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At Saint George Hospital University Medical Center in Beirut, Lebanon, we determine (1) annual blood culture (BC) contamination (BCC) and utilization (BCU) rates vs international benchmarks, (2) identify blood culture contaminants, (3) bloodstream infections episodes in patients with and without COVID-19 after the pandemic onset, and (4) any epidemiologic trends in BCC and BCU.
Design:
Retrospective observational study.
Setting:
Private tertiary referral center, from January 1, 2010, to December 31, 2022.
Methods:
We define a contaminated BC as the growth of a typical contaminant/skin flora in 1-2/4 BC bottles. We calculate BCC rates as a percentage of the contaminated BC/total BC during the period and BCU rates as the number of BC/1000 patient days (PD).
Results:
The average BCU rate of 85.9/1000 PD in 2010–2019 increased to 106.6/1000 PD in 2020–2022. On average, patients with COVID-19 had a higher BCU rate of 185.9/1000 PD, corresponding to an additional 100 blood cultures/1000 PD. The average BCC rate was 7%, ranging from 6% in 2010–2019 to 8% in 2020–2022. We observed the highest BCC rate of 9% in patients with COVID-19, likely due to the higher BCU. The most frequently isolated contaminants were coagulase-negative Staphylococcus (96%), of which 65% were Staphylococcus epidermidis.
Conclusion:
We saw a multifactorial, persistently elevated rate of BCC over 13 years as unaffected by strict infection control practices. We think that further research targeting a standardized, low BCU rather than inevitable BCC while advocating for diagnostic stewardship of low-middle-income countries is essential, especially where the lack of appropriate resource allocation and awareness are problematic.
To compare the per-patient direct and indirect costs associated with achieving remission with esketamine nasal spray plus oral antidepressants (ESK NS+OAD) versus quetiapine extended release plus oral antidepressants (QTP XR+OAD) among patients with treatment-resistant depression (TRD). This comparison was based on a subanalysis of results from the ESCAPE-TRD Phase 3b trial (ex-US) comparing response and remission rates for ESK NS+OAD vs QTP XR+OAD in TRD patients over 32 weeks.
Methods
An Excel-based model was developed to estimate the cost-per-remitter for ESK NS+OAD and QTP XR+OAD from the perspective of a commercial insurance plan in the US. Remission rates, response rates, and relapse rates (among patients remitting or responding during the first 8 weeks of treatment) were estimated in 4-week intervals over 32 weeks using data from the ESCAPE-TRD Phase 3b clinical trial comparing ESK NS+OAD versus QTP XR+OAD in patients with TRD. Patients not remitting/responding (non-responders) or experiencing a relapse either stayed on current treatment (i.e., ESK NS+OAD or QTP XR+OAD) or discontinued current treatment and initiated either augmented therapy with antipsychotics (APS) or recurring transcranial magnetic stimulation (rTMS). For basecase analysis, equal proportions of non-responders off-treatment initiated rTMS or augmented therapy with APS. In a scenario analysis, all non-responders off-treatment initiated rTMS. Direct costs, including medical and drug costs, were derived from health economic literature and the RED BOOK® drug pricing database. Indirect costs attributed to work productivity loss from presenteeism and absenteeism were derived from a separate analysis of ESCAPE-TRD patients using the Work Productivity and Activity Impairment: Depression (WPAI:D) questionnaire and US Bureau of Labor Statistics survey results.
Results
The cumulative relapse-free remission rate at 32 weeks was 50% for patients receiving ESK NS+OAD and 33% for patients receiving QTP XR+OAD. In the basecase analysis, the cost-per-remitter (including direct and indirect costs) for ESK NS+OAD was $3,102.17 lower than that of QTP XR+OAD. In the scenario where 100% of non-responders off-treatment were assumed to initiate rTMS, the cost-per-remitter (including direct and indirect costs) for ESK NS+OAD was $15,133.66 lower than that of QTP XR+OAD.
