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Background An outbreak of Legionella pneumonia occurred at a university hospital using copper-silver ionization for potable water disinfection. We present the epidemiological and laboratory investigation of the outbreak, and associated case-control study. Methods Cases were defined by syndrome compatible with Legionella pneumonia with laboratory-confirmed Legionella infection. The water circuit and disinfection system were assessed, and water samples collected for Legionella culture. Whole genome multi-locus sequence typing (wgMLST) was used to compare the genetic similarity of patient and environmental isolates. A case-control study was conducted to identify risk factors for Legionella pneumonia. Results We identified 13 cases of hospital-acquired Legionella. wgMLST revealed >99.9% shared allele content among strains isolated from clinical and water samples. Smoking (P= .008), steroid use (P= .007), and documented shower during hospitalization (P= .03) were risk factors for Legionella pneumonia on multivariable analysis. Environmental assessment identified modifications to the hospital water system had occurred in the month preceding the outbreak. Multiple mitigation efforts and application of point of use water filters stopped the outbreak. Conclusions Potable water system Legionella colonization occurs despite existing copper-silver ionization systems, particularly after structural disruptions. Multidisciplinary collaboration and direct monitoring for Legionella are important for outbreak prevention. Showering is a modifiable risk factor for nosocomial Legionella pneumonia. Shower restriction and point-of-use filters merit consideration during an outbreak.

Objectives We investigated associations of mothers' preterm birth (PTB) status with her infants' PTB risk. We also examined whether this relationship differs by mothers' race and generational socio-economic neighborhood context. Methods Participants were 6592 non-Hispanic (NH) white and NH black mother-infant pairs born in 2009-2011 and 1979-1998, respectively, in Allegheny County, Pennsylvania. Birth records were used to determine gestational age at birth, PTB status (

Duodenoscope use in healthcare facilities has been associated with transmission of multidrug resistant pathogens between patients. To assist healthcare facilities in monitoring the quality of their duodenoscope reprocessing procedures and limit patient risk of infection, the Centers for Disease Control and Prevention (CDC) deployed voluntary interim duodenoscope sampling and culturing surveillance protocols in 2015. Though the interim methods were widely adopted, alternative surveillance protocols were developed and implemented at individual institutions. Here, we compared two sampling methods—the 2015 CDC interim protocol and an alternative protocol developed by the University of Wisconsin Hospitals and Clinics (UWHC). We hypothesized that the UWHC protocol would detect a higher incidence of bacterial contamination from reprocessed duodenoscopes. A total of 248 sampling events were performed at UWHC. The CDC protocol (n = 129 sampling events) required culturing samples collected from each duodenoscope after brushing its terminal end and flushing its lumen with sterile water. The UWHC protocol (n = 119 sampling events) required culturing samples collected from each duodenoscope after swabbing its elevator, immersing its terminal end into broth and flushing its lumen with saline. With the CDC method, 8.53% (n = 11) of the duodenoscopes sampled were positive for bacterial growth with 15 isolates recovered. Using the UWHC method, 15.13% (n = 18) of cultures were positive for bacterial growth with 20 isolates recovered. The relative risk of identifying a contaminated duodenoscope using the CDC interim method, however, was not different than when using the UWHC protocol. Mean processing time (27.35 and 5.11 minutes, p<0.001) and total cost per sample event ($17.87 and $15.04) were lower using the UWHC method. As the UWHC protocol provides similar detection rates as the CDC protocol, the UWHC method is useful, provided the shorter processing time and lower cost to perform.

There is a lack of research on health care providers’ use of and perspectives on expedited partner therapy in a state where expedited partner therapy is not prohibited or explicitly allowed. The aim of our study was to understand if and how health care providers use expedited partner therapy, if specific demographic factors and knowledge contribute to increased use of expedited partner therapy, and to describe barriers and facilitators to the use of expedited partner therapy in Pittsburgh, Pennsylvania. A convenience sample of 112 health care providers from diverse disciplines who treat young women at risk for chlamydia completed an online survey. About 11% of health care providers used expedited partner therapy consistently. Those who self-reported that they were knowledgeable about expedited partner therapy were more likely to use expedited partner therapy (73% vs. 49%, p = .009) as were those who said no or were unsure about their institution’s guidelines for expedited partner therapy (35% vs. 22%, p = 0.01) (62% vs. 57%, p = 0.01). The most commonly reported facilitator of expedited partner therapy was having clear legal guidelines (86%). This study finds that in a setting where expedited partner therapy is not expressly permitted, health care providers still use the practice but also experience barriers that limit uptake. Legislation expressly endorsing expedited partner therapy in the state and in medical institutions is needed to increase expedited partner therapy use.

