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Seattle, WA, United States

Klontz K.C.,Outreach | Singh N.,George Washington University
Expert Review of Anti-Infective Therapy

Since the introduction of sulfonamides in the late 1930s, selective pressure and the widespread dissemination of mobile genetic elements conferring antimicrobial resistance have forced clinicians to seek successive agents for the treatment of multidrug-resistant shigellosis. Over the decades, the principal antibiotics used to treat Shigella infections have included tetracycline, chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, and nalidixic acid. Presently, ciprofloxacin, azithromycin, and ceftriaxone serve as the mainstays of treatment, although growing evidence has documented decreased susceptibility or full resistance to these agents in some regions. With diminishing pharmaceutical options available, there is an enhanced need for preventive measures in the form of improved sanitation and hygiene standards, strict use of currently effective agents, and a safe and effective licensed vaccine. © Informa UK, Ltd. Source

BACKGROUND: Multi-morbidity, or the presence of multiple chronic diseases, is a major problem in clinical care and is associated with worse outcomes. Additionally, the presence of mental health conditions, such as depression, anxiety, etc., has further negative impact on clinical outcomes. However, most health systems are generally configured for management of individual diseases instead of multi-morbidity. The study examined the prevalence and differential impact of medical and psychiatric multi-morbidity on risk of death in adults with diabetes.METHODS: A national cohort of 625,903 veterans with type 2 diabetes was created by linking multiple patient and administrative files from 2002 through 2006. The main outcome was time to death. Primary independent variables were numbers of medical and psychiatric comorbidities over the study period. Covariates included age, gender, race/ethnicity, marital status, area of residence, service connection, and geographic region. Cox regression was used to model the association between time to death and multi-morbidity adjusting for relevant covariates.RESULTS: Hypertension (78%) and depression (13%) were the most prevalent medical and psychiatric comorbidities, respectively; 23% had 3+ medical comorbidities, 3% had 2+ psychiatric comorbidities and 22% died. Among medical comorbidities, mortality risk was highest in those with congestive heart failure (hazard ratio, HR = 1.92; 95% CI 1.89-1.95), Lung disease (HR = 1.42; 95% CI 1.40-1.44) and cerebrovascular disease (HR = 1.39; 95% CI 1.37-1.40). Among psychiatric comorbidities, mortality risk was highest in those with substance abuse (HR = 1.50; 95% CI 1.46-1.54), psychoses (HR = 1.16; 95% CI 1.14-1.19) and depression (HR = 1.05; 95% CI 1.03-1.07). There was an interaction between medical and psychiatric comorbidity (p = 0.003) so stratified analyses were performed. HRs for effect of 3+ medical comorbidity (2.63, 2.66, 2.15) remained high across levels of psychiatric comorbidities (0, 1, 2+), respectively. HRs for effect of 2+ psychiatric comorbidity (1.69, 1.63, 1.42, 1.38) declined across levels of medical comorbidity (0, 1, 2, 3+), respectively.CONCLUSIONS: Medical and psychiatric multi-morbidity are significant predictors of mortality among older adults (veterans) with type 2 diabetes with a graded response as multimorbidity increases. Source

"Sivulirijat aksururnaqtukkuurnikugijangat aktuiniqaqsimaninga kinguvaanginnut" translates as "the trauma experienced by generations past having an effect in their descendants." The legacy of the history of colonialism is starting to take narrative shape as Inuit give voice to the past and its manifestations in the present through public commissions such as the federal Truth and Reconciliation Commission and the Inuit-led Qikiqtani Truth Commission. However, an examination of other discursive contexts reveals a collective narrative of the colonial past that is at times silent, incomplete or seemingly inconsistent. Reading the political narrative through the Nunavut Land Claims Agreement, and the proceedings of the Legislative Assembly of Nunavut since its formation on April 1, 1999, exposes an almost complete silence about this history. Oral histories, an important form for the preservation and transmission of traditional cultural knowledge, do narrate aspects of this experience of contact, but in accounts that can appear highly individual, fragmented, even contradictory. In contrast, one domain that does seem to register and engage with the impacts of this history of colonialism is Inuit art, specifically visual art and film. In some cases these artistic narratives pre-date the historical trauma narratives of the commissions, which began with the Royal Commission on Aboriginal Peoples (RCAP) in the mid-1990s. This paper examines these narrative alternatives for recounting historic trauma in Nunavut, while also considering the implications of understanding historical trauma as narrative. © The Author(s) 2014. Source

