Rapid detection of health-care-associated bloodstream infection in critical care using multipathogen real-time polymerase chain reaction technology: a diagnostic accuracy study and systematic review

Background: There is growing interest in the potential utility of real-time polymerase chain reaction (PCR) in diagnosing bloodstream infection by detecting pathogen deoxyribonucleic acid (DNA) in blood samples within a few hours. SeptiFast (Roche Diagnostics GmBH, Mannheim, Germany) is a multipathogen probe-based system targeting ribosomal DNA sequences of bacteria and fungi. It detects and identifies the commonest pathogens causing bloodstream infection. As background to this study, we report a systematic review of Phase III diagnostic accuracy studies of SeptiFast, which reveals uncertainty about its likely clinical utility based on widespread evidence of deficiencies in study design and reporting with a high risk of bias. 

Objective: Determine the accuracy of SeptiFast real-time PCR for the detection of health-care-associated bloodstream infection, against standard microbiological culture. 

Design: Prospective multicentre Phase III clinical diagnostic accuracy study using the standards for the reporting of diagnostic accuracy studies criteria. 

Setting: Critical care departments within NHS hospitals in the north-west of England. 

Participants: Adult patients requiring blood culture (BC) when developing new signs of systemic inflammation. 

Main outcome measures: SeptiFast real-time PCR results at species/genus level compared with microbiological culture in association with independent adjudication of infection. Metrics of diagnostic accuracy were derived including sensitivity, specificity, likelihood ratios and predictive values, with their 95% confidence intervals (CIs). Latent class analysis was used to explore the diagnostic performance of culture as a reference standard. 

Results: Of 1006 new patient episodes of systemic inflammation in 853 patients, 922 (92%) met the inclusion criteria and provided sufficient information for analysis. Index test assay failure occurred on 69 (7%) occasions. Adult patients had been exposed to a median of 8 days (interquartile range 4–16 days) of hospital care, had high levels of organ support activities and recent antibiotic exposure. SeptiFast real-time PCR, when compared with culture-proven bloodstream infection at species/genus level, had better specificity (85.8%, 95% CI 83.3% to 88.1%) than sensitivity (50%, 95% CI 39.1% to 60.8%). When compared with pooled diagnostic metrics derived from our systematic review, our clinical study revealed lower test accuracy of SeptiFast real-time PCR, mainly as a result of low diagnostic sensitivity. There was a low prevalence of BC-proven pathogens in these patients (9.2%, 95% CI 7.4% to 11.2%) such that the post-test probabilities of both a positive (26.3%, 95% CI 19.8% to 33.7%) and a negative SeptiFast test (5.6%, 95% CI 4.1% to 7.4%) indicate the potential limitations of this technology in the diagnosis of bloodstream infection. However, latent class analysis indicates that BC has a low sensitivity, questioning its relevance as a reference test in this setting. Using this analysis approach, the sensitivity of the SeptiFast test was low but also appeared significantly better than BC. Blood samples identified as positive by either culture or SeptiFast real-time PCR were associated with a high probability (> 95%) of infection, indicating higher diagnostic rule-in utility than was apparent using conventional analyses of diagnostic accuracy. 

Conclusion: SeptiFast real-time PCR on blood samples may have rapid rule-in utility for the diagnosis of health-care-associated bloodstream infection but the lack of sensitivity is a significant limiting factor. Innovations aimed at improved diagnostic sensitivity of real-time PCR in this setting are urgently required. Future work recommendations include technology developments to improve the efficiency of pathogen DNA extraction and the capacity to detect a much broader range of pathogens and drug resistance genes and the application of new statistical approaches able to more reliably assess test performance in situation where the reference standard (e.g. blood culture in the setting of high antimicrobial use) is prone to error.

