Associations with antibiotic prescribing for acute exacerbation of COPD in primary care: secondary analysis of a randomised controlled trial

Background C-reactive protein (CRP) point-of-care testing can reduce antibiotic use in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in primary care, without compromising patient care. Further safe reductions may be possible. Aim To investigate the associations between presenting features and antibiotic prescribing in patients with AECOPD in primary care. Design and setting Secondary analysis of a randomised controlled trial of participants presenting with AECOPD in primary care (the PACE trial). Method Clinicians collected participants’ demographic features, comorbid illnesses, clinical signs, and symptoms. Antibiotic prescribing decisions were made after participants were randomised to receive a point-of-care CRP measurement or usual care. Multivariable regression models were fitted to explore the association between patient and clinical features and antibiotic prescribing, and extended to further explore any interactions with CRP measurement category (CRP not measured, CRP <20 mg/l, or CRP ≥20 mg/l). Results A total of 649 participants from 86 general practices across England and Wales were included. Odds of antibiotic prescribing were higher in the presence of clinician-recorded crackles (adjusted odds ratio [AOR] = 5.22, 95% confidence interval [CI] = 3.24 to 8.41), wheeze (AOR = 1.64, 95% CI = 1.07 to 2.52), diminished vesicular breathing (AOR = 2.95, 95% CI = 1.70 to 5.10), or clinician-reported evidence of consolidation (AOR = 34.40, 95% CI = 2.84 to 417.27). Increased age was associated with lower odds of antibiotic prescribing (AOR per additional year increase = 0.98, 95% CI = 0.95 to 1.00), as was the presence of heart failure (AOR = 0.32, 95% CI = 0.12 to 0.85). Conclusion Several demographic features and clinical signs and symptoms are associated with antibiotic prescribing in AECOPD. Diagnostic and prognostic value of these features may help identify further safe reductions

Comparative Study of Modelling and Forecasting Volatility: The Case of Egypt, and Japan

The purpose of this paper is to evaluate the forecasting performance of linear and non-linear (GARCH) models in terms of their in-sample and out-of-sample forecasting accuracy for EGX30 and Nikkei225 indices as an example of an emerging and developed markets respectively. We employ GARCH, GARCH-IN-MEAN, EGARCH, GJR-GARCH, Multivariate GARCH, and Nelson's EGARCH for forecasting using daily price data of the indices for the period of 2001 to 2019. We find that the volatility shocks on the indices returns are quite persistent. Furthermore, our findings show that the indices have leverage effect, and the impact of shocks is asymmetric, and consequently it can be stated that the impact of negative shocks on volatility are higher than positive shocks. The results suggest that the Nelson's EGARCH model is the most accurate model in the GARCH class for forecasting, as this model outperforms the other models. Additionally, we find that emerging stock markets have higher volatilities than those in developed markets. Further, these results imply that the EGARCH model might be more useful than other models when implementing risk management strategies and developing stock pricing model. This paper contributes to the literature by comparing two significant global markets; one of the largest developed economies in the world, Japan, and one of Africa’s largest developing economies, Egypt

Hemolysis of PM10 on RBCs in vitro: An indoor air study in a coal-burning lung cancer epidemic area

Epidemiological studies have suggested that inhalation exposure to indoor ambient air from coal-burning environments is causally associated with respiratory health risks. In order to explore the toxicological mechanisms behind the adverse health effects, the hemolytic activity of PM10 (particulate matter with an aerodynamic diameter of 10um or less) samples collected from homes burning coal in the recognized China “cancer village” Xuanwei were evaluated and matched against their trace elemental contents. The results demonstrated that the hemolytic activity of indoor PM10 in coal-burning environments ranged from 4.28% to 5.24%, with a clear positive dose-response relationship. Although low dose samples exhibited a reduced hemolytic activity, PM10 could have a toxic effect upon people in a coal-burning indoor environment for extended time periods. The concentrations of analyzed trace elements in PM10 samples ranged from 6966 to 12,958 ppm. Among the analyzed elements, Zn, Ti, Ni, Cu, Pb, Ba, Mn, Cr and V were found at higher concentrations and accounted for over 95% of the total elements. The concentrations of total analyzed elements in the PM10 samples revealed a significant positive correlation with PM10 hemolytic activity. Of the analyzed elements, Zn, Pb and Cs positively correlated with hemolysis, while Li, U and V negatively correlated with the hemolysis of human red blood cells (RBCs). Therefore, the heavy metal elements could be one of the main factors responsible for the hemolytic capacity of indoor PM10 in coal-burning environments