Over one-third of women experience intimate partner violence in their lifetime. Intimate partner violence increases the risk of infection and re-infection with sexually transmitted infections. The extent to which health care providers consider intimate partner violence when recommending partner notification and expedited partner therapy is unknown. The objective of this qualitative study was to understand health care providers' views on intimate partner violence and sexually transmitted infections when recommending partner treatment to patients with chlamydia. Using a purposive sampling strategy to include health care providers who treat young women at risk for chlamydia, 23 semi-structured, in-depth interviews were conducted. While some health care providers expressed concern for their patients' safety and believed assessing for intimate partner violence was needed before provision of expedited partner therapy, nearly a third had not considered the links between intimate partner violence and sexually transmitted infections. Strategies used by health care providers to assess for intimate partner violence did not include inquiry about specific behaviours related to intimate partner violence, sexually transmitted infection risk, and sexual coercion. Many health care providers understand the risk for intimate partner violence in the setting of sexually transmitted infection treatment, yet a significant portion of those interviewed failed to recognise the link between intimate partner violence and sexually transmitted infections. Provider education is necessary to increase knowledge and implement more effective inquiry and counselling about intimate partner violence to more safely recommend expedited partner therapy. Language: en

Objectives Expedited partner therapy (EPT) effectively reduces rates of reinfection with chlamydia and increases the number of partners treated for the infection. Healthcare provider (HCP) provision of EPT is low. The objective of this qualitative study was to understand HCP views and opinions regarding the use of EPT in a state where EPT is permissible but underused. Methods Using a purposive sampling strategy to include diverse HCPs who treat young women at risk for chlamydia, 23 semistructured, in-depth interviews were conducted between October and December 2013. The interviews included questions about knowledge, attitudes, experiences with, and barriers and facilitators regarding the use of EPT. Results Many respondents report using EPT and believe the practice is beneficial for their patients. Most providers were unaware of their colleagues’ practices and had limited knowledge regarding institutional policies around EPT. HCPs noted a variety of barriers, such as fear of liability, confusion around the legal status of EPT and not being able to counsel patients’ partners that make routine use of this practice a challenge. Facilitators of EPT include speaking on the phone with patients’ partners and establishing legislation enabling EPT. Conclusions This is the first study to qualitatively examine HCPs’ perspectives on EPT in the USA. Barriers to EPT, including concerns about counselling patients’ partners and the legal status of EPT, can be overcome. EPT recommendations could include the use of phone calls as part of their guidelines. Changing EPT legislation at the state level in the USA is an important factor to facilitate EPT use.

OBJECTIVE: To examine the association of maternal low birthweight (LBW) with infant LBW and infant LBW subgroups (i.e. moderate and very LBW), overall and among non-Hispanic (NH) white and NH black mothers. DESIGN: We conducted a population-based cohort study in Allegheny County, Pennsylvania, using linked birth record data of NH white and NH black mother-infant pairs (N=6,633) born in 1979-1998 and 2009-2011, respectively. The exposure of interest was maternal LBW (birthweight

Advances in clinical therapies for people living with HIV have greatly increased life expectancies, but the high levels of adherence that are necessary for clinical success are infrequently achieved, especially for chronically homeless substance users. The Open Door is a harm reduction housing program that seeks to improve clinical outcomes for this population. We present findings from qualitative interviews with residents of the program, conducted to explore facilitators of residents’ success in the program, which is ultimately defined as HIV clinical adherence. Two major themes developed. Positive changes captures processes or characteristics that residents reported as having changed as a result of living in the program. Mechanisms of success reflects aspects of the program to which residents attributed their improved adherence. Given that improving adherence in vulnerable populations has both clinical and public health implications, our study suggests future avenues for research and foundations on whic...

