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This study introduces a novel approach to measuring the evolution of union power in Latin America. Using an original dataset covering ten dimensions of union activity across 17 countries from 1990 to 2020, it addresses shortcomings in prior research based on overly broad indicators or narrow case studies. In line with the specialized literature, factor analysis identifies four distinct dimensions of union power—associational, structural, institutional, and societal—each showing unique variation across countries. Hierarchical cluster analysis reveals four ideal types: (1) strongly embedded unionism, with robust associational and institutional strength (Argentina, Uruguay); (2) social movement unionism, marked by strong societal alliances but limited institutional access (e.g., Bolivia, Ecuador); (3) bureaucratic and isolated unionism, with institutional integration but weak societal mobilization (Brazil, Chile, Mexico); and (4) low-intensity unionism, prevalent in Central America. Correlation analyses reveal complex interactions among these dimensions. The study provides new empirical and conceptual tools to advance comparative research on labor movements in the region.
Avocados are a widely consumed fruit and are part of many Latin American cuisines and plant-based diets globally. However, producing avocados is water-intensive, and plantations can cause soil erosion and water stress. In Chile, avocados are produced in semiarid zones and require irrigation. They are widely consumed locally but are increasingly exported to meet growing global demand. This causes significant local conflicts over water, especially because of the system of private water rights in Chile. There are many gaps in understanding the complex and interconnected system of avocado production and international markets, especially its impacts on local communities and biodiversity.
Technical Summary.
The popularity of avocados has increased globally in alternative diets, alongside its integral role in Latin American cuisine. In Chile, avocados are grown extensively and intensively in orchards in the dry and Mediterranean climate of Central Chile. Avocado is a water-demanding crop and the severe water crisis in Chile has called attention to the conflicts caused by its water use. As most of the pressure to produce avocado comes from international demand but results in impacts on native ecosystems and local communities, avocado production in Chile is an example of a telecoupled system. Here, we characterize avocado production as a telecoupled social–ecological system in order to identify gaps in knowledge, based on a review of key studies. Research priorities include how to improve water-use efficiency, especially in the context of climate change; the impacts on biodiversity; and the socioeconomic dynamics between local communities, trade, and governance. The analysis is constrained by limited access to data and few interdisciplinary studies on the matter. To reduce the impacts of avocado production and increase its sustainability, there is an urgent need to amplify the interdisciplinary research that emphasizes the interconnections between the social and ecological components in avocado production in Chile.
Social Media Summary.
Global avocado demand fuels local conflicts in Chile due to water stress and social–ecological pressures on communities.
Young stellar objects (YSOs) are protostars that exhibit bipolar outflows fed by accretion disks. Theories of the transition between disk and outflow often involve a complex magnetic field structure thought to be created by the disk coiling field lines at the jet base; however, due to limited resolution, these theories cannot be confirmed with observation and thus may benefit from laboratory astrophysics studies. We create a dynamically similar laboratory system by driving a $\sim$1 MA current pulse with a 200 ns rise through a $\approx$2 mm-tall Al cylindrical wire array mounted to a three-dimensional (3-D)-printed, stainless steel scaffolding. This system creates a plasma that converges on the centre axis and ejects cm-scale bipolar outflows. Depending on the chosen 3-D-printed load path, the system may be designed to push the ablated plasma flow radially inwards or off-axis to make rotation. In this paper, we present results from the simplest iteration of the load which generates radially converging streams that launch non-rotating jets. The temperature, velocity and density of the radial inflows and axial outflows are characterized using interferometry, gated optical and ultraviolet imaging, and Thomson scattering diagnostics. We show that experimental measurements of the Reynolds number and sonic Mach number in three different stages of the experiment scale favourably to the observed properties of YSO jets with $Re\sim 10^5\unicode{x2013}10^9$ and $M\sim 1\unicode{x2013}10$, while our magnetic Reynolds number of $Re_M\sim 1\unicode{x2013}15$ indicates that the magnetic field diffuses out of our plasma over multiple hydrodynamical time scales. We compare our results with 3-D numerical simulations in the PERSEUS extended magnetohydrodynamics code.