Systematic analysis of the methodological structure of the lean literature

The purpose of this paper is to analyse and evaluate the methodological structure of the Lean literature so that its characteristics and influence among academics and practitioners might be better understood. We define ‘methodological structure’ to be comprised of six categorical components: publication category, degree of methodological disclosure, research strategies, data collection instruments, type of data collected & analysed, and type of research informants. This study is a systematic bibliometric analysis of the Lean literature. It has a two-stage research design. The first stage involves the identification of the top fifty most highly cited publications on ‘Lean’, with the resultant reference details being entered into a Focal Population Set (FPS) spreadsheet. The second stage involves coding and adding the six component fields of the methodological structure for each of the FPS entries. Both citation analysis and publication counting are then used to analyse patterns in these six components of methodological structure. The top fifty publications in the FPS represent over 52,700 citations. All are either journal papers or books, but books are the most influential. Based upon this FPS sample, the Lean literature is found to be both largely atheoretical in nature and also methodologically weak. Over half of the FPS publications are Viewpoint-type publications and 46% have no methodological disclosure. The Lean literature is predominantly qualitative in nature. Where disclosed, the most common research strategy is the case study and the most common data collection instrument is the interview. High and mid-level managers are the most frequently encountered research informants, whilst shop floor workers are infrequently utilised. This paper starts with the most extensive known systematic review of systematic reviews of the Lean literature; the result of which is the characterisation of a number of gaps in this body of knowledge. One of these gaps is the lack of any previous citation analysis (CA). The paper then proceeds to address this gap by providing the first CA within the Lean literature. This is also the most comprehensive known CA within the field of Operations and Supply Chain Management more generally. As a consequence of this analysis, previously unknown patterns and insights into the methodological structure of the Lean literature are revealed

Storying Sports Injury Experiences of Elite Track Athletes: A Narrative Analysis

Abstract Objective: Taking a social and cultural perspective, this study extends research in the field of sport injury psychology by storying elite track athletes’ injury experiences to identify dominant socio-cultural narratives that structure their tales. Methods: Fifteen elite track athletes participated. Data collection spanned 18 months and involved two methods of collection: life-story interviews and timelining. A total of 42 interviews were collected. Dialogical narrative analysis was used to identify the narrative typologies. Results: Six narrative typologies were identified: Resilience, Merry-Go-Round, Longevity, Pendulum, Snowball, and More-to-Me. Conclusion: This study extends the sport injury psychology evidence-base by highlighting how socio-cultural practices and processes influenced the thoughts, feelings, and behaviours of athletes throughout the full spectrum of injury. By creating and sharing narratives of injury, we can expand the opportunities available to athletes to enable them to make sense of their injury experiences in diverse and meaningful ways

Network and Hypervisor-Based Attacks in Cloud Computing Environments

Cloud Computing (CC) has become one of the most transform ativ e computing technologies and a key business avenue, following in the footsteps of main-frames, minicomputers, personal computers, the World Wide Web an d smartphones. Its vital features have considerably reduced IT costs, contributing to its rapid adoption by businesses and governments worldwide. Despite the many technological and economic benefits that CC offers, at the same t im e, it poses complex security threats resulting from the use of virtualisation technology. Compromising the security of any component in the cloud v irt ual infrastructure will negatively affect the security of other elements and so impact the overall system security. Therefore, to create a practical understanding of such threats, this paper provides an analysis of common and underexplored network- and hypervisor-based attacks against CC systems from a technical viewpoint

The Effectiveness of a 30-Week Concurrent Strength and Endurance Training Program in Preparation for an Ultra-Endurance Handcycling Challenge: A Case Study

Purpose: The aim of the following case study was to evaluate the effectiveness of a 30-week concurrent strength and endurance training program designed to prepare a trained H4 male handcyclist (aged 28 y, bilateral, above knee amputee, and body mass 65.6 kg) for a 1407-km ultra-endurance handcycling challenge. Methods: This observational case study tracked selected physiological measures, training intensity distribution, and total training load over the course of a 30-week concurrent training protocol. Furthermore, the athlete’s performance profile during the ultra-endurance challenge was monitored with power output, cadence, speed, and heart rate recorded throughout. Results: Findings revealed considerable improvements in power output at a fixed blood lactate concentration of 4 mmol·L−1 (+25.7%), peak aerobic power output (+18.9%), power-to-mass ratio (+18.3%), relative peak oxygen uptake (+13.9%), gross mechanical efficiency (+4.6%), bench press 1-repetition maximum (+4.3%), and prone bench pull 1-repetition maximum (+14.9%). The athlete completed the 1407-km route in a new handcycling world record time of 89:55 hours. Average speed was 18.7 (2.1) km·h−1; cadence averaged 70.0 (2.6) rpm, while average power output was 67 (12) W. In terms of internal load, the athlete’s average heart rate was 111 (11) beats per minute. Conclusion: These findings demonstrate how a long-term concurrent strength and endurance training program can be used to optimize handcycling performance capabilities in preparation for an ultra-endurance cycling event. Knowledge emerging from this case study provides valuable information that can guide best practices with respect to handcycling training for ultra-endurance events

Influence of iron manipulation on hypoxic pulmonary vasoconstriction and pulmonary reactivity during ascent and acclimatization to 5050 m

