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Evaluate prescribing practices and risk factors for treatment failure in obese patients treated for purulent cellulitis with oral antibiotics in the outpatient setting.
Design:
Retrospective, multicenter, observational cohort.
Setting:
Emergency departments, primary care, and urgent care sites throughout Michigan.
Patients:
Adult patients with a body mass index of ≥ 30 kg/m2 who received ≥ 5 days of oral antibiotics for purulent cellulitis were included. Key exclusion criteria were chronic infections, antibiotic treatment within the past 30 days, and suspected polymicrobial infections.
Methods:
Obese patients receiving oral antibiotics for purulent cellulitis between February 1, 2020, and August 31, 2023, were assessed. The primary objective was to describe outpatient prescribing trends. Secondary objectives included comparing patient risk factors for treatment failure and safety outcomes between patients experiencing treatment success and those experiencing treatment failure.
Results:
Two hundred patients were included (Treatment success, n = 100; Treatment failure, n = 100). Patients received 11 antibiotic regimens with 26 dosing variations; 45.5% were inappropriately dosed. Sixty-seven percent of patients received MRSA-active therapy. Treatment failure was similar between those appropriately dosed (46.4%) versus under-dosed (54.4%) (P = 0.256), those receiving 5–7 days of therapy (47.1%) versus 10–14 days (54.4%) (P = 0.311), and those receiving MRSA-active therapy (52.2%) versus no MRSA therapy (45.5%) (P = 0.367). Patients treated with clindamycin were more likely to experience treatment failure (73.7% vs 47.5%, P = 0.030).
Conclusions:
Nearly half of antimicrobial regimens prescribed for outpatient treatment of cellulitis in patients with obesity were suboptimally prescribed. Opportunities exist to optimize agent selection, dosing, and duration of therapy in this population.
Veterinarians are custodians of animal welfare, ensuring practices remain current and effective in the face of the ever-changing demands of the profession. Continuing Professional Development (CPD) is essential for protecting animal welfare, however access to quality CPD is a challenge in many countries. India has one of the fastest growing veterinary industries globally, emphasising the importance of accessible CPD opportunities that are relevant to this setting. This study used focus groups to explore how Indian veterinarians identify relevant CPD, barriers they encounter, and their experiences with CPD. We describe three themes: (1) ‘career vs calling’, where veterinarians’ extrinsic and intrinsic motivational factors were identified, such as their desire to protect animal welfare; (2) being ‘willing to learn but can’t’, with context-specific barriers, such as accessing reliable CPD information; and (3) ‘real interactions matter’, where participants described how pedagogical design influenced their choices, e.g. being able to observe animal welfare improvements through practical teaching. We have three recommendations: firstly, to improve CPD learning opportunities informed by evidence-based methods, to meet knowledge and skills gaps such as the high demand for practically focused training; secondly, the development of a unified accreditation and quality assurance framework to assess content, relevance and delivery standards of available CPD options to veterinarians; and, lastly, improved support from employers to address current barriers and facilitate attendance. These findings contribute to the current knowledge gap of factors that influence Indian veterinarians’ experiences of attaining relevant, accessible CPD and makes suggestions to improve standards of veterinary care and, ultimately, patient welfare.
In recent years, scholars worldwide have begun organising and developing a coherent framework and research agenda focused on the emerging field of ‘global administrative law’. This nascent body of law, unlike domestic or national forms of administrative law, does not operate within the bounds of unitary nation states, and unlike traditional accounts of public international law, it does not arise exclusively between nation states. Instead it operates in a transnational or global space occupied by a vast variety of administrative actors responsible for trans-governmental regulation and administration; the field of ‘global governance’. To combat growing concerns that there are crucial legitimacy, accountability and democratic deficiencies inherent in this system of global governance, numerous administrative law type mechanisms and principles have been developed by global administrative bodies. Global administrative law embodies the totality of these various mechanisms and principles.
Soldiers must be treated in the first instance with humanity but kept under control by means of iron discipline.
In the past fifty years the High Court of Australia has scrutinised the constitutional validity of military service tribunals on several occasions. Each time, the validity of service tribunals to conduct trials and impose punishment in relation to the particular offence has been upheld on the basis that it derives from a proper exercise by the legislature of its power under s 51(vi) of the Constitution. On no occasion has this been considered by the Court as a whole to involve a breach of the separation of powers doctrine. However, while it is generally accepted that service tribunals exercise what would ordinarily be seen as falling within the definition of “judicial power”, there has been no unifying and satisfactory explanation as to why this does not breach the separation of powers doctrine.