The authors report on ancient DNA data from two human skeletons buried within the chancel of the 1608–1616 church at the North American colonial settlement of Jamestown, Virginia. Available archaeological, osteological and documentary evidence suggest that these individuals are Sir Ferdinando Wenman and Captain William West, kinsmen of the colony's first Governor, Thomas West, Third Baron De La Warr. Genomic analyses of the skeletons identify unexpected maternal relatedness as both carried the mitochondrial haplogroup H10e. In this unusual case, aDNA prompted further historical research that led to the discovery of illegitimacy in the West family, an aspect of identity omitted, likely intentionally, from genealogical records.
Multiple studies have demonstrated that European colonization of the Americas led to the death of nearly all North American dog mitochondrial lineages and replacement with European ones sometime between AD 1492 and the present day. Historical records indicate that colonists imported dogs from Europe to North America, where they became objects of interest and exchange as early as the seventeenth century. However, it is not clear whether the earliest archaeological dogs recovered from colonial contexts were of European, Indigenous, or mixed descent. To clarify the ancestry of dogs from the Jamestown Colony, Virginia, we sequenced ancient mitochondrial DNA from six archaeological dogs from the period 1609–1617. Our analysis shows that the Jamestown dogs have maternal lineages most closely associated with those of ancient Indigenous dogs of North America. Furthermore, these maternal lineages cluster with dogs from Late Woodland, Hopewell, and Virginia Algonquian archaeological sites. Our recovery of Indigenous dog lineages from a European colonial site suggests a complex social history of dogs at the interface of Indigenous and European populations during the early colonial period.
Humankind's main defence against the virus that causes COVID-19 (SARS-CoV-2), besides vaccine development, was co-ordinated behaviour change. In many countries, co-ordination was assisted by tracking surveys designed to measure self-reported behaviour and attitudes. This paper describes an alternative, complementary approach, which was undertaken in close collaboration with officials in the Department of the Taoiseach (Irish Prime Minister). We adapted the Day Reconstruction Method (DRM) to develop the ‘Social Activity Measure’ (SAM). The study was conducted fortnightly for 18 months, with findings delivered directly to the Department. This paper describes the method and shows how SAM generated a detailed picture of where and why transmission risk occurred. By using the DRM, we built aggregate measures from narrative accounts of how individuals spent their previous day. SAM recorded the amount, location and type of social activity, including the incidence of close contact and mask-wearing, as well as compliance with public health restrictions by shops and businesses. The method also permitted a detailed analysis of how public perceptions and comprehension are related to behaviour. The results informed government communications and strategies for lifting public health restrictions. The method could be applied to other future situations that might require co-ordinated public behaviour over an extended period.
The Cambrian (Miaolingian; Wuliuan) Spence Shale Lagerstätte of northern Utah and southern Idaho is one of the most diverse Burgess Shale-type deposits of Laurentia. It yields a diverse fauna consisting of abundant biomineralized and locally abundant soft-bodied fossils, along a range of environments from shallow-water carbonates to deep-shelf dark shales. Panarthropods are the dominant component throughout the deposit, both in time and space, but whereas the trilobites and agnostoids are abundant, most of the soft-bodied taxa are only known from very few specimens. Additionally, the knowledge of soft-bodied panarthropods is currently largely limited to locations in the Wellsville Mountains of northeastern Utah. This contribution describes 21 new soft-bodied panarthropods from six locations, including the first occurrences of soft-bodied panarthropods in the High-Creek, Smithfield Creek, Spence Gulch, and Two-Mile Canyon localities. Additionally, we report the presence of bradoriids— i.e., Branchiocaris pretiosa Resser, 1929, Perspicaris? dilatus Robison and Richards, 1981, Naraoia? sp. indet., Thelxiope cf. T. palaeothalassia Simonetta and Delle Cave, 1975, and Tuzoia guntheri Robison and Richards, 1981—for the first time from the Spence Shale Lagerstätte; the first reported occurrence outside of the Burgess Shale for Thelxiope cf. T. palaeothalassia; and the first Wuliuan occurrence of Tuzoia guntheri. We also report on a new hurdiid carapace element and additional specimens of Buccaspinea cooperi? Pates et al., 2021, Dioxycaris argenta Walcott, 1886, Hurdia sp. indet., and Tuzoia retifera Walcott, 1912. This new material improves our understanding of the panarthropod fauna of the Spence Shale Lagerstätte and substantially increases our understanding of the distribution of the described taxa in time and space.