To examine the adaptational role of iron bioavailability on the pulmonary vascular responses to acute and chronic hypobaric hypoxia, the hematological and cardiopulmonary profile of lowlanders and Sherpa were determined during: 1) a nine-day ascent to 5050m (20 lowlanders; 12 Sherpa), and 2) following partial acclimatization (11±4 days) to 5050m (18 lowlanders; 20 Sherpa), where both groups received either an i.v. infusion of iron (iron (III)-hydroxide sucrose) or an iron chelator (desferrioxamine). During ascent, there were reductions in iron status in both lowlanders and Sherpa; however, Sherpa appeared to demonstrate a more efficient capacity to mobilize stored iron, compared to lowlanders, when expressed as a hepcidin per unit change in either body iron or the soluble transferrin receptor index, between 3400-5050m (p=0.016 and p=0.029 respectively). The rise in pulmonary artery systolic pressure (PASP) was blunted in Sherpa, compared to lowlanders during ascent; however, PASP was comparable in both groups upon arrival to 5050m. Following partial acclimatization, despite Sherpa demonstrating a blunted hypoxic ventilatory response and greater resting hypoxemia, they had similar hypoxic pulmonary vasoconstriction when compared to lowlanders at rest. Iron-infusion attenuated PASP in both groups at rest (p=0.005), while chelation did not exaggerate PASP in either group at rest or during exaggerated hypoxemia (PIO2=67 mmHg). During exercise at 25% peak wattage, PASP was only consistently elevated in Sherpa, which persisted following both iron infusion or chelation. These findings provide new evidence on the complex interplay of iron regulation on pulmonary vascular regulation during acclimatization and adaptation to high altitude

Bilingual phonological development across generations: Segmental accuracy and error patterns in second-and third-generation British Bengali children

Introduction: While developmental normsfor speech sound development have been widely reported for monolingual children, and increasingly for bilingual children, little is known about speech sound developmentacrossdifferent generations of children growing up in heritage language settings.The purpose of the present study was to gain a better understanding of inter-generational differences in the phonological development ofBritish Bengali children.Methods: Typically-developing second-generation and third-generationBengali heritage children living in Wales(n=19), aged between 4 and 5 years, participated in a picture-naming task in Sylheti and English. The single-word speech samples were transcribed phonetically and analyzedin terms of consonant and vowelaccuracy measures,and error patterns.Subsequently, logistic mixed-effects regression models were fitted to identify thefactors that predict accurate speech patterns in the children’s productions. Results: The results revealed high levels of accuracy in consonant and vowel production by both sets of children, particularlyin English. On Sylheti consonants, second-generation children significantly outperformed third-generation children, howeveronly on language-specific sounds. In contrast, generation wasnot a significant predictor for accuracy on English consonants, but allchildren performed better on shared sounds thanon English-specific categories, and on stops than affricates. The third-generation children exhibited a greater number of error types in Sylheti than the second-generation children, and more common replacement of Sylheti dental stops with alveolars. Conclusion:Theresults suggest that third-generation children have less developed pronunciation patterns inthe heritage language, but not the majority language, thantheir age-matched second-generation peers, however only on language-specific sounds. These findingsindicatethat differentiating between the phonological norms of monolingual and bilingual children may not be clinically sufficiently sensitive, at least in the minority language, and that more fine-grained language use variables, such as the generation to which a bilingual child belongs, need to be considered

Increased Aortic Stiffness is Associated with Higher Rates of Stroke, GI-bleeding and Pump Thrombosis in CF-LVAD Patients

Background In the general population, increased aortic stiffness is associated with an increased risk of cardiovascular events. Previous studies have demonstrated an increase in aortic stiffness in patients with a continuous flow left ventricular assist device (CF-LVAD). However, the association between aortic stiffness and common adverse events is unknown. Methods and results Forty patients with a HeartMate II (HMII) (51 $ 11 years; 20% female; 25% ischemic) implanted between January 2011 and September 2017 were included. Two-dimensional transthoracic echocardiograms of the ascending aorta, obtained before HMII placement and early after heart transplant, were analyzed to calculate the aortic stiffness index (AO-SI). The study cohort was divided into patients who had an increased vs decreased AO-SI after LVAD support. A composite outcome of gastrointestinal bleeding, stroke, and pump thrombosis was defined as the primary end point and compared between the groups. While median AO-SI increased significantly after HMII support (AO-SI 4.4-6.5, P = .012), 16 patients had a lower AO-SI. Patients with increased (n = 24) AO-SI had a significantly higher rate of the composite end point (58% vs 12%, odds ratio 9.8, P < .01). Similarly, those with increased AO-SI tended to be on LVAD support for a longer duration, had higher LVAD speed and reduced use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Conclusions Increased aortic stiffness in patients with a HMII is associated with a significantly higher rates of adverse events. Further studies are warranted to determine the causality between aortic stiffness and adverse events, as well as the effect of neurohormonal modulation on the conduit vasculature in patients with a CF-LVAD