The USDA has implemented policies to address inequities for socially disadvantaged farmers and ranchers. This research examines agricultural risk inequities and the impact of 2018 Farm Bill programs on crop insurance use among minority and veteran farmers. Results indicate that minority and veteran farmers are disproportionately located in regions of the U.S. with higher risks of drought and excess precipitation. Yet, these producer groups had lower use of crop insurance prior to the implementation of the 2018 Farm Bill. However, the incentive programs created under the 2018 Farm Bill have increased use of federal crop insurance among these vulnerable populations.
Obsessive-compulsive disorder (OCD) is a neurobehavioral condition that can lead to functional impairment and decreased quality of life. In this chapter, clinical presentation, diagnostic considerations, and pathophysiology of OCD are reviewed. An overview of the theoretical models of OCD are provided, and evidence-based treatments for OCD, specifically cognitive behavioral therapy (CBT) with exposure and response prevention (ERP), pharmacotherapy, and neurosurgery, are discussed. The chapter concludes with suggestions for future research directions.
In Global Navigation Satellite Systems (GNSS)-denied environments, aiding a vehicle's inertial navigation system (INS) is crucial to reducing the accumulated navigation drift caused by sensor errors (e.g. bias and noise). One potential solution is to use measurements of gravity as an aiding source. The measurements are matched to a geo-referenced map of Earth's gravity to estimate the vehicle's position. In this paper, we propose a novel formulation of the map matching problem using a hidden Markov model (HMM). Specifically, we treat the spatial cells of the map as the hidden states of the HMM and present a Viterbi style algorithm to estimate the most likely sequence of states, i.e. most likely sequence of vehicle positions, that results in the sequence of observed gravity measurements. Using a realistic gravity map, we demonstrate the accuracy of our Viterbi map matching algorithm in a navigation scenario and illustrate its robustness compared with existing methods.
In this chapter, we examine the public’s understanding of implicit bias, a topic that has only recently caught the public’s attention. Given that political elites often set the contours of debate on political issues, we begin by conducting a systematic content analysis of newspaper headlines and cable news transcripts to assess the prevalence and nature of media coverage of implicit bias. We find that partisan media utilize starkly different frames regarding the scientific validity of the concept of implicit bias, the political intentions of those who use the phrase, and the requisite political recourses (if any). We then utilize two individual-level datasets to examine the mass public’s understanding of implicit bias. An original survey reveals a stark gulf in partisan understandings of implicit bias and an analysis of Project Implicit data highlights the interplay between personalized feedback from the IAT and ideology in shaping evaluations of the IAT. We conclude with a discussion of the challenges of science communication, particularly on issues relating to race, in a politically polarized age.
We present a cognitive process model of response choice and response time performance data that has excellent psychometric properties and may be used in a wide variety of contexts. In the model there is an accumulator associated with each response option. These accumulators have bounds, and the first accumulator to reach its bound determines the response time and response choice. The times at which accumulator reaches its bound is assumed to be lognormally distributed, hence the model is race or minima process among lognormal variables. A key property of the model is that it is relatively straightforward to place a wide variety of models on the logarithm of these finishing times including linear models, structural equation models, autoregressive models, growth-curve models, etc. Consequently, the model has excellent statistical and psychometric properties and can be used in a wide range of contexts, from laboratory experiments to high-stakes testing, to assess performance. We provide a Bayesian hierarchical analysis of the model, and illustrate its flexibility with an application in testing and one in lexical decision making, a reading skill.
We present a re-discovery of G278.94+1.35a as possibly one of the largest known Galactic supernova remnants (SNRs) – that we name Diprotodon. While previously established as a Galactic SNR, Diprotodon is visible in our new Evolutionary Map of the Universe (EMU) and GaLactic and Extragalactic All-sky MWA (GLEAM) radio continuum images at an angular size of $3{{{{.\!^\circ}}}}33\times3{{{{.\!^\circ}}}}23$, much larger than previously measured. At the previously suggested distance of 2.7 kpc, this implies a diameter of 157$\times$152 pc. This size would qualify Diprotodon as the largest known SNR and pushes our estimates of SNR sizes to the upper limits. We investigate the environment in which the SNR is located and examine various scenarios that might explain such a large and relatively bright SNR appearance. We find that Diprotodon is most likely at a much closer distance of $\sim$1 kpc, implying its diameter is 58$\times$56 pc and it is in the radiative evolutionary phase. We also present a new Fermi-LAT data analysis that confirms the angular extent of the SNR in gamma rays. The origin of the high-energy emission remains somewhat puzzling, and the scenarios we explore reveal new puzzles, given this unexpected and unique observation of a seemingly evolved SNR having a hard GeV spectrum with no breaks. We explore both leptonic and hadronic scenarios, as well as the possibility that the high-energy emission arises from the leftover particle population of a historic pulsar wind nebula.