Deriving meteorological variables across Africa for the study and control of vector-borne disease:a comparison of remote sensing and spatial interpolation of climate

This paper presents the results of an investigation into the utility of remote sensing (RS) using meteorological satellites sensors and spatial interpolation (SI) of data from meteorological stations, for the prediction of spatial variation in monthly climate across continental Africa in 1990. Information from the Advanced Very High Resolution Radiometer (AVHRR) of the National Oceanic and Atmospheric Administration's (NOAA) polar-orbiting meteorological satellites was used to estimate land surface temperature (LST) and atmospheric moisture. Cold cloud duration (CCD) data derived from the High Resolution Radiometer (HRR) onboard the European Meteorological Satellite programme's (EUMETSAT) Meteosat satellite series were also used as a RS proxy measurement of rainfall. Temperature, atmospheric moisture and rainfall surfaces were independently derived from SI of measurements from the World Meteorological Organization (WMO) member stations of Africa. These meteorological station data were then used to test the accuracy of each methodology, so that the appropriateness of the two techniques for epidemiological research could be compared. SI was a more accurate predictor of temperature, whereas RS provided a better surrogate for rainfall; both were equally accurate at predicting atmospheric moisture. The implications of these results for mapping short and long-term climate change and hence their potential for the study anti control of disease vectors are considered. Taking into account logistic and analytical problems, there were no clear conclusions regarding the optimality of either technique, but there was considerable potential for synergy.

Hydroprocessing of waste cooking oil over a dispersed nano catalyst: Kinetics study and temperature effect

The kinetics of hydrodeoxygenation of waste cooking oil (WCO) is investigated with unsupported CoMoS catalysts. A kinetic model is established and a comprehensive analysis of each reaction pathway is carried out. The results show that hydrodecarbonylation/decarboxylation (HDC) routes are the predominant reaction pathways in the elimination of oxygen, with the rate constant three times as high as that of hydrodeoxygenation (HDO). However, the HDC activity of the CoMoS catalyst deactivates due to gradual loss of sulfur from the catalyst. HDO process is insensitive to the sulfur deficiency. The kinetic modeling shows that direct hydrodecarbonylation of fatty acids dominates the HDC routes and, in the HDO route, fatty acids are transferred to aldehydes/alcohols and then to C-18 hydrocarbons, a final product, and the reduction of acids is the rate limiting step. The HDO route via alcohols is dominant over aldehydes due to a significantly higher reaction rate constant. The difference of C-18/C-17 ratio in unsupported and supported catalysts show that a support with Lewis acid sites may play an important role in the selectivity for the hydrodeoxygenation pathways and promoting the final product quality

Hints for bird study

This document is the first bulletin of the Audubon Society of South Carolina. The bulletin provides information for those who wish to study birds or teach bird study.

Partnership for arts integration : exploring the experiences of teachers and artists working with integrated arts programs

This research acknowledges the difficulties experienced by teachers presenting integrated arts curricula. Instructional support is offered by arts organizations that provide arts partnerships with local schools boards. The study focuses on the experiences of 8 teachers from a Catholic school board in southern Ontario who participated in integrated arts programs offered by The Royal Conservatory of Music's Learning Through the Arts™ (LTTATM) program and a local art gallery's Art Based Integrated Learning (ABIL) program and examines their responses to the programs and their perception of personal and professional development through this association. Additionally, questions were posed to the . "aftisfs"from-tneSe]Jfograrrrs;-and"they liiscus·sed·how"participating in-collaboration with teachers in the development of in-school programs enabled them to experience personal and professional development as well. Seven themes emerged from the data. These themes included: teachers' feelings of a lack of preparedness to teach the arts; the value of the arts and arts partnerships in schools; the role of the artists in the education of teachers; professional development for both teachers and artists; the development of collegiality; perceptions of student engagement; and the benefits and obstacles of integrating the arts into the curriculum. This document highlights the benefits to both teachers and artists of arts partnerships between schools and outside arts organizations.

Design, development and assessment of the Java Intelligent Tutoring System

The "Java Intelligent Tutoring System" (JITS) research project focused on designing, constructing, and determining the effectiveness of an Intelligent Tutoring System for beginner Java programming students at the postsecondary level. The participants in this research were students in the School of Applied Computing and Engineering Sciences at Sheridan College. This research involved consistently gathering input from students and instructors using JITS as it developed. The cyclic process involving designing, developing, testing, and refinement was used for the construction of JITS to ensure that it adequately meets the needs of students and instructors. The second objective in this dissertation determined the effectiveness of learning within this environment. The main findings indicate that JITS is a richly interactive ITS that engages students on Java programming problems. JITS is equipped with a sophisticated personalized feedback mechanism that models and supports each student in his/her learning style. The assessment component involved 2 main quantitative experiments to determine the effectiveness of JITS in terms of student performance. In both experiments it was determined that a statistically significant difference was achieved between the control group and the experimental group (i.e., JITS group). The main effect for Test (i.e., pre- and postiest), F( l , 35) == 119.43,p < .001, was qualified by a Test by Group interaction, F( l , 35) == 4.98,p < .05, and a Test by Time interaction, F( l , 35) == 43.82, p < .001. Similar findings were found for the second experiment; Test by Group interaction revealed F( 1 , 92) == 5.36, p < .025. In both experiments the JITS groups outperformed the corresponding control groups at posttest.

