductions in MDR-AB rates., Conclusions: Although fundamental MRSA and MDR-AB control practices are used regularly in most Thai hospitals, compliance with more comprehensive bundled prevention approaches is suboptimal. Improving compliance with bundled infection prevention approaches and promoting the integration of certain hospital factors into infection control efforts may help reduce MDRO infections in Thai hospitals., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

We have built an absolutely calibrated, highly efficient, Bragg crystal spectrometer in von Hamos geometry. This zinc von Hamos spectrometer uses a crystal made from highly oriented pyrolytic graphite that is cylindrically bent along the non-dispersive axis. It is tuned to measure x-ray spectra in the 7-10 keV range and has been designed to be used on a Ten Inch Manipulator for the Omega and OmegaEP target chambers at the Laboratory for Laser Energetics in Rochester, USA. Significant shielding strategies and fluorescence mitigation have been implemented in addition to an imaging plate detector making it well suited for experiments in high-intensity environments. Here we present the design and absolute calibration as well as mosaicity and integrated reflectivity measurements.

Background: Scalds have distinct epidemiological and predisposing risk factors amongst all types of burns. Though scald affects all age groups, the brunt falls on the minor age groups. It may result in major physical disabilities and significant loss of school years. Apart from the economic burden on family, major scald burn may compromise overall development of the affected children. Most of the scald injuries occur in domestic settings and are preventable. Despite improvement in living conditions, the incidence of scald burn has failed to decline. Our aim was to study the detailed epidemiology and severity of scald burn amongst all age groups., Methods: A retrospective study was carried out from the records of all burn patients who attended a tertiary burn care center from January 2013 and December 2014. Data of the patients with scald injury was segregated and analyzed using Microsoft excel spreadsheet., Result: 10,175 burn patients attended the burn casualty during the study period, of which 42.3% had sustained scald. 56.85% of patients were under 15 years of age with preschool children (36.4%) being the prime victims of scald. The % TBSA involved is also relatively larger in children. Scald follows definite seasonal variation peaking in winters. 36.8% patients arrived to the hospital without any first aid. 74.2% of patients reported to casualty with in 24hours after sustaining scald injury. The median time interval between injury and reporting to casualty was 3hours 30minutes., Conclusion: This study concludes that the scald is injury of all age groups, though majority of them are children. The first aid is not given to large number of patients and late reporting is quite common. These are the factors which may affect the course of scald burn. Spreading public awareness regarding safe household practises and educating them for proper first aid management after scald may have significant impact on the burden of care and outcome., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

We report on measurements of the electron temperature in the hotspot of inertially confined, layered, spherical implosions on the National Ignition Facility using a differential filtering diagnostic. Measurements of the DT and DD ion temperatures using neutron time-of-flight detectors are complicated by the contribution of hot spot motion to the peak width, which produce an apparent temperature higher than the thermal temperature. The electron temperature is not sensitive to this non-thermal velocity and is thus a valuable input to interpreting the stagnated hot spot conditions. Here we show that the current differential filtering diagnostic provides insufficient temperature resolution for the hot spot temperatures of interest. We then propose a new differential filter configuration utilizing larger pinhole size to increase spectral fluence, as well as thicker filtration. This new configuration will improve measurement uncertainty by more than a factor of three, allowing for a more accurate hotspot temperature.

The electron temperature at stagnation of an ICF implosion can be measured from the emission spectrum of high-energy x-rays that pass through the cold material surrounding the hot stagnating core. Here we describe a platform developed on the National Ignition Facility where trace levels of a mid-Z dopant (krypton) are added to the fuel gas of a symcap (symmetry surrogate) implosion to allow for the use of x-ray spectroscopy of the krypton line emission.

A new platform of ion-selective optodes is presented here to detect cations under thermodynamic equilibrium via ratiometric analysis. This novel platform utilizes a 'one of a kind' visible light-induced metastable photoacid as a reference ion indicator to achieve activatable and controllable sensors. These ion-selective optodes were studied in terms of their stability, sensitivity, selectivity, and theoretical aspects.