Neil Lazarus describes a field of postcolonial literature that is both too big and too small. Too big, in that this “vast and hitherto unevenly and indifferently theorized corpus” contains too many works published in too many places and circulating in too many ways to be neatly summed up (35). The field is too small, however, in that few postcolonial works actually garner anything like meaningful scholarly attention. Saying he is “tempted to overstate the case,” Lazarus declares “that there is in a strict sense only one author in the postcolonial literary canon. That author is Salman Rushdie, whose novels—especially Midnight’s Children, Shame, and The Satanic Verses—are endlessly, not to say catechistically, cited in the critical literature” (22). The point remains even if one is inclined to supplement this canon with another likely suspect or two—J.M. Coetzee, say, or Arundhati Roy.

Prior research found that financial hardship or distress is one of the most important underlying factors for depression/depressive symptoms, yet factors that contribute to financial distress remain unexplored or unaddressed. Given this, the goals of the present study were (1) to examine the relationship between perceived financial distress and depressive symptoms, and (2) to identify financial priorities and needs that may contribute to financial distress. Surveys from 111 African American women, ages 18–44, who reside in Allegheny County, PA, were used to gather demographic information and measures of depressive symptoms and financial distress/financial well-being. Correlation and regression analyses revealed that perceived financial distress was significantly associated with levels of depressive symptoms. To assess financial priorities and needs, responses to two open-ended questions were analyzed and coded for common themes: “Imagine you won a $10,000 prize in a local lottery. What would you do with this money?” and “What kinds of programs or other help would be beneficial to you during times of financial difficulties?” The highest five priorities identified by the participants were paying bills and debt, saving, purchasing a home or making home repairs, and/or helping others. The participant’s perceived needs during times of financial difficulty included tangible assistance and/or financial education. The findings from this study can be used to create new and/or enhance existing programs, services, and/or interventions that focus on the identified financial priorities and needs. Collaborative efforts among professionals in different disciplines are also needed, as ways to manage and alleviate financial distress should be considered and discussed when addressing the mental health of African American women.

Recent scholarship on governmentality promises to reinvigorate literary critical analysis of how novels, poems, and plays help to organize the world’s populations as they interact. In turn, literary criticism helps to illuminate the global implications of Michel Foucault’s lectures at the College de France, published in English as Security, Territory, Population (2007) and The Birth of Biopolitics (2008). By privileging varied practice over unifying theory, Foucault’s approach leads scholars to examine the circulation of governmental techniques in conjunction with the circulation of governable populations. An emphasis on mobility and exchange should appeal particularly to specialists in immigrant, imperial, and postcolonial literature. While considering a range of literary critical and social scientific scholarship on governmentality, this essay also shows how literature itself authorizes discrepant forms of administration. I contend that literature and literary criticism engage in imaginative reformulations and reinventions of the art of government, and in so doing contribute to debates about governing that are every bit as cross-disciplinary as they are transnational.

Directed by Neill Blomkamp. Written by Neill Blomkamp and Terri Tatchell. Produced by Peter Jackson and Carolynne Cunningham. Co-produced by Philippa Boyens. Executive Producers Bill Block, Elliot ...

The conventional wisdom that contemporary fiction has little use for the nation cannot explain the plurality of recent novels that attend to states in crisis. To detail the effects of state collapse is, at the very least, to insist on the state's continued relevance to the form. I argue that this fiction of failure also has a stake in the state's future, which it demonstrates by treating civil war as a setting for generic experimentation. I offer an admittedly truncated genealogy of literary interest in state crisis to suggest how fiction collaborates with political scientific scholarship in defining the failed state as a more or less normative condition in much of the world. In so doing, these writings subordinate the notion of the state as a setting for national development or popular self-determination. Instead they portray the state as a context that shapes and is shaped by experts in their administration of populations. Fiction's collaboration with political science takes shape as a counter discourse. Where social science privileges quantitative data, literature counters with the qual ity of local knowledge. A good recent example is Chimamanda Ngozi Adichie's 2006 novel Half of a Yellow Sun, which supplements think tank statistics measuring state instability with a narrative of civil war written from the standpoint of its survivors. Half of a Yellow Sun offers a detailed account of everyday life before and during the late 1960s Biafran civil war. In so doing, the novel argues that life dur ing such a crisis can be conceived as ordinary existence, of an admittedly violent variety. To put this somewhat differently, Adichie's fiction fleshes out the notion that what goes on in the most unstable of states is never so extreme that it cannot be normed.