A classroom-based investigation of reciprocal teaching at the grade seven level

This study assessed the effectiveness of a reciprocal teaching program as a method of teaching reading comprehension, using narrative text material in a t.ypical grade seven classroom. In order to determine the effectiveness of the reciprocal teaching program, this method was compared to two other reading instruction approaches that, unlike rcciprocal teaching, did not include social interaction components. Two intact grade scven classes, and a grade seven teacher, participated in this study. Students were appropriately assigned to three treatment groups by reading achievement level as determined from a norm-referenced test. Training proceeded for a five week intervention period during regularly scheduled English periods. Throughout the program curriculum-based tests were administered. These tests were designed to assess comprehension in two distinct ways; namely, character analysis components as they relate to narrative text, and strategy use components as they contribute to student understanding of narrative and expository text. Pre, post, and maintenance tests were administered to measure overall training effects. Moreover, during intervention, training probes were administered in the last period of each week to evaluate treatment group performance. AU curriculum-based tests were coded and comparisons of pre, post, maintenance tests and training probes were presented in graph form. Results showed that the reciprocal group achieved some improvement in reading comprehension scores in the strategy use component of the tests. No improvements were observed for the character analysis components of the curriculum-based tests and the norm-referenced tests. At pre and post intervention, interviews requiring students to respond to questions that addressed metacomprehension awareness of study strategies were administered. The intelviews were coded and comparisons were made between the two intelVicws. No significant improvements were observed regarding student awareness of ten identified study strategies . This study indicated that reciprocal teaching is a viable approach that can be utilized to help students acquire more effective comprehension strategies. However, the maximum utility of the technique when administered to a population of grade seven students performing at average to above average levels of reading achievement has yet to be determined. In order to explore this issue, the refinement of training materials and curriculum-based measurements need to be explored. As well, this study revealed that reciprocal teaching placed heavier demands on the classroom teacher when compared to other reading instruction methods. This may suggest that innovative and intensive teacher training techniques are required before it is feasible to use this method in the classroom.

An exploration of transformation theory and the western tradition: a critical evaluation of a graduate studies class

This qualitative study is an exploration of transformation theory, the Western tradition, and a critical evaluation of a graduate studies class at a university. It is an exploration of assumptions that are embedded in experience, that influence the experience and provide meaning about the experience. An attempt has been made to identify assumptions that are embedded in Western experience and connect them with assumptions that shape the graduate class experience. The focus is on assumptions that facilitate and impede large group discussions. Jungian psychology of personality type and archetype and developmental psychology is used to analyze the group experience. The pragmatic problem solving model, developed by Knoop, is used to guide thinking about the Western tradition. It is used to guide the analysis, synthesis and writing of the experience of the graduate studies class members. A search through Western history, philosophy. and science revealed assumptions about the nature of truth, reality, and the self. Assumptions embedded in Western thinking about the subject-object relationship, unity and diversity are made explicit. An attempt is made to identify Western tradition assumptions underlying transformation theory. The critical evaluation of the graduate studies class experience focuses upon issues associated with group process, self-directed learning, the educator-learner transaction and the definition of adult education. The advantages of making implicit assumptions explicit is explored.

Changes in education and student-centred learning as related to senior secondary school English

The main purpose of this thesis is to t r ace broadly the educational changes in the past two decades showing a shift of emphasis from a teacher-directed, content-centred philosophy of teaching to a self-directed, student-centred mode of learning. The major justification for an Independent or an Individualized Learning programme with emphasis on "the response to literature approach" is 2 to produce the independent learner. Comprehensive r eading and t he use of t he ERIC system reveal widespread educational thought and practice related t o Individualization and Independent Study as a really democratic way of learning with freedom, independence and responsibility.

