Background: OPAT has emerged as an effective modality for continued treatment of serious infections outside the hospital, requiring complex care coordination and close monitoring for patient safety. Despite increasing availability of OPAT services nationwide, monitoring and benchmarking of treatment-related adverse events, patient outcomes, and program quality remain labor intensive and inconsistent across programs. Method: A previously reported OPAT-specific bundle of modifications to an Epic® Systems Corporation electronic health record (EHR) at a large academic OPAT program was leveraged to develop a model for longitudinal electronic monitoring and reporting of OPAT adverse event and safety outcomes data. An EHR-based SQL report evaluated mortality within 1 year of OPAT start, as well as intravascular access device (IVAD) occlusions (defined as documented intracatheter administration of alteplase), IVAD associated deep venous thromboses (DVT) (defined by 212 Upper Extremity DVT ICD-10 codes via custom SNOMED CT concept hierarchy grouper), anaphylaxis (defined by ICD-10 codes T78.2 and T88.6), and nephrotoxicity (defined as >0.3 increase or >1.5 times increase in baseline serum creatinine) while on OPAT. Hospital readmissions, emergency department utilization, non-anaphylactic allergic reaction (defined as documentation of new allergy to OPAT antibiotic), were evaluated while on OPAT or within 30 days of conclusion. Result: Total of 5190 OPAT episodes (10/18/2018 to 12/3/2024) in 4213 unique patients were examined (Figure 1). Bone/joint infection and bacteremia were most frequent indications for OPAT (Figure 2), with vancomycin, ceftriaxone, and cefazolin most common antibiotics (Figure 3). Rates of adverse events over time (Figure 4) were notable for high prevalence of nephrotoxicity affecting 2075 (40%) of all episodes, and demonstrating significant association with vancomycin therapy, although no difference was observed between vancomycin monotherapy and vancomycin-containing combination regimens (Table 1). The highest incidence of non-anaphylactic allergic reactions was noted with nafcillin, affecting 8.51% courses (rate 2.51/1000 Nafcillin OPAT days, p=0.018) and cefepime, affecting 4.18% courses, (rate 1.36/1000 Cefepime OPAT days, p=0.008). One-year mortality following enrollment into OPAT was 11%. Conclusions: Leveraging a robust informatics and reporting infrastructure may allow for consistent and ongoing capture of OPAT-related adverse events and outcomes. More studies are needed to validate standardized approaches for longitudinal evaluation of OPAT program safety and quality, supported by development of regional and national performance benchmarks.

This paper puts forward a theoretically derived measure of firm-level political influence defined over a sample of firms from a diverse set of countries, permitting new inferences into state-business relations. We derive this measure from original surveys of 27,613 firms in 41 countries, which include information on several interactions with political actors. Using a Bayesian item response theory measurement model that incorporates non-ignorable missing data, we estimate influence scores that incorporate survey data on diverse mechanisms by which firms attempt to obtain influence. From the measurement model, we learn that membership in a business association contains the most positive information about a firm’s influence, while bribes, state ownership, firm size, and a reliance on collective lobbying tend to be substitutes for influence in equilibrium. Empirically, we are able to show for the first time how such influence is distributed across different types of political regimes using a measurement model, leading to intriguing hypotheses about how the costs and benefits of political activity structure corporate influence-seeking.