cynical. Reminding readers of the author's survival is, rather, the point of departure for an argument that ends by specifying a "form of responsive authorial agency" (177). Brouillette argues that select writers have found ways to shake off the "excessive burden within specifically postcolonial literatures" of "the association between an author and a national authenticity" (177). Even though Brouillette argues that "postcolonial authorship" is "in part a generative and saleable feature" (7), she does not suggest that writers are dupes of a global publishing machine. Rather, Brouillette is interested in how writers respond to the market's dictates. They do so, she argues, by writing novels that display a keen understanding of an author's function. By scrutinizing a discrete set of canonical (and near-canonical) postcolonial books, Brouillette tracks a "trope of self-authorization," which writers acquire "through awareness of the political uses or appropriations of one's works" (74). In short, figuring out how writers work with and against the publishing industry is what Brouillette is after. Her argument is a bracing account of authorship that ought to make it harder for scholars to trot out the habitual romanticist and modernist account of writers as the innocent victims of an increas

We report three patients infected with unique strains of vancomycin-dependent enterococci. Two were first infected by genetically identical strains of vancomycin-resistant enterococci (VRE). All three patients had much greater exposure to vancomycin and third-generation cephalosporins than did two control groups (patients infected with VRE and hospitalized patients without enterococcal infections). While antimicrobial pressure promotes nosocomial colonization by VRE, prolonged exposure to vancomycin may foster the transition from vancomycin resistance to dependence.

Privatization of public health is seemingly an oxymoron. Functions such as environmental regulation and communicable disease control would seem to be the unique purview of governmental public health departments. These services constitute public goods in that they affect entire communities, whereas personal health services are private goods, privately consumed by individuals.1 Recent pressures such as the penetration of managed care has led to shifts in personal health service provision from the public to the private sector and to various forms of public–private collaboration.2,3 However, some privatization theorists contend that public goods cannot be as effectively provided by the private sector. Others contend that even certain private goods, such as personal health services, should not be contracted out to the private sector.1 These opinions suggest that research on privatization in local health departments should examine the specific services, both public and private, that have been contracted out, a task previous studies of such health departments have not systematically addressed (L. Whitehand, M. Bechamps, and R. Bialek, unpublished data, 1997).4–15 Other articles based on the national survey of local health department directors described here have not outlined in detail the specific services privatized.16 In the present study, we examined the specific services privatized, the profit vs nonprofit status of contractors, and directors’ views about what services should not be privatized.

OBJECTIVES: This article presents nationally representative data on environmental health (EH) services privatized by local public health departments, enforcement and assurance mechanisms for privatized services, and administrators' views about EH services that should not be privatized. METHODS: A national sample of 380 local public health departments, stratified by jurisdiction size, was drawn from a universe of 2,488 departments. Telephone interviews were conducted with 347 administrators of departments. Results were weighted to be nationally representative. RESULTS: Approximately one-quarter of departments had privatized at least one EH service, almost always to for-profit organizations. The two most common reasons given for privatizing EH services were cost savings or increased efficiency and lack of capacity or expertise to carry out the service. The most rigorous, although infrequent, technique of enforcement and assurance of EH standards when services were privatized was double-testing of samples. Departments more commonly relied on state licensing and certification of contractors. When asked what services should not be privatized, 27% of respondents cited EH services. Many respondents argued against privatizing environmental services that have inherent regulatory functions. They expressed concern that privatization would fragment the public health infrastructure by impairing communication, diminishing control over performance, or weakening health departments' capacity to respond to environmental and other health crises. CONCLUSION: These findings raise serious concerns about the privatization of EH.