The aim of this study was to evaluate the effect of a short-acting antipsychotic (acepromazine) on the stress response to transport in roe deer (Capreolus capreolus). Twenty-one roe deer were submitted to a nine-hour road journey in order to reintroduce and restock this species into Catalonia (north-eastern Spain). The animals were divided into two groups: animals in the treatment group received an intramuscular injection of acepromazine (0.13 mg kg−1 in 0.5 ml; n = 9) while animals in the control group received the same volume of saline (n = 12). Clinical (heart rate and body temperature, measured during transport using remote devices), haematological, and biochemical indicators of stress were used to evaluate the effect of the antipsychotic. Heart rate increased during transportation, but no differences were found between groups. Body temperature decreased during transportation in both groups, but this reduction was faster in acepromazine-treated animals. Comparison of blood parameters before and after transport revealed significantly lower red blood cell counts and haemoglobin concentrations after transport in treated animals compared with control animals; a reduction in lymphocyte count, eosinophil count and serum creatinine levels over transport in treated animals; a decrease in serum potassium levels over transport in the control group; an increase in serum creatine kinase (CK), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) activities over transport in control animals; an increase in serum urea and chloride concentrations over transport in both groups; and finally, a decrease in serum glucose concentrations in both groups. These results demonstrate the suitability of acepromazine in transport operations in order to reduce the stress response and prevent its adverse effects in roe deer.
The aim of this trial was to describe the behavioural, neuroendocrine, immune and acute phase stress responses in dogs undergoing elective surgery in normal, clinical practice conditions. Sixteen dogs were submitted to elective orchiectomy or ovariohysterectomy using a standardised surgical protocol. Each animal was confined to the Intensive Care Unit during pre- and post-surgery and perioperative behavioural, neuroendocrine, immune and acute phase responses were studied. Behavioural categories, cortisol, prolactin, white blood cell, C-reactive protein and haptoglobin variation were evaluated. Values at different times were compared with basal values shown by the dog in its usual environment. Communicative and explorative behaviours showed high occurrence pre-surgery and were inhibited post-surgery. Decreases in post-surgery activity, interactive behaviours and changes in waking/sleeping patterns were observed. The most sensitive marker of psychological stress, cortisol, in comparison with basal values, showed a significant increase both during pre- and post-surgery confinement in the ICU cage. Prolactin values were characterised by a significant decrease early into the post-surgery period. The immune response was characterised by long-term neutrophilia and monocytosis, but by short-term lymphopaenia and eosinopaenia, limited to the early post-operative period. With regard to the acute phase response, both C-reactive protein and haptoglobin showed a long-term increase, post-surgery. Changes in behavioural, haematological and biochemical markers showed that perioperative stress represents a major challenge to dog welfare.
The Asteropyginae Delo, 1935 is a group of phacopid trilobites in the family Acastidae Delo, 1935 that has served as the focus for several studies due to their distinctive morphologies and diversity. However, despite an interest in these characteristic morphologies, there have been no studies that have examined this group using morphometric techniques. Our investigation utilized both geometric morphometric and elliptical Fourier methods to quantify the morphology of cephalic sclerites of asteropyginid specimens representing wide taxonomic sampling of the clade. We constructed a phylomorphospace that shows temporal and spatial patterns of phenotypic evolution within the framework of a novel tip-dated phylogenetic tree generated using Bayesian inference. We recovered similar patterns in disparity regardless of the morphometric approach. Both analyses illustrated a marked expansion into morphospace throughout the temporal range of the clade, peaking in disparity in the Emsian and with European taxa exhibiting the highest disparity in glabellar morphospace. Additionally, glabellar shape showed low phylogenetic signal and no major patterns in phylomorphospace. This study highlights the utility of employing different methodologies to quantitatively explore the disparity of fossil taxa. It also illustrates some of the patterns of morphological change occurring during one of the final and major evolutionary radiations within Phacopida.