AIM: To share an experience of examining the true extent of the number of patients with severe sepsis being admitted, and the overall compliance with existing treatment guidelines in a district general hospital (DGH). BACKGROUND: Because of its aggressive, multi-factorial nature, sepsis is a rapid killer. Mortality associated with severe sepsis remains unacceptably high: 30-50%. When shock is present, mortality is reported to be even higher: 50-60%. The rapid diagnosis and management of sepsis is vital to successful treatment. The International Surviving Sepsis Campaign (SSC) was developed to help meet the challenges of sepsis and to improve its management, diagnosis and treatment. The overall aim is to reduce mortality from sepsis by 25% by 2009. DATA SOURCES AND METHODS: Data on the number of patients admitted with severe sepsis to the DGH were previously unknown. The aim of the baseline audits was to determine the true extent of the problem and baseline mortality rates, resulting in an action plan to provide evidence-based care to patients with sepsis regardless of where in the hospital they were located. RESULTS: It was found that 11% of the patients audited presented with signs of severe sepsis and demonstrated elements of poor compliance with some elements of existing treatment guidelines as set out by the resuscitation component of the Surviving Sepsis Care Bundle. CONCLUSION: As an international campaign introduced predominantly within critical care, within this DGH the SSC teams' innovative approach has resulted in: * Better educated staff; * Objectives agreed within multi-disciplinary teams; * The appropriate assessment of resources; * Standardization of practice in terms of patients presenting with severe sepsis. Source

BACKGROUND: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an auto immune-disorder. It is a life threatening condition that typically presents with viral illness, headaches, severe psychiatric symptoms, seizures, behavioural changes, decreasing levels of unconsciousness and progressive unresponsiveness, cognitive impairment, abnormal movements (e.g., dyskinesia), ataxia and hypoventilation. OBJECTIVE: This paper describes the long term outcome and rehabilitation management of patients with NMDAR encephalitis and highlights the diverse outcome of this condition and the unique and individual long term management needs associated with this disorder. METHODS: This is a case report study of three different patients with NMDAR encephalitis. All three cases are young women, two of whom presented with ovarian teratoma. Patient KH is the most impaired and was resident in a slow stream rehabilitation care home and presented with challenging behaviour. Patients RM and OA both lived in the community and presented with similar anxieties but diverse levels of cognition and motivation. A review of the literature is provided summarizing the disorder, interventions, management and challenges of this varied and complex condition. Standard neuropsychological tests and questionnaires to assess community integration (BICRO-39), quality of life (QOLIBRI-OS) and mood (HADS) were administered. RESULTS: Positive outcomes were achieved for all three patients using a variety of interventions which included behavioural management, family psycho-education and an integrated holistic multi-disciplinary team community approach. Memory and executive deficits were persistent in the long term and severity of impairments showed wide variability between patients. Emotional distress and behavioural difficulties were prominent and persistent and had a pronounced impact on rehabilitation. Continence issues were also a major factor impacting on the rehabilitation. CONCLUSIONS: Long term integrated and multi-disciplinary input by a variety of therapies and health disciplines is required in order to improve the long term outcome and quality of life for NMDAR patients and their families, and ultimately leads to improved positive outcomes. Each of these cases had markedly differing cognitive profiles suggesting that in the context of long term rehabilitation outcome, cognition may have less valence than emotional and behavioural factors. Guidelines and standardised procedures for ethical issues and counselling for iatrogenic infertility should be developed and integrated into long term programmes of rehabilitation care. © 2014 -IOS Press and the authors. Source

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