Expedited partner therapy (EPT) effectively reduces rates of reinfection with chlamydia and increases the number of partners treated for the infection. Healthcare provider (HCP) provision of EPT is low. The objective of this qualitative study was to understand HCP views and opinions regarding the use of EPT in a state where EPT is permissible but underused.Using a purposive sampling strategy to include diverse HCPs who treat young women at risk for chlamydia, 23 semistructured, in-depth interviews were conducted between October and December 2013. The interviews included questions about knowledge, attitudes, experiences with, and barriers and facilitators regarding the use of EPT.Many respondents report using EPT and believe the practice is beneficial for their patients. Most providers were unaware of their colleagues' practices and had limited knowledge regarding institutional policies around EPT. HCPs noted a variety of barriers, such as fear of liability, confusion around the legal status of EPT and not being able to counsel patients' partners that make routine use of this practice a challenge. Facilitators of EPT include speaking on the phone with patients' partners and establishing legislation enabling EPT.This is the first study to qualitatively examine HCPs' perspectives on EPT in the USA. Barriers to EPT, including concerns about counselling patients' partners and the legal status of EPT, can be overcome. EPT recommendations could include the use of phone calls as part of their guidelines. Changing EPT legislation at the state level in the USA is an important factor to facilitate EPT use.

OBJECTIVES: This study sought to obtain and analyze nationally representative data on (1) privatization of local health department services, (2) local health department directors' beliefs and perspectives on the desirable role and focus of health departments, and (3) the influence of these views on privatization practices. METHODS: A stratified representative national sample of 380 local health department directors was drawn, and 347 directors were interviewed by telephone. Logistic regression established the independent effects of various factors on decisions to privatize. RESULTS: Almost three quarters (73%) of the local health departments privatized public health services of some type. The 12% of the directors who believed that local health departments should be restricted to the core public health functions and move entirely out of direct provision of personal health care were more likely to privatize services. The 77% of the directors who believed that local health departments should be involved in an increasing array of social problems were more likely to privatize. CONCLUSIONS: Privatization has quietly and quickly become commonplace in public health, and privatization practices are intimately related to divergent conceptions of public health and the role of local health departments.

Almost three quarters of the nation's local health departments (LHDs) have privatized some services. About half of LHD directors who privatized services reported cost savings and half reported that privatization had facilitated their performance of the core public health functions. Expanded access to services was the most commonly reported positive outcome. Of those privatizing, over two-fifths of LHDs reported a resulting increase in time devoted to management. Yet, one-third of directors reported difficulty monitoring and controlling services that have been contracted out. Communicable disease services was cited most often as a service that should not be privatized. There is a pervasive concern that by contracting out services, health departments can lose the capacity to respond to disease outbreaks and other crises.

Computers have the potential to radically change the process of architectural design, and match more closely the formal aspirations of contemporary designers. What, then, should be the direction educators take in response to the opportunities created by the use of computers in the design process? There are, perhaps, two obvious methods of teaching Digital Design at a university level; a course adjunct to a design studio, or a course offered independently of a design studio. The computer is a facilitator of design ideas, but by itself, is not a creator of content. The primary responsibility of the design studio is the creation of content. It is the implementation of theory and critical analysis which should be the core concern of studio instruction. Given the limited time students are exposed to design studio it would seem appropriate, then, that the digital tools, which facilitate the design process, be taught separately, so as not to dilute the design studios importance. Likewise, this separation should allow the student to concentrate attention on Digital Design as a comprehensive process, beginning with initial massing studies and ending with high resolution presentation drawings. The burden of learning this new process is difficult as well as time consuming. Students are generally struggling to learn how to design, much less to design on the computer. In addition, the current lack of digital skills on the part of design faculty makes it difficult to create a level of consistency in teaching digital design. Compounding these problems is the cost to architectural departments of providing hardware and software resources sufficient to have a computer on every studio desk. Une proposition de methodologies alternatives pour l’enseignement du design digital Depuis des siecles les architectes ont utilise le plan et l’elevation comme outils primaires lors de conception. La nature abstraite et deux-dimensionelle fait partie integrale de l’usage de ces outils, mais les architectes, par definition, participent a la construction d’une forme trois-dimensionnelle. L’architecture moderne au debut du vingtieme siecle est devenue de plus en plus trois-dimensionnelle de nature. Nous nous trouvons maintenant dans une position ou les outils de creation de conviennent plus aux methodes de conception. L’ordinateur facilite le processus de conception, mais en soi ne cree pas le contenu des idees. La responsabilite premiere du studio de design est la creation de ce contenu. L’implantation de la theorie et de l’analyse critique devraient etre le focus de l’instruction en studio. Etant donne le temps limite durant lequel les etudiants se trouvent en studio de design, il serait alors bon que les methodes digitales servant a faciliter le processus de conception soient enseignees separement, pour ne pas diluer l’importance du studio de design. De meme, cette separation permettrait a l’etudiant de se concentrer sur les methodes electroniques de conception en tant que processus comprehensif, debutant avec etudes de masse, et terminant avec des dessins de presentation a haute resolution. Cette apprentissage est une tâche longue et difficile. Les etudiants ont generalement assez a apprendre le design, sans parler du design sur ordinateur. De plus, la presente manque de connaissances sur les methodes de conception par ordinateur de la part des professeurs, fait qu’il est difficile d’atteindre un niveau consistent lors de l’enseignement du design digital. A ces problemes s’ajoute le cout pour les departements d’architecture de fournir des ressources suffisantes a l’emplacement d’un ordinateur sur chaque bureau du studio.