When samples from a single taxonomic species are resolved as monophyletic, or coalescent, in a phylogenetic analysis of DNA sequences, this is often the basis for “cryptic” or otherwise overlooked plant species. Here, we examine ecological evolutionary reasons behind genetic patterns within plant species.. We suggest that coalescence or monophyly of conspecific genetic samples occurs more commonly in animal than plant clades, which implies that plant species are more likely to have some combination of larger effective population sizes from a population or genomic perspective, inhabit less dispersal-limited habitats or niches, or have evolutionary younger ages. For woody plant species, we suspect that dry environments are more dispersal limited than wetter environments. We give examples that suggest coalescence of conspecific plant samples likely occurs more often among genetic samples taken from isolated populations that are phylogenetically niche conserved to the succulent biome. This is in comparison to those taken from isolated plant populations that are niche conserved to tropical wet forests. However, these suggested patterns will be context dependent. Recency of evolution, large effective population sizes, or polyploid genomes could work against detecting coalescent patterns of conspecific genetic samples in plant taxa that are niche conserved to the succulent biome.
Nonnative plant invasions can have devastating effects on native plant communities; conversely, management efforts can have nontarget and deleterious impacts on desirable plants. In the arid sagebrush steppe rangelands of the western United States, nonnative winter annual species affect forage production and biodiversity. One method proposed to control these species is to suppress the soil seedbank using the preemergent herbicide indaziflam. Our goal was to evaluate the efficacy of indaziflam to control nonnative annual mustards (Alyssum spp.) and to understand potential nontarget effects of management on the diverse mountain sagebrush steppe plant communities within Yellowstone National Park. Six sites were established along an elevation gradient (1,615 to 2,437 m), each with high and low Alyssum spp. infestations. We applied 63g ai ha−1 of indaziflam in late summer of 2018 and evaluated plant community cover in situ for 2 yr after treatment and emergence of forb species from the soil seedbank ex situ. Indaziflam was highly effective at controlling emergence of Alyssum spp. for 2 yr. Richness and Shannon’s diversity of the nontarget plant community were significantly lower in sprayed plots than in the control, and both decreased along the elevation gradient. These reductions were due to a decrease in perennial forbs and native annual forbs in the sprayed plots; perennial graminoids were not affected. Overall, the aboveground and seedbank community composition was negatively impacted by indaziflam, and these effects were strongest for the native annual forbs that rely on annual regeneration from the seedbank. The effects of this herbicide to the nontarget community should be evaluated beyond the length of our study time; however, we conclude that indaziflam should likely be reserved for use in areas that are severely invaded and have seedbanks that are composed of nondesirable species rather than diverse, native mountain sagebrush communities.