Flower flies (Diptera: Syrphidae) are a ubiquitous family of true flies known for their hovering mating displays and pollinating behaviour. The flower fly genus Pterallastes Loew is represented by Pterallastes thoracicus Loew in North America, and its previously published range encompasses only the United States of America. Here, we report two new records for Canada and a previously overlooked historical record for the country. These data were used to generate an updated range map for the species, with additional iNaturalist records further expanding its known distribution in the United States of America. Finally, flower associations and natural history data for the species gathered from iNaturalist photos are discussed briefly.
Zonal flows are mean flows in the east–west direction, which are ubiquitous on planets, and can be formed through ‘zonostrophic instability’: within turbulence or random waves, a weak large-scale zonal flow can grow exponentially to become prominent. In this paper, we study the statistical behaviour of the zonostrophic instability and the effect of magnetic fields. We use a stochastic white noise forcing to drive random waves, and study the growth of a mean flow in this random system. The dispersion relation for the growth rate of the expectation of the mean flow is derived, and properties of the instability are discussed. In the limits of weak and strong magnetic diffusivity, the dispersion relation reduces to manageable expressions, which provide clear insights into the effect of the magnetic field and scaling laws for the threshold of instability. The magnetic field mainly plays a stabilising role and thus impedes the formation of the zonal flow, but under certain conditions it can also have destabilising effects. Numerical simulation of the stochastic flow is performed to confirm the theory. Results indicate that the magnetic field can significantly increase the randomness of the zonal flow. It is found that the zonal flow of an individual realisation may behave very differently from the expectation. For weak magnetic diffusivity and moderate magnetic field strengths, this leads to considerable variation of the outcome, that is whether zonostrophic instability takes place or not in individual realisations.
The population of adults with single-ventricle congenital heart disease (CHD) is growing. This study explores their lived experiences through an adult developmental psychology framework.
Methods:
Individuals aged 18 and older with single-ventricle CHD participated in Experience Group sessions and 1:1 interviews. Sessions were transcribed and analysed thematically. Themes were categorized by developmental domains and age group.
Results:
Of the 29 participants, 18 (62%) were female, 10 (35%) were emerging (18–29 years), 13 (45%) were established (30–45 years), and 6 (21%) were midlife adults (46–60 years). Emerging adults expressed reluctance to initiate romantic relationships and fear of burdening partners, while established adults reported strong relationships with partners deeply involved in caregiving. Emerging adults struggled with finding fulfilling work that meets their health needs, whereas established and midlife adults faced unemployment or early retirement due to health limits. Family dynamics shifted, with established and midlife adults educating their children to become caregivers. Physical limitations and low self-rated health were consistent across life stages, and midlife adults did not worry about traditional chronic conditions. Mental health concerns, including anxiety and depression, persisted across all life stages, but resiliency and positive affect were also evident.
Conclusion:
Adults with single-ventricle CHD experience developmental milestones differently, indicating the need for early anticipatory guidance in these domains to achieve optimal outcomes in adulthood.
The gut microbiome is impacted by certain types of dietary fibre. However, the type, duration and dose needed to elicit gut microbial changes and whether these changes also influence microbial metabolites remain unclear. This study investigated the effects of supplementing healthy participants with two types of non-digestible carbohydrates (resistant starch (RS) and polydextrose (PD)) on the stool microbiota and microbial metabolite concentrations in plasma, stool and urine, as secondary outcomes in the Dietary Intervention Stem Cells and Colorectal Cancer (DISC) Study. The DISC study was a double-blind, randomised controlled trial that supplemented healthy participants with RS and/or PD or placebo for 50 d in a 2 × 2 factorial design. DNA was extracted from stool samples collected pre- and post-intervention, and V4 16S rRNA gene sequencing was used to profile the gut microbiota. Metabolite concentrations were measured in stool, plasma and urine by high-performance liquid chromatography. A total of fifty-eight participants with paired samples available were included. After 50 d, no effects of RS or PD were detected on composition of the gut microbiota diversity (alpha- and beta-diversity), on genus relative abundance or on metabolite concentrations. However, Drichlet’s multinomial mixture clustering-based approach suggests that some participants changed microbial enterotype post-intervention. The gut microbiota and fecal, plasma and urinary microbial metabolites were stable in response to a 50-d fibre intervention in middle-aged adults. Larger and longer studies, including those which explore the effects of specific fibre sub-types, may be required to determine the relationships between fibre intake, the gut microbiome and host health.
Clostridioides difficile infection (CDI) may be misdiagnosed if testing is performed in the absence of signs or symptoms of disease. This study sought to support appropriate testing by estimating the impact of signs, symptoms, and healthcare exposures on pre-test likelihood of CDI.
Methods:
A panel of fifteen experts in infectious diseases participated in a modified UCLA/RAND Delphi study to estimate likelihood of CDI. Consensus, defined as agreement by >70% of panelists, was assessed via a REDCap survey. Items without consensus were discussed in a virtual meeting followed by a second survey.