As stated in the Institute of Medicine report Who Will Keep the Public Healthy? the doctor of public health (DrPH) degree is offered for advanced training in public health leadership.1 The Association of Schools of Public Health (ASPH) classifies the DrPH as a professional degree, as opposed to the more academic, research-oriented PhD degree.2 As a professional degree, the DrPH is oriented toward practice (i.e., the strategic, interdisciplinary application of knowledge and skills necessary to execute the public health core functions of assessment, policy development, and assurance3) in public health settings, including community, state, federal, and international agencies.2 These descriptions of the DrPH degree are consistent with those presented on the Web sites of the 23 of 38 ASPH-accredited schools of public health that offer the degree.4 Based on these widely endorsed descriptions of the DrPH degree, it is appropriate to recognize it as the highest professional degree in public health. Unfortunately, despite the degree’s significance, there is currently no national competency model for DrPH training. In addition, the fieldwide leadership role of DrPH practitioners is relatively undefined. Incomplete and inefficient treatment, combined with the collapse of public health systems in Abkhazia, have helped create strains of bacilli that are resistant to antituberculosis drugs. Used with permission of Aurora Photos. Copyright by Serge Sibert/Cosmos/Aurora.

Rarely do historical events cooperate with the work of cultural studies as readily as they appear to have done with Paul Smith’s Millennial Dreams: Contemporary Culture and Capital in the North. Several months after his book first appeared in stores, a worldwide stock market crisis seemed to provide corroborating evidence for Smith’s most audacious claim, that globalization’s promise of a stateless, borderless world is little more than an elaborate cover story told by capitalism’s apologists in a variety of fields. Smith identifies a tendency in cultural studies in particular to treat globalization as a revolutionary change in the way the world does business. In truth, he argues, it is nothing of the sort. Far from introducing a radically new mode of production, “the budding global economy simply nurtures the social relations of colonial business as usual” (10). The methodological upshot of this argument should be clear. High-profile theorists such as Stuart Hall and Saskia Sassen make a fatal error, Smith contends, if they assume that globalization has so changed capitalism that the old-fashioned tools of Marxist analysis no longer apply. Echoing ongoing debates over post-Fordism and postmodernity, Smith sets out to prove that “the fundamentally different descriptions of the world that Marxism can offer are still crucial” (3). Though certain aspects of Smith’s defense of Marxism are open to question, his assessment of late modern capitalism appears to be borne out by the historical narratives he reconsiders in Millennial Dreams. The market collapse of 27 October 1997, an event that happened well after his book went to press, lends further credence to his claims. Sparked in the markets of Asia, the crisis at first seemed to testify to a genuine shift in global economic power. Within a matter of days, however, the old imperial calculus of Northern management of Southern economies returned to the fore.

Traumatic spine injuries (TSIs) carry significantly high risks of morbidity, mortality, and exorbitant health care costs from associated medical needs following injury. For these reasons, TSI was chosen as an ENLS protocol. This article offers a comprehensive review on the management of spinal column injuries using the best available evidence. Though the review focuses primarily on cervical spinal column injuries, thoracolumbar injuries are briefly discussed as well. The initial emergency department clinical evaluation of possible spinal fractures and cord injuries, along with the definitive early management of confirmed injuries, are also covered.