Background: Measles cases have been increasing in the United States and globally. However, the nonspecific presentation and ability to mimic and coexist with other common infections can delay diagnosis. During July 2024, a 12-year-old patient fully vaccinated for measles with recent international travel was admitted to an acute care pediatric hospital with fever, rash, mouth sores, and cough and initially thought to have a common viral infection. Rash progression during hospitalization prompted measles polymerase chain reaction (PCR) testing, which was positive. The hospital rapidly conducted contact tracing and infection prevention (IP) efforts, including quarantine, symptom monitoring, and postexposure prophylaxis (PEP) administration, to prevent secondary measles transmission. Methods: The patient was placed on airborne isolation ~24 hours after presentation, pending measles testing results. After notification of the positive PCR test, hospital IP staff performed unit walkthroughs and reviewed security footage to retrace the patient’s movements. Staff determined the patient was transported for an echocardiogram, chest radiograph, and walked about the emergency department before isolation. Findings were used to identify contacts requiring quarantine, immunity testing, and PEP. Contacts were notified and those within the PEP window period who were immunocompromised or without presumptive evidence of immunity were offered PEP. All contacts were monitored for development of measles infection. Results: Within 36 hours, 158 staff contacts and 90 contacts among patients and visitors were identified, including 9 infants and 24 patients with incomplete measles immunization. At completion, the investigation identified 350 contacts, including 187 staff, 73 patients, and 90 visitors. The hospital administered PEP to 24 staff, 21 patients, and 6 visitors in accordance with American Academy of Pediatrics Redbook recommendations. Among 51 PEP recipients, 2 patients received intramuscular immunoglobulin, 8 patients received intravenous immunoglobulin, and 41 contacts, including all staff and visitors receiving PEP, received MMR vaccine. Six staff members who had no evidence of immunity were furloughed from work for 21 days after index patient contact. No secondary infections were reported. Conclusions: A single measles case resulted in 350 contacts among patients, visitors, and hospital staff, exemplifying the broad reach measles can have in healthcare settings. This event highlights the need for a high level of suspicion to promptly identify, isolate, and test possible measles patients. Secondary transmission can be prevented through thorough and coordinated investigations to identify all contacts at the facility, rapidly placing contacts without immunity in quarantine, and mobilizing resources to ensure timely PEP administration to eligible contacts.

Background: Clostridioides difficile infection (CDI) disproportionately impacts hematology-oncology patients. In June 2022, our hospital implemented screening of asymptomatic patients admitted to the hematology-oncology unit to reduce CDI rates by early identification and isolation of C. difficile carriers. We evaluated the impact of admission screening on rates of CDI and compared incidence of diarrhea and subsequent symptomatic testing stratified by asymptomatic admission testing result. Method: During the intervention period (July 2022 – July 2024), asymptomatic patients admitted to the hematology-oncology unit were tested for C. difficile (perirectal swab, Cepheid GeneXpert®, Sunnyvale, CA). Guidelines for C. difficile symptomatic testing (unformed stool, Cepheid GeneXpert®) and treatment did not change between the baseline (May 2020 – May 2022) and intervention periods. Monthly CDI rates were calculated using CDC definitions based on clinical symptoms and positive C. difficile testing (community onset [CO] if positive in the first three hospital days, hospital-onset [HO] if day 4 or later). We performed an interrupted time-series analysis adjusted for repeated measures to compare CO-CDI and HO-CDI rates per 10,000 patient-days between baseline and intervention periods. The risk of developing diarrhea through hospital day 14 or being tested for symptomatic CDI during the intervention’s first year (July 2022 – June 2023) was analyzed using a cohort of asymptomatic C. difficile carriers and non-carriers in a 1:2 ratio, matched on hospital length of stay and date of admission. Result: The incidence rate ratio was 0.45 (P=0.10) for HO-CDI (Figure 1) and 0.15 (P=0.049) for CO-CDI (Figure 2) after screening implementation. During the first year of the intervention, 25 individuals were identified as asymptomatic C. difficile carriers by positive admission screen and were matched to a cohort of 50 asymptomatic non-carriers. There were no significant differences in development of diarrhea during hospital days 1-3 or days 4-14 between carriers and non-carriers (Table). None of the carriers received symptomatic C. difficile testing during hospitalization, compared to 20% of matched non-carriers (P=0.03). Conclusion: There was no significant change in HO-CDI rates and a statistically significant reduction in CO-CDI rates after implementation of C. difficile admission screening. Patients identified as carriers at time of admission were less likely to be tested for CDI during hospitalization than non-carriers, despite similar rates of diarrhea. Admission screening for C. difficile may reduce CDI rates through a variety of mechanisms; changes in provider testing behavior for patients previously screened for C. difficile may play a role.

Philosophers have been drawing their attention to the metaphysics of symmetries. Most have taken a Closed System View, that is, the metaphysical assumption that closed systems are ontologically fundamental. In this article, I explore the consequences of adopting a different perspective, the Open System View, according to which open systems are regarded as ontologically fundamental. I argue that by doing so, our metaphysical understanding of symmetries changes substantially in three respects: Epistemic approaches are favored, ontic approaches should change the set of physical symmetries regarded as fundamental, and the metaphysical connection between conservation principles and symmetries is weaker than thought.