Background: Carbapenem-resistant Enterobacteriaceae (CRE) are endemic in the Chicago region. We assessed the regional impact of a CRE control intervention targeting high-prevalence facilities; that is, long-term acute-care hospitals (LTACHs) and ventilator-capable skilled nursing facilities (vSNFs). Methods: In July 2017, an academic–public health partnership launched a regional CRE prevention bundle: (1) identifying patient CRE status by querying Illinois’ XDRO registry and periodic point-prevalence surveys reported to public health, (2) cohorting or private rooms with contact precautions for CRE patients, (3) combining hand hygiene adherence, monitoring with general infection control education, and guidance by project coordinators and public health, and (4) daily chlorhexidine gluconate (CHG) bathing. Informed by epidemiology and modeling, we targeted LTACHs and vSNFs in a 13-mile radius from the coordinating center. Illinois mandates CRE reporting to the XDRO registry, which can also be manually queried or generate automated alerts to facilitate interfacility communication. The regional intervention promoted increased automation of alerts to hospitals. The prespecified primary outcome was incident clinical CRE culture reported to the XDRO registry in Cook County by month, analyzed by segmented regression modeling. A secondary outcome was colonization prevalence measured by serial point-prevalence surveys for carbapenemase-producing organism colonization in LTACHs and vSNFs. Results: All eligible LTACHs (n = 6) and vSNFs (n = 9) participated in the intervention. One vSNF declined CHG bathing. vSNFs that implemented CHG bathing typically bathed residents 2–3 times per week instead of daily. Overall, there were significant gaps in infection control practices, especially in vSNFs. Also, 75 Illinois hospitals adopted automated alerts (56 during the intervention period). Mean CRE incidence in Cook County decreased from 59.0 cases per month during baseline to 40.6 cases per month during intervention (P < .001). In a segmented regression model, there was an average reduction of 10.56 cases per month during the 24-month intervention period (P = .02) (Fig. 1), and an estimated 253 incident CRE cases were averted. Mean CRE incidence also decreased among the stratum of vSNF/LTACH intervention facilities (P = .03). However, evidence of ongoing CRE transmission, particularly in vSNFs, persisted, and CRE colonization prevalence remained high at intervention facilities (Table 1). Conclusions: A resource-intensive public health regional CRE intervention was implemented that included enhanced interfacility communication and targeted infection prevention. There was a significant decline in incident CRE clinical cases in Cook County, despite high persistent CRE colonization prevalence in intervention facilities. vSNFs, where understaffing or underresourcing were common and lengths of stay range from months to years, had a major prevalence challenge, underscoring the need for aggressive infection control improvements in these facilities.
Funding: The Centers for Disease Control and Prevention (SHEPheRD Contract No. 200-2011-42037)
Disclosures: M.Y.L. has received research support in the form of contributed product from OpGen and Sage Products (now part of Stryker Corporation), and has received an investigator-initiated grant from CareFusion Foundation (now part of BD).
Background:Candida auris prevalence in Illinois, particularly in the metropolitan Chicago area, is high. The Illinois Department of Public Health recommends empiric contact precautions for patients with a tracheostomy or requiring mechanical ventilation from skilled nursing facilities (vSNFs) or long-term acute-care hospitals (LTACHs) who are admitted to an acute-care hospital. Cases of C. auris infection and colonization are reportable to the Illinois Extensively Drug Resistant Organism Registry (XDRO Registry). NorthShore University HealthSystem (NSUHS) actively screens adult intensive care unit (ICU) admissions from LTACHs and vSNFs for CA. Methods: NSUHS is a 4-hospital system located north of Chicago with 750 beds, 4 ICUs and ∼64,000 annual admissions. Beginning in April 2019, a composite axilla–groin swab was collected from all ICU LTACH or vSNF admissions. Composite swabs are cultured on Inhibitory Mold Agar. In July 2019, an ICU clinical case of C. auris was identified from a ventilated patient admitted from an outside hospital prompting the expansion of screening to include acute-care hospital transfers. To evaluate the value of screening criteria, a medical record review and retrospective query of the XDRO Registry was performed for all screened patients. Because cocolonization with carbapenemase-producing organisms (CPO) has been reported, CPO status was also queried. Results: Between April 1 and October 31, 2019, 70 patients were screened. Two screened patients did not meet the screening criteria (Fig. 1). No patients, with the exception of the clinical case, were found to be colonized with CA. The XDRO Registry query identified no patients with C. auris. Of the 70 patients, 9 (13%) had a CPO. Of those screened, 14 (20%) had a tracheostomy and/or mechanical ventilation (Table 1). Conclusions: Querying the XDRO registry at admission in combination with a medical record review appears adequate to identify patients admitted to a NSUHS ICU with C. auris and CPOs. Targeting patients admitted with a tracheostomy and/or mechanical ventilation may further reduce the number of screening cultures performed.