Conclusion
These findings suggest that esketamine nasal spray in conjunction with oral antidepressants is a cost-efficient alternative compared with quetiapine extended release for treatment of TRD for commercial insurance plans. The comparative benefits associated with ESK NS+OAD treatment are driven primarily by better short- and long-term efficacy observed in the trial and particularly pronounced when considering the costs associated with lost productivity.
Jordan’s mammalian fauna has experienced significant declines due to intensified hunting since the early twentieth century, leading to the extinction of six species and threatening 39% of the remaining species. This research evaluates the evolution of Jordan’s hunting laws across three historical stages – the Ottoman period, the establishment of Jordan and the modern era – highlighting their impacts on mammalian diversity and identifying legislative gaps contributing to species declines. Using Arabic-based legal databases and historical archives, we found that inadequate legal frameworks, political instability, economic pressures and weak enforcement often accelerated species depletion. Notably, the 1957 Hunting Law permitted hunting of vulnerable species with a licence and of predators without a licence, worsening species decline. Although the 1962 Defense Law aimed to protect nature, its expiration hindered progress. The 1966 Hunting Law largely duplicated the 1957 law, perpetuating these problems, and then hunting regulations were absorbed into agricultural law, undermining conservation efforts. Despite these legal shortcomings, Jordan’s modernization vision provides hope for reform, including the potential restoration of the Hunting Law under the Ministry of Environment and incorporating the right to a healthy environment into Jordan’s constitution to help prevent a mass extinction of mammals.
A new model of confirmatory factor analysis (CFA) for multitrait-multimethod (MTMM) data sets is presented. It is shown that this model can be defined by only three assumptions in the framework of classical psychometric test theory (CTT). All other properties of the model, particularly the uncorrelatedness of the trait with the method factors are logical consequences of the definition of the model. In the model proposed there are as many trait factors as different traits considered, but the number of method factors is one fewer than the number of methods included in an MTMM study. The covariance structure implied by this model is derived, and it is shown that this model is identified even under conditions under which other CFA-MTMM models are not. The model is illustrated by two empirical applications. Furthermore, its advantages and limitations are discussed with respect to previously developed CFA models for MTMM data.
In this article, we present a general theorem and proof for the global identification of composed CFA models. They consist of identified submodels that are related only through covariances between their respective latent factors. Composed CFA models are frequently used in the analysis of multimethod data, longitudinal data, or multidimensional psychometric data. Firstly, our theorem enables researchers to reduce the problem of identifying the composed model to the problem of identifying the submodels and verifying the conditions given by our theorem. Secondly, we show that composed CFA models are globally identified if the primary models are reduced models such as the CT-C\documentclass[12pt]{minimal}\usepackage{amsmath}\usepackage{wasysym}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{amsbsy}\usepackage{mathrsfs}\usepackage{upgreek}\setlength{\oddsidemargin}{-69pt}\begin{document}$$(M-1)$$\end{document} model or similar types of models. In contrast, composed CFA models that include non-reduced primary models can be globally underidentified for certain types of cross-model covariance assumptions. We discuss necessary and sufficient conditions for the global identification of arbitrary composed CFA models and provide a Python code to check the identification status for an illustrative example. The code we provide can be easily adapted to more complex models.
A new multiple indicator multilevel latent state-trait (LST) model for the analysis of multitrait–multimethod–multioccasion (MTMM-MO) data is proposed. The LST-COM model combines current CFA-MTMM modeling approaches of interchangeable and structurally different methods and LST modeling approaches. The model enables researchers to specify construct and method factors on the level of time-stable (trait) as well as time-variable (occasion-specific) latent variables and analyze the convergent and discriminant validity among different rater groups across time. The statistical performance of the model is scrutinized by a simulation study and guidelines for empirical applications are provided.