Surgical site infection (SSI) is one of the most common complications following cesarean section (CSEC) and adds significant burden to the healthcare system. We aimed to explore factors associated with increased risk of these infections and to compare disease severity based on tissue level.

Observational study of post-CSEC SSIs from Jan 2021-Dec 2023 at Henry Ford Hospital in Detroit. SSIs were defined according to National Healthcare Safety Network (NHSN) criteria. Cases were categorized as superficial incisional (SI), deep incisional (DI) and organ space (OS). Demographics, risk factors, clinical features and outcomes were evaluated. DI and OS were grouped together into non-superficial infections for comparative analysis. 70 (3%) of 2,230 CSECs performed during the study period met post-CSEC SSI criteria, of which 41 (60%) were SI, 4 (6%) DI, and 25 (34%) OS (Table 1). Majority of patients were black (51.5%) with BMI>30 (56%), had Medicaid insurance (66%) and underwent emergent CSEC (60%). Anemia (hemoglobin 3 manual exams prior to surgery (55% vs. 29%, p=0.017) were significantly more common among patients with non-superficial infections. Receipt of perioperative antibiotics was similar between the two groups, and most were administered within 1 hour of incision; cefazolin was frequently used. Incisional pain and drainage were the most prevalent symptoms (Table 2). Abdominal pain (69% vs. 10%, 3 manual exams and worse clinical outcomes compared to patients with superficial infections. Implementing evidence-based practices and recommendations are therefore critical to reduce the morbidity associated with non-superficial CSEC infections.

This paper argues in favour of a desire-based account of normativity. In addition, it demonstrates that the view is particularly well-placed to answer ‘bootstrapping’ objections. Such objections have previously been taken to be a problem not just for desire-based accounts, but for a variety of other subjective accounts of practical normativity.

I will begin by explaining desire-based accounts of normativity, and then by explicating two different kinds of bootstrapping objection: one about normative conflicts, and one about normativity coming from the wrong kind of source. Both objections, I will show, can be answered with a clear explanation of what makes desire-based accounts of normativity so attractive: their ability to explain practical normative force. As such, this paper aims to go further than simply being a new response to a popular objection, or a new argument in support of a controversial view. It will also contribute to a better understanding of practical normativity itself, and how the nature of the normativity depends on and changes with the corresponding desire.

The first geographically widespread metazoans form the Avalon assemblage (Ediacaran; 574–560 Ma). These early animals were regularly disturbed by sedimentation events such as ash flows and turbidites, leading to an apparent “resetting” of communities. However, it is not clear how biological legacies—remains or survivors of disturbance events—influenced community ecology in the Avalon. Here, we use spatial point process analysis on 19 Avalon paleocommunities to test whether two forms of biological legacy (fragmentary remains of Fractofusus and survivor fronds) impacted the recolonization dynamics of Avalon paleocommunities. We found that densities of Fractofusus were increased around the Fractofusus fragments, suggesting that they helped to recolonize the post-disturbance substrate, potentially contributing to the Fractofusus dominance found in 8 of the 19 paleocommunities. However, we found no such effects for survivor fronds. Our results suggest that the evolution of height was for long-distance dispersal rather than local recolonization. In modern deep-sea environments, there is a trade-off between local and long-distance dispersal, and our work demonstrates that this differentiation of reproductive strategies had already developed in the early animals of the Avalon.

Dubbed ‘the Impaler’ by his contemporaries, Vlad III Dracula (c. 1431–76), was accused of the slaughter of between 40,000 and 100,000 individuals, 20,000 of them allegedly impaled at the Wallachian capital Targovişte. Although historians have often considered these figures inflated, none of the numerous studies dedicated to the voivode of Wallachia have undertaken a methodical evaluation of the extent of this exaggeration. This article takes up this historiographical challenge by examining all available documentation. In so doing, it provides a full reassessment of the practice of impalement in fifteenth-century south-eastern Europe. Contrary to assumptions of previous scholarship, Vlad’s use of impalement was influenced simultaneously by pre-existing Hungarian and Ottoman practices. Quantitative analysis shows that only 7–10 per cent of the impalements claimed by sources can be considered plausible and proposes a new data-driven estimation of Vlad’s impaled victims. Finally, a comparison with other rulers shows that, while Vlad ordered collective impalements more frequently, the average number of victims per impalement was similar to that elsewhere in south-eastern Europe.