Background: Catheter-associated urinary tract infections (CAUTIs) account for >15% of hospital-acquired infections, resulting in increased length of stay and costs. Consequently, methods to improve indwelling urinary catheter (IUC) care and maintenance are warranted to reduce the risk of hospital-acquired CAUTIs. This study was a prospective quality improvement (QI) project to reduce CAUTIs using prepackaged cloths (ReadyCleanse by Medline Industries) and a simple, standardized cleaning process for care and maintenance of IUCs. Methods: This study is an ongoing QI project at NorthShore University HealthSystem, a 4-hospital system located north of Chicago, Illinois, with 750 beds and ∼64,000 annual admissions. The study consists of a 1.5-month staff training on proper product use (phase 1), followed by an intervention using the cloths for IUC care (phase 2). Each package contains 5 individual cloths corresponding to a simple, 5-step, cleansing protocol. IUC care and maintenance are performed twice daily on a routine basis and after each incontinent episode. Beginning July 2018, current practice (soap and wash cloth) was replaced with the ReadyCleanse cloths, and on August 1, 2018, data collection began. Adult patients admitted at all 4 NorthShore Hospitals with an IUC for >24 hours are enrolled in the study. From patient electronic health records, we collected patient demographics, reason for IUC insertion, days of catheter use, and development of CAUTI (according to the NHSN definition). During the intervention, observations of compliance and performance of catheter care were also performed. For the analysis described here, results for the first 14 months of the study were compared to CAUTI numbers from the 14-month period prior to the start of the study (February 2017–March 2018); the data presented represent ∼50% of the planned data collection. Results: As of September 30, 2019, 4,969 patients were prospectively enrolled in the study: 1,491 patients from hospital A, 1,451 from hospital B, 1,091 from hospital C, and 936 from hospital D. Patient demographics for the study cohort were 47% female, with a median age of 77 years and an average of 3.9 catheter days per patient. Systemwide, observational audits for compliance using the cloths averaged 95%. Upon completion of study month 14, 22 CAUTIs had been identified, compared to 26 CAUTIs for the comparison period, indicating a 15% reduction. Conclusion: Implementation of this simple, standardized alternative for IUC care is feasible on a large scale and may have potential for reducing CAUTI rates.
Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent source of infection in the neonatal intensive care unit (NICU). Due to the serious consequences associated with MRSA infections in neonates, much effort has been made to prevent and control epidemics in NICUs. Since 2006, our hospital has performed MRSA nasal surveillance screening of all newborns in the NICU in accordance with the recommendations of the Chicago-Area Neonatal MRSA Working Group. In 2017, a MRSA infection was identified in a newborn shortly after transfer from an outside hospital and who had an initial negative MRSA admission screen. As a result, we modified the admission screening process for all transfers from outside NICUs. Methods: The Evanston Hospital Infant Special Care Unit is a level 3 NICU in the northern suburbs of Chicago with 44 NICU beds and 450 admissions per year. Effective July 1, 2017, all NICU transfers have a nasal MRSA screen performed upon admission and after 48 hours. The transferred baby is placed on contact isolation until both screening results return negative. Nasal MRSA testing is performed using both PCR on the BD MAX MRSA Assay platform and is confirmed by culture using MRSA CHROMagar TM. Results: Between July 1, 2017, and October 31, 2019, 112 neonates were transferred from outside NICUs. Moreover, 105 (94%) had at least 1 MRSA screen completed and 99 (88%) had both MRSA screens completed. Of 99 with 2 screens, only 1 neonate had an initial positive nasal MRSA screen. Of the remaining 98 negative babies, none had a repeat positive nasal MRSA screen within 48 hours of admission. of 99 neonates with 2 serial admission MRSA screens, 82 (83%) were transferred within 48 hours of birth. In addition, 17 neonates were transferred >48 hours after birth, including the 1 MRSA-positive baby. Conclusions: In an attempt to identify all potential MRSA-positive neonates transferred to our NICU, we instituted a policy of 2 admission nares swabs. However, our data suggest that a single initial MRSA swab may be sufficient. If continued collection of a second screen is performed, it may be sufficient to screen babies who have been hospitalized for at least 48 hours prior to transfer, which eliminates 83% of admission testing and results in a cost savings.