One of the main challenges in weight loss programmes is compliance with diet and achievement of sustainable changes in eating habits and lifestyles. Most clients desire to lose weight quickly, rather than looking at long-term changes. The literature suggests applying telenutrition, owing to its convenience and easy access in combination with both telemonitoring and health coaching, where confounding factors in the diet are tackled. A 6-month randomised controlled trial will be conducted to compare the effectiveness of telenutrition v. telenutrition supported by weekly telemonitoring and monthly health coaching in a weight loss programme. Participants are obese and overweight adults of both sex groups, aged 20–50 years who will be randomised to join a control or an intervention group. A total of three visits will be scheduled for all participants: at baseline, after three months and after six months. This study aims to answer the question of whether participants following a weight loss programme supported by telemonitoring and health coaching will increase their weight loss and compliance to the diet in comparison with the control group. This will be the first trial to assess the impact of integrating telemonitoring and health coaching in weight loss programmes, including the evaluation of associated confounding factors such as general nutrition education, eating behaviour, sensory modalities and hunger, and stress. This trial will support dietary weight loss programmes, contribute to the emerging field of telenutrition and provide advice for clinical dietitians and health coaches to work together to help individuals lose and maintain weight.
Oral cancer survival rates have seen little improvement over the past few decades. This is mainly due to late detection and a lack of reliable markers to predict disease progression in oral potentially malignant disorders (OPMDs). There is a need for highly specific and sensitive screening tools to enable early detection of malignant transformation. Biochemical alterations to tissues occur as an early response to pathological processes; manifesting as modifications to molecular structure, concentration or conformation. Raman spectroscopy is a powerful analytical technique that can probe these biochemical changes and can be exploited for the generation of novel disease-specific biomarkers. Therefore, Raman spectroscopy has the potential as an adjunct tool that can assist in the early diagnosis of oral cancer and the detection of disease progression in OPMDs. This review describes the use of Raman spectroscopy for the diagnosis of oral cancer and OPMDs based on ex vivo and liquid biopsies as well as in vivo applications that show the potential of this powerful tool to progress from benchtop to chairside.
Maternal anxiety, depression, and stress during and after pregnancy are negatively associated with child cognitive development. However, the contribution of positive maternal experiences, such as social support, to child cognitive development has received less attention. Furthermore, how maternal experience of social support during specific developmental periods impacts child cognitive development is largely unknown.
Methods
Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC; n = 5784) and the Prediction and Prevention of Preeclampsia and Intrauterine Growth Restriction study (PREDO; n = 420), we investigated the associations between maternal perceived social support during and after pregnancy and child's general cognitive ability at 8 years of age, assessed with the Wechsler Intelligence Scale for Children (WISC). Bayesian relevant life course modeling was used to investigate timing effects of maternal social support on child cognitive ability.
Results
In both cohorts, higher maternal perceived social support during pregnancy was associated with higher performance on the WISC, independent of sociodemographic factors and concurrent maternal symptoms of depression and anxiety. In ALSPAC, pregnancy emerged as a sensitive period for the effects of perceived social support on child cognitive ability, with a stronger effect of social support during pregnancy than after pregnancy on child cognitive ability.
Conclusions
Our findings, supported from two prospective longitudinal cohorts, suggest a distinct role of maternal perceived social support during pregnancy for cognitive development in children. Our study suggests that interventions aimed at increasing maternal social support during pregnancy may be an important strategy for promoting maternal and child well-being.
This rejoinder responds to a commentary (Horak et al., 2023) on our article ‘De-Linking from Western Epistemologies: Using Guanxi-Type Relationships to Attract and Retain Hotel Guests in the Middle East' (2022). We thank the authors for engaging with our work and are grateful to the editor for the chance to respond. Firstly, we do not accept the central assertion that we imposed the Chinese concept of guanxi on a Middle Eastern context. Some aspects of guanxi extend beyond China, and we consider it part of our role as researchers to explore universal behavioral aspects that transcend specific cultural settings. While we described guanxi to introduce the variables, we drew a clear distinction between guanxi itself and guanxi-type relationships, and provided on page 859 an explicit statement about what we meant by the term ‘guanxi-type relationships’, i.e. the networks of interpersonal ties found in the Middle East. While this distinction could have been more clearly emphasized in places, we consider that the article as a whole made it abundantly clear.
Monoclonal antibody (mAb) treatment for coronavirus disease 2019 (COVID-19) has been underutilized due to logistical challenges, lack of access, and variable treatment awareness among patients and health-care professionals. The use of telehealth during the pandemic provides an opportunity to increase access to COVID-19 care.