Creativity and the working artist/teacher : the relationships

The purpose of this qualitative study was to understand the relationships between creativity and the working artist/teacher employed by an art college. The topic emerged from my job as an instructor at The Ontario College of Art which was used as the primary data resource and provided the highest caliber of professionals to chose from. Existent data were used to facilitate the study generated by the research of Cawelti, Rappaport, and Wood (1992). The data were generated by a group of 5 faculty members from The University of Northern Iowa, recognized for their expertise in the arts (a painter, a poet, a sculptor, a novelist, and a photographer). They were asked to respond to the following statement: "In as much detail as you like, list the things that you did, thought, or felt the last time you created an artistic product. II Cawelti, Rappaport, and Wood (1992) produced three models of the creative process, each building on the previous, with the resultant third,being in my opinion, an excellent illustration (text/visual) of the creative process. Model three (Appendix D) presented a "multi-dimensional view of the creative process: time, space, observatility, and consciousnessll (p. 90). Model three utilized a visual mapping device along the bottom of the page linked to text segments above. Both the visual and the text were interrelated so that they harmonized into a comprehensive "picture." The parti'cipants of this qualitative study were asked to consider model three from their professional perspective as artist/teachers. The interpretive sciences directed the methodology. The hermeneutic circle of continuous reflection from the whole to the part and back to the whole was an important aspect of the data analyses. Four members of the Foundation Department at The Ontario College of Art were the key participants. A series of conversational interviews was the primary source of data collection, this was augmented by observation, fie,ldnotes, and follow up telephone interviews. Transcripts of interviews were returned to participants for reflection and the telephone was used to discuss any additional -points raised. Analysis consisted of coding and organizing data according to emerging themes. These themes formed the basis for the narrative stories. The text of the narrative stories were given back to each participant for further comment. Revisions were made until both the researcher and the participants felt that the stories reflected reality. The resultant whole was critiqued from the researcher's perspective. The significance of this study was discussed as it pertains to the working artist/teacher and areas in need of further study are pointed out.

Exploring the relationship between professional and organizational commitment : the attitudes of Ontario chartered accountancy students

This study was undertaken to investigate the attitudes of chartered accountancy (CA) students toward professional commitment and organizational commitment. The focus of the study was to discover if a relationship between these two constructs existed and determine which situational and individual characteristics facilitate or impede commitment. The sample included those CA students who wrote the 1995 UFE (n=423). Four instruments were used for data collection: Job Diagnostic Survey, Organizational Commitment Questionnaire, Career Commitment Questionnaire, Career Facilitation Survey, and individual demographic inquiry. The study found a significant relationship between professional commitment and organizational commitment. Situational characteristics tended to influence organizational commitment, while individual characteristics more often governed professional commitment. Specific satisfactions, general satisfaction, growth satisfaction, and satisfaction with compensation, co-workers, and supervision were found to facilitate organizational commitment. Organizational commitment was also influenced by supplemental job characteristics, internal work motivation, career facilitation, and autonomy. Implications for practice involved the cooperation and collaboration of the governing body for the CA profession and the CA firms in activities addressing pertinent issues that influence commitment. Implications for future research were also discussed.

The effect of social skills training on grade 3 students' self-esteem, moral development and perceptions of classroom environment

Two Grade 3 classes were used to study the effects of a formal social skills training program. Specifically, comparisons were made on self-esteem, classroom environment, and moral development to see whether changes occurred as a direct result of social skills training. One group participated in the social skills program, while the other group did not. It was hypothesized that formal social skills training would improve students' selfesteem, moral development, and the classroom environment. At the end of the program, however, data from class observations, teacher interviews, journal of the social skills training group teacher, and measures of self-esteem, classroom environment and moral development did not support this hypothesis. Although the social skills training group scored significantly higher in class cohesiveness, they did not show marked improvement in the other measures. In fact, in some measures (e.g., friction and competitiveness), they demonstrated greater scores at both pretest and posttests. The social skills training group was, however, able to vocalize and utilize the strategies of several skills which had been a focus of the program, suggesting that formal social skills training is a useful tool for presenting and reinforcing some specific behaviours.