An innovative approach to perioperative antiseptic skin preparation is warranted because of potential adverse skin irritation, rare risk of serious allergic reaction, and perceived diminished clinical efficacy of current perioperative antiseptic agents. The results of a confirmatory US Food and Drug Administration (FDA) phase 3 efficacy analysis of a recently approved innovative perioperative surgical skin antiseptic agent are discussed.
Methods:
The microbial skin flora on abdominal and groin sites in healthy volunteers were microbiologically sampled following randomization to either ZuraGard, a 2% chlorhexidine/70% isopropyl alcohol preparation (Chloraprep), or a control vehicle (alcohol-free ZuraGard). Mean log10 reduction of colony-forming units (CFU) was assessed at 30 seconds, 10 minutes, and 6 hours.
Results:
For combined groin sites (1,721 paired observations) at all time points, the mean log10 CFU reductions were significantly greater in the ZuraGard group than in the Chloraprep group (P < .02). Mean log10 CFU reductions across combined abdominal and groin sites at all time points (3,277 paired observations) were significantly greater in the ZuraGard group than in the Chloraprep group (P < .02).
Conclusions:
A confirmatory FDA phase 3 efficacy analysis of skin antisepsis in human volunteers documented that ZuraGard was efficacious in significantly reducing the microbial burden on abdominal and groin test sites, exceeding that of Chloraprep. No significant adverse reactions were observed following the application of ZuraGard.
The aim of this paper is to display an alternative to the familiar decompositional approach in action theory, one that resists the demand for an explanation of action in non-agential terms, while not simply treating the notion of intentional agency as an unexplained primitive. On this Anscombean alternative, action is not a worldly event with certain psychological causes, but a distinctive form of material process, one that is not simply caused by an exercise of reason but is itself a productive exercise of reason. I argue that to comprehend the proposed alternative requires an account of the temporality of events in general. An event does not simply have a position in time, but is itself temporally structured. With the inner temporality of events in view, the Anscombean conception of action as a specifically self-conscious form of temporal unity is made available for critical reflection.
Describe and validate the CHROME (CHemical Restraints avOidance MEthodology) criteria.
Design:
Observational prospective longitudinal study.
Setting:
Single nursing home in Las Palmas de Gran Canaria, Spain.
Participants:
288 residents; mean age: 81.6 (SD 10.6). 77.4% had dementia.
Intervention:
Multicomponent training and consultancy program to eliminate physical and chemical restraints and promote overall quality care. Clinicians were trained in stringent diagnostic criteria of neuropsychiatric syndromes and adequate psychotropic prescription.
Measurements:
Psychotropic prescription (primary study target), neuropsychiatric syndromes, physical restraints, falls, and emergency room visits were semi-annually collected from December 2015 to December 2017. Results are presented for all residents and for those who had dementia and participated in the five study waves (completer analysis, n=107).
Results:
For the study completers, atypical neuroleptic prescription dropped from 42.7% to 18.7%, long half-life benzodiazepines dropped from 25.2% to 6.5%, and hypnotic medications from 47.7% to 12.1% (p<0.0005). Any kind of fall evolved from 67.3 to 32.7 (number of falls by 100 residents per year). Physicians’ diagnostic confidence increased, while the frequency of diagnoses of neuropsychiatric syndromes decreased (p<0.0005).
Conclusions:
Implementing the CHROME criteria reduced the prescription of the most dangerous medications in institutionalized people with dementia. Two independent audits found no physical or chemical restraint and confirmed prescription quality of psychotropic drugs. Adequate diagnosis and independent audits appear to be the keys to help and motivate professionals to optimize and reduce the use of psychotropic medication. The CHROME criteria unify, in a single compendium, neuropsychiatric diagnostic criteria, prescription guidelines, independent audit methodology, and minimum legal standards. These criteria can be easily adapted to other countries.