Methods:
This is a single-center descriptive study of telehealth-based patient self-referral for mAb therapy between March 1, 2021, and October 31, 2021, at Baltimore Convention Center Field Hospital (BCCFH).
Results:
Among the 1001 self-referral patients, the mean age was 47, and most were female (57%). White (66%), and had a primary care provider (PCP) (62%). During the study period, self-referrals increased from 14/mo in March to 427 in October resulting in a 30-fold increase. Approximately 57% of self-referred patients received a telehealth visit, and of those 82% of patients received mAb infusion therapy. The median time from self-referral to onsite infusion was 2 d (1-3 IQR).
Discussion:
Our study shows the integration of telehealth with a self-referral process improved access to mAb infusion. A high proportion of self-referrals were appropriate and led to timely treatment. This approach helped those without traditional avenues for care and avoided potential delay for patients seeking referral from their PCPs.
The relationship between non-communicable diseases and eating behaviour has long been attributed to a surplus of food and energy. However, the increase in the prevalence of non-communicable disease and their underlying low-grade inflammatory milieu among people of low socio-economic status has highlighted the existence of a confounding factor. In this work, we aim to study the effect of lysine deficiency on some inflammatory markers in the absence or presence of an inflammatory insult (lipopolysaccharide (LPS)). For this purpose, thirty-two 5-week-old male Sprague Dawley rats were randomly distributed into four groups: (1) control diet, (2) control diet+LPS, (3) lysine-deficient diet and (4) lysine-deficient diet + LPS. Groups were only allowed their experimental diets for 4 weeks, during which LPS (50 µg/kg) or saline injections were administered intraperitoneally three times per week. The study showed that lysine deficiency blunted growth and body compartments development, decreased albumin production and elevated liver C-reactive protein (CRP) expression, independently of IL-6 and IL-1β, the main precursors of CRP. Also, the insufficient levels of lysine in the diet increased hyperactivity and triggered an anxiety-like behaviour, exacerbated with LPS. This work presents evidence that various physiological changes are associated with the absence of a sufficient amount of lysine in the diet and can potentially increase the risk factor for diseases. Thus, the increment in non-communicable disease among the low socio-economic status populations, who heavily rely on cereals as a main source of protein, can be, at least partially, blamed on low lysine availability in diets.
In response to the coronavirus disease (COVID-19) pandemic, the State of Maryland established a 250-bed emergency response field hospital at the Baltimore Convention Center to support the existing health care infrastructure. To operationalize this hospital with 65 full-time equivalent clinicians in less than 4 weeks, more than 300 applications were reviewed, 186 candidates were interviewed, and 159 clinicians were credentialed and onboarded. The key steps to achieve this undertaking involved employing multidisciplinary teams with experienced personnel, mass outreach, streamlined candidate tracking, pre-interview screening, utilizing all available expertise, expedited credentialing, and focused onboarding. To ensure staff preparedness, the leadership developed innovative team models, applied principles of effective team building, and provided “just in time” training on COVID-19 and non-COVID-19-related topics to the staff. The leadership focused on staff safety and well-being, offered appropriate financial remuneration, and provided leadership opportunities that allowed retention of staff.
The association between maternal metabolic status at the time of conception and subsequent embryogenesis and offspring development has been studied in detail. However, less attention has been given to the significance of paternal nutrition and metabolism in directing offspring health. Despite this disparity, emerging evidence has begun to highlight an important connection between paternal metabolic well-being, semen quality, embryonic development and ultimately adult offspring health. This has established a new component within the Developmental Origins of Health and Disease hypothesis. Building on the decades of understanding and insight derived from the numerous models of maternal programming, attention is now becoming focused on defining the mechanisms underlying the links between paternal well-being, post-fertilisation development and offspring health. Understanding how the health and fitness of the father impact on semen quality is of fundamental importance for providing better information to intending fathers. Furthermore, assisted reproductive practices such as in vitro fertilisation rely on our ability to select the best quality sperm from a diverse and heterogeneous population. With considerable advances in sequencing capabilities, our understanding of the molecular and epigenetic composition of the sperm and seminal plasma, and their association with male metabolic health, has developed dramatically over recent years. This review will summarise our current understanding of how a father's metabolic status at the time of conception can affect sperm quality, post-fertilisation embryonic and fetal development and offspring health.