The consequences of small scale-length precursor plasmas on high-intensity laser-driven relativistic electrons are studied via experiments and simulations. Longer scale-length plasmas are shown to dramatically increase the efficiency of electron acceleration, yet, if too long, they reduce the coupling of these electrons into the solid target. Evidence for the existence of an optimal plasma scale-length is presented and estimated to be from 1 to 5μm. Experiments on the Trident laser (I=5×10(19)W/cm(2)) diagnosed via Kα emission from Cu wires attached to Au cones are quantitively reproduced using 2D particle-in-cell simulations that capture the full temporal and spatial scale of the nonlinear laser interaction and electron transport. The simulations indicate that 32%±8%(6.5%±2%) of the laser energy is coupled into electrons of all energies (1-3 MeV) reaching the inner cone tip and that, with an optimized scale-length, this could increase to 35% (9%).

We report a case of recurrent Achromobacter xylosoxidans infections including bacteremia, sepsis, septic joints and endocarditis in a 72 year old female with granulomatosis with polyangiitis. Achromobacter xylosoxidans is a gram negative bacteria increasingly identified in immunocompromised patients. Surgical and medical therapy may need to be combined.

Hydrodynamic instabilities can cause capsule defects and other perturbations to grow and degrade implosion performance in ignition experiments at the National Ignition Facility (NIF). Here, we show the first experimental demonstration that a strong unsupported first shock in indirect drive implosions at the NIF reduces ablation front instability growth leading to a 3 to 10 times higher yield with fuel ρR>1  g/cm(2). This work shows the importance of ablation front instability growth during the National Ignition Campaign and may provide a path to improved performance at the high compression necessary for ignition.

Mannose binding lectin (MBL) is a collectin with C-terminus Carbohydrate Recognition Domain (CRD) which binds with pathogen and arbitrate functions like activation of complement pathway, opsonization etc. The CRD required Ca(2+) ions to recognize the sugar moieties. In the present study the binding properties of CRD with divalent ions were characterized by Electron Paramagnetic Resonance (EPR) spectroscopy. The results revealed that the metal binding site of CRD is of approximately 1 Å diameter and ions greater than the size are not able to enter., (Copyright © 2015 Elsevier B.V. All rights reserved.)

We present the design and commissioning of a new single-shot, frequency-resolved optical gating system on the OMEGA EP laser facility - dubbed "SpecFROG" - for characterizing the instantaneous intensity and phase of ∼10 ps pulses used to study ultra-intense laser-plasma interactions. A polarization-gating geometry is employed to ensure tha the diagnostic is broadband and has unambiguous time directionality. SpecFROG is capable of characterizing ∼10 s of mJ pulses with durations between 0.5-25 ps with ≲285 fs geometrical temporal blurring and ∼0.1% spectral shift resolutions over an adjustable total spectral shifting window of ∼15% of the carrier wavelength λo; configurations currently exist for both the fundamental (1ω, λo = 1.054 μm) and second harmonic (2ω, λo = 0.527 μm) of the EP pulse. Initial specular reflectivity measurements of the ∼1 kJ, ∼10 ps OMEGA EP laser off solid density aluminum targets suggest drastically different scalings for specular pulse properties compared to picosecond-scale pulses of comparable intensities.

We report on the first layered deuterium-tritium (DT) capsule implosions indirectly driven by a "high-foot" laser pulse that were fielded in depleted uranium hohlraums at the National Ignition Facility. Recently, high-foot implosions have demonstrated improved resistance to ablation-front Rayleigh-Taylor instability induced mixing of ablator material into the DT hot spot [Hurricane et al., Nature (London) 506, 343 (2014)]. Uranium hohlraums provide a higher albedo and thus an increased drive equivalent to an additional 25 TW laser power at the peak of the drive compared to standard gold hohlraums leading to higher implosion velocity. Additionally, we observe an improved hot-spot shape closer to round which indicates enhanced drive from the waist. In contrast to findings in the National Ignition Campaign, now all of our highest performing experiments have been done in uranium hohlraums and achieved total yields approaching 10^{16} neutrons where more than 50% of the yield was due to additional heating of alpha particles stopping in the DT fuel.