The objective of this study is to assess the effects of the configuration, size, and density of family and personal networks on women’s current fertility in Ouagadougou. The association between women’s reproductive histories and their social networks was evaluated using Poisson regression models and fairly original data on these networks. The study is based on three family configurations: ‘Restricted’ (children and friends), ‘Kinship’ (blood or marital relatives), and ‘Sibling’ (brothers and sisters). Results show that the type of family configuration has a significant effect on current fertility. ‘Kinship’ and ‘Sibling’ configurations are associated with higher current fertility, while the ‘Restricted’ configuration is associated with lower fertility. Regarding the size and density of the network, the findings indicate that network size and density are negatively associated with current fertility. These results highlight the need to take social networks into account in strategies aimed at controlling fertility in the city of Ouagadougou.

For a family $\mathcal {F}$ of graphs, let ${\mathrm {ex}}(n,\mathcal {F})$ denote the maximum number of edges in an n-vertex graph which contains none of the members of $\mathcal {F}$ as a subgraph. A longstanding problem in extremal graph theory asks to determine the function ${\mathrm {ex}}(n,\{C_3,C_4\})$. Here we give a new construction for dense graphs of girth at least five with arbitrary number of vertices, providing the first improvement on the lower bound of ${\mathrm {ex}}(n,\{C_3,C_4\})$ since 1976. As a corollary, this yields a negative answer to a problem in Chung-Graham [3].

Embodied cognition theory posits that language comprehension is grounded in sensorimotor experience. For instance, abstract concepts such as perceived power are metaphorically associated with spatial information such as physical size. Here, using a size judgement task, we investigated whether perceived power embodiment differs between languages in Chinese–English bilinguals. Asked to make judgements regarding the physical size of words, participants responded faster and made fewer errors to high-power words (e.g., king) presented in bold and large font than in thin and small font, while no such effect was found for low-power words. Furthermore, this congruency effect was stronger in bilinguals’ L1 (Chinese) than in their L2 (English). Thus, while embodiment of perceived power is detectable in both languages of bilinguals, it appears weaker in the L2. This study highlights cross-linguistic similarities and differences in the embodiment of abstract concepts and contributes to our understanding of conceptual knowledge grounding in bilinguals.

This paper reassesses the genealogy of the registered company constitution, focusing on the enforceability against the company of individual shareholder rights in the articles of association. Orthodox accounts posit that the statutory covenant, now found in the Companies Act 2006, s 33(1), has since 1856 been the sole source of the constitution’s bindingness as between the shareholders and the company. But adherents to the orthodox account have been unable to agree on the precise legal effect of the statutory covenant, especially in respect of which rights in the articles can be enforced by shareholders against the company. This paper proposes an alternative account, whereby the statutory covenant’s only effect was deeming assignees and allottees of shares to have covenanted, upon joining the company, to observe the articles. Ordinary privity of contract rendered the articles binding between the original parties to the constitution – ie the company and the subscribers. Furthermore, ordinary privity of estate determined that allottees and assignees of shares could enforce insider rights, but not outsider rights, against the company. This recognition that the benefit of certain articles should be given proprietary status was crucial in shaping the proprietary nature of shares.

La gestion socioterritoriale du vieillissement constitue un enjeu fondamental au Nouveau-Brunswick. Comme cette province ne possède pas de stratégie territoriale du vieillissement, il revient aux municipalités d’aménager leur territoire afin de favoriser le vieillissement sur place. L’objectif de cet article consiste à évaluer la perception des élus municipaux, des intervenants communautaires et des aînés en ce qui a trait à la gestion socioterritoriale du vieillissement dans quatre villes du Nouveau-Brunswick. L’approche utilisée est celle des représentations sociales des acteurs à partir d’entrevues semi-dirigées. Sur le plan théorique, notre analyse s’appuie sur le modèle de gérontologie environnementale. Bien que les résultats de nos entretiens révèlent une satisfaction généralisée des répondants concernant l’implication des élus à la gestion socioterritoriale du vieillissement, des disparités persistent notamment au chapitre de l’accessibilité par rapport à certains édifices et au manque d’infrastructures dédiées spécifiquement aux aînés. Pour pallier ces difficultés, le déploiement d’une stratégie territoriale du vieillissement multiniveau constitue une piste de solutions à envisager.