Bidirectional longitudinal relationships between depression and diabetes have been observed, but the dominant direction of their temporal relationships remains controversial.
Methods
The random-intercept cross-lagged panel model decomposes observed variables into a latent intercept representing the traits, and occasion-specific latent ‘state’ variables. This permits correlations to be assessed between the traits, while longitudinal ‘cross-lagged’ associations and cross-sectional correlations can be assessed between occasion-specific latent variables. We examined dynamic relationships between depressive symptoms and insulin resistance across five visits over 20 years of adulthood in the population-based Coronary Artery Risk Development in Young Adults (CARDIA) study. Possible differences based on population group (Black v. White participants), sex and years of education were tested. Depressive symptoms and insulin resistance were quantified using the Center for Epidemiologic Studies Depression (CES-D) scale and the homeostatic model assessment for insulin resistance (HOMA-IR), respectively.
Results
Among 4044 participants (baseline mean age 34.9 ± 3.7 years, 53% women, 51% Black participants), HOMA-IR and CES-D traits were weakly correlated (r = 0.081, p = 0.002). Some occasion-specific correlations, but no cross-lagged associations were observed overall. Longitudinal dynamics of these relationships differed by population groups such that HOMA-IR at age 50 was associated with CES-D score at age 55 (β = 0.076, p = 0.038) in White participants only. Longitudinal dynamics were consistent between sexes and based on education.
Conclusions
The relationship between depressive symptoms and insulin resistance was best characterized by weak correlations between occasion-specific states and enduring traits, with weak evidence that insulin resistance might be temporally associated with subsequent depressive symptoms among White participants later in adulthood.
Relationships are widely recognized as key to business success in the form of both informal interpersonal networks and formal organizational relationships. While Chinese personal networks (guanxi) have attracted scholars’ interest, the concept has not been fully investigated or understood in other contexts, especially the Middle East, where personal networks fulfill some of the same roles. The underlying socio-cultural formulae of the distinctive cultural dimensions that influence relationship formation in the Middle East also remain under-explored. This research therefore investigates the dimensions of guanxi-type relationships in the Middle East and introduces a new model integrating these relationships into the existing relationship marketing framework, enabling firms to harness personal networks for organizational gain, in turn generating customer satisfaction and retention. Using empirical data from a survey of 637 hotel guests in 17 countries – drawn from a unique target population of guests introduced to Middle Eastern hotels via personal relationships – we show how guanxi-type relationships influence organizational relationships and improve satisfaction and retention. Our significant contributions to theory and practice include extending a holistic understanding of guanxi, enhancing knowledge of its dimensions in the Middle East, and providing managers with clear evidence for a hybrid system of guanxi-type and organizational relationships.
Ever since the World Health Organization (WHO) declared the new coronavirus disease 2019 (COVID-19) as a pandemic, there has been a public health debate concerning medical resources and supplies including hospital beds, intensive care units (ICU), ventilators and protective personal equipment (PPE). Forecasting COVID-19 dissemination has played a key role in informing healthcare professionals and governments on how to manage overburdened healthcare systems. However, forecasting during the pandemic remained challenging and sometimes highly controversial. Here, we highlight this challenge by performing a comparative evaluation for the estimations obtained from three COVID-19 surge calculators under different social distancing approaches, taking Lebanon as a case study. Despite discrepancies in estimations, the three surge calculators used herein agree that there will be a relative shortage in the capacity of medical resources and a significant surge in PPE demand if the social distancing policy is removed. Our results underscore the importance of implementing containment interventions including social distancing in alleviating the demand for medical care during the COVID-19 pandemic in the absence of any medication or vaccine. The paper also highlights the value of employing several models in surge planning.