Results:
All fifteen panelists completed both surveys (100% response rate). In the initial survey, consensus was present on 6 of 15 (40%) items related to risk of CDI. After panel discussion and clarification of questions, consensus (>70% agreement) was reached on all remaining items in the second survey. Antibiotics were identified as the primary risk factor for CDI and grouped into three categories: high-risk (likelihood ratio [LR] 7, 93% agreement among panelists in first survey), low-risk (LR 3, 87% agreement in first survey), and minimal-risk (LR 1, 71% agreement in first survey). Other major factors included new or unexplained severe diarrhea (e.g., ≥ 10 liquid bowel movements per day; LR 5, 100% agreement in second survey) and severe immunosuppression (LR 5, 87% agreement in second survey).
Conclusion:
Infectious disease experts concurred on the importance of signs, symptoms, and healthcare exposures for diagnosing CDI. The resulting risk estimates can be used by clinicians to optimize CDI testing and treatment.
SARS-CoV-2 superspreading occurs when transmission is highly efficient and/or an individual infects many others, contributing to rapid spread. To better quantify heterogeneity in SARS-CoV-2 transmission, particularly superspreading, we performed a systematic review of transmission events with data on secondary attack rates or contact tracing of individual index cases published before September 2021 prior to the emergence of variants of concern and widespread vaccination. We reviewed 592 distinct events and 9,883 index cases from 491 papers. A meta-analysis of secondary attack rates identified substantial heterogeneity across 12 chosen event types/settings, with the highest transmission (25–35%) in co-living situations including households, nursing homes, and other congregate housing. Among index cases, 67% reported zero secondary cases and only 3% (287) infected >5 secondary cases (“superspreaders”). Index case demographic data were limited, with only 55% of individuals reporting age, sex, symptoms, real-time polymerase chain reaction (PCR) cycle threshold values, or total contacts. With the data available, we identified a higher percentage of superspreaders among symptomatic individuals, individuals aged 49–64 years, and individuals with over 100 total contacts. Addressing gaps in the literature regarding transmission events and contact tracing is needed to properly explain the heterogeneity in transmission and facilitate control efforts for SARS-CoV-2 and other infections.
In the current study we evaluated an afterschool nutrition education programme, called Vetri Cooking Lab (VCL), for promoting healthy and diverse eating habits among at-risk children in the Greater Philadelphia area. To understand potential programme impacts, we conducted a longitudinal analysis of survey data collected before and after participation in VCL. Main study included cooking confidence, cooking knowledge, changes in dietary consumption behaviours, and changes in vegetable preferences. Participants included students in grades 3–11 enrolled in VCL during the 2018–19 school year at VCL sites (n = 60) throughout Philadelphia, PA, and Camden, NJ. Eligible participants completed surveys both before and after participating in the programme. We found that students’ confidence and knowledge increased (P < 0.001) after the cooking intervention. Knowledge and confidence were positively associated (r = 0.55; P < 0.001). Confidence was correlated with consumption behaviour changes (r = 0.18; P = 0.022). Confidence was positively associated with consumption changes in both our adjusted (OR = 1.81; P < 0.001) and unadjusted models (aOR = 1.88; P = 0.013). Compared to Black students, White students were more likely to report consumption changes (aOR = 5.83; P = 0.013). Hispanic/Latino participants and participants who spoke Spanish had nearly three times higher odds of consumption behaviour changes (Hispanic/Latino OR = 2.55; P = 0.007; Spanish OR = 3.04; P = 0.005). Student age and gender were not associated with behaviour changes. Our research demonstrates that programmes integrating practical cooking skills education along with nutrition, food, and cooking education can improve confidence and knowledge about healthy food choices amongst children driving an overall improvement in children’s eating habits.
Studies have shown an association between workplace safety climate scores and patient outcomes. This study aimed to investigate (1) performance of the hospital safety climate scale that was adapted to assess acute respiratory illness safety climate, (2) factors associated with safety climate scores, and (3) whether the safety scores were associated with following recommended droplet and contact precautions.
Methods:
A survey of Canadian healthcare personnel participating in a cohort study of influenza during the 2010/2011–2013/2014 winter seasons. Factor analysis and structural equation modeling were used for analyses.
Results:
Of the 1359 participants eligible for inclusion, 88% were female and 52% were nurses. The adapted items loaded to the same factors as the original scale. Personnel working on higher risk wards, nurses, and younger staff rated their hospital’s safety climate lower than other staff. Following guidelines for droplet and contact precautions was positively associated with ratings of management support and absence of job hindrances.
Conclusion:
The adapted tool can be used to assess hospital safety climates regarding respiratory pathogens. Management support and the absence of job hindrances are associated with hospital staff’s propensity and ability to follow precautions against the transmission of respiratory illnesses.