Modelling the impact of antibiotic use and infection control practices on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus: a time-series analysis

Objectives: Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen worldwide. A wide range of factors have been suggested to influence the spread of MRSA. The objective of this study was to evaluate the effect of antimicrobial drug use and infection control practices on nosocomial MRSA incidence in a 426-bed general teaching hospital in Northern Ireland.

Methods: The present research involved the retrospective collection of monthly data on the usage of antibiotics and on infection control practices within the hospital over a 5 year period (January 2000–December 2004). A multivariate ARIMA (time-series analysis) model was built to relate MRSA incidence with antibiotic use and infection control practices.

Results: Analysis of the 5 year data set showed that temporal variations in MRSA incidence followed temporal variations in the use of fluoroquinolones, third-generation cephalosporins, macrolides and amoxicillin/clavulanic acid (coefficients = 0.005, 0.03, 0.002 and 0.003, respectively, with various time lags). Temporal relationships were also observed between MRSA incidence and infection control practices, i.e. the number of patients actively screened for MRSA (coefficient = -0.007), the use of alcohol-impregnated wipes (coefficient = -0.0003) and the bulk orders of alcohol-based handrub (coefficients = -0.04 and -0.08), with increased infection control activity being associated with decreased MRSA incidence, and between MRSA incidence and the number of new patients admitted with MRSA (coefficient = 0.22). The model explained 78.4% of the variance in the monthly incidence of MRSA.

Conclusions: The results of this study confirm the value of infection control policies as well as suggest the usefulness of restricting the use of certain antimicrobial classes to control MRSA.

"All Have to Live in Me...": A Study of the Use of English Alongside Other African Languages in a Kenyan School

The purpose of this paper, which builds on an earlier paper published in this Journal (Vol. 20, No. 6), is to develop the discussion around how English has been taught, used and perceived in Kenya, using data gathered from a small second-level English-medium school in Kenya. The complex relationships between language and identity are at work in the everyday routines of both staff and pupils within such a context. The paper seeks to set out a clear methodology for gathering data which could help describe these relationships with more clarity while also subjecting the data to analysis informed by the growing body of research and theory that focuses on language policy in post-colonial and neo-colonial settings. Finally, these pieces of data are used as the basis of a further exploration of the implications for classroom practice in teaching English in this environment.

On the Problems of Mixing RCTs with Qualitative Research: The Case of the MRC Framework for the Evaluation of Complex Healthcare Interventions

In the perceived hierarchy of research designs, the results from randomized controlled trials are considered to provide the highest level of evidence. Indeed these trials have been upheld as the gold standard in research. The benefits and limitations of the randomized controlled trial as a method of evaluating the effectiveness of healthcare interventions are presented. The article then examines the different levels of complexity within healthcare interventions and the problems this poses in determining effectiveness. In an effort to provide a solution to this problem, the Medical Research Council produced a framework to assist investigators to develop and evaluate complex healthcare interventions. The framework is described with reference to an example of implementing and evaluating protocols for weaning patients in the intensive care unit. The framework is critiqued on the basis that it involves an ambiguous or contradictory ontology, which fails to articulate the relationship between the positivism of randomized controlled trials with the relativism of qualitative approaches. It is concluded that the use of realist strategies in combination with randomized controlled trials provides the most coherent solution to this quandary

Residential segregation in Northern Ireland in 2001: assessing the value of exploring spatial variations

Segregation measures have been applied in the study of many societies, and traditionally such measures have been used to assess the degree of division between social and cultural groups across urban areas, wider regions, or perhaps national areas. The degree of segregation can vary substantially from place to place even within very small areas. In this paper the substantive concern is with religious/political segregation in Northern Ireland—particularly the proportion of Protestants (often taken as an indicator of those who wish to retain the union with Britain) to Catholics (often taken as an indicator of those who favour union with the Republic of Ireland). Traditionally, segregation is measured globally—that is, across all units in a given area. A recent trend in spatial data analysis generally, and in segregation analysis specifically, is to assess local features of spatial datasets. The rationale behind such approaches is that global methods may obscure important spatial variations in the property of interest, and thus prevent full use of the data. In this paper the utility of local measures of residential segregation is assessed with reference to the religious/political composition of Northern Ireland. The paper demonstrates marked spatial variations in the degree and nature of residential segregation across Northern Ireland. It is argued that local measures provide highly useful information in addition to that provided in maps of the raw variables and in standard global segregation measures.

How Porosity and Permeability Vary Spatially With Grain Size, Sorting, Cement Volume, and Mineral Dissolution In Fluvial Triassic Sandstones: The Value of Geostatistics and Local Regression

Although it is well known that sandstone porosity and permeability are controlled by a range of parameters such as grain size and sorting, amount, type, and location of diagenetic cements, extent and type of compaction, and the generation of intergranular and intragranular secondary porosity, it is less constrained how these controlling parameters link up in rock volumes (within and between beds) and how they spatially interact to determine porosity and permeability. To address these unknowns, this study examined Triassic fluvial sandstone outcrops from the UK using field logging, probe permeametry of 200 points, and sampling at 100 points on a gridded rock surface. These field observations were supplemented by laser particle-size analysis, thin-section point-count analysis of primary and diagenetic mineralogy, quantitiative XRD mineral analysis, and SEM/EDAX analysis of all 100 samples. These data were analyzed using global regression, variography, kriging, conditional simulation, and geographically weighted regression to examine the spatial relationships between porosity and permeability and their potential controls. The results of bivariate analysis (global regression) of the entire outcrop dataset indicate only a weak correlation between both permeability porosity and their diagenetic and depositional controls and provide very limited information on the role of primary textural structures such as grain size and sorting. Subdividing the dataset further by bedding unit revealed details of more local controls on porosity and permeability. An alternative geostatistical approach combined with a local modelling technique (geographically weighted regression; GWR) subsequently was used to examine the spatial variability of porosity and permeability and their controls. The use of GWR does not require prior knowledge of divisions between bedding units, but the results from GWR broadly concur with results of regression analysis by bedding unit and provide much greater clarity of how porosity and permeability and their controls vary laterally and vertically. The close relationship between depositional lithofacies in each bed, diagenesis, and permeability, porosity demonstrates that each influences the other, and in turn how understanding of reservoir properties is enhanced by integration of paleoenvironmental reconstruction, stratigraphy, mineralogy, and geostatistics.

Theoretical and spatial limits to the value of rural environmental benefits: Evidence from the forestry sector

The valuation of environmental benefits has been well researched in the forestry sector. This is not generally the case in the agriculture sector although schemes to compensate farmers for provision of officially defined environmental benefits are already in place throughout the European Union. This paper draws on empirical findings from forestry and deductions from economic theory to challenge the notion of the universality of such benefits. Empirical findings from forestry suggest recreational use value is location specific rather than widely spread. Household utility theory predicts zero willingness to pay to maintain the status quo level of a previously unpaid for environmental benefit (when provision is not perceived as under risk) but a positive willingness to pay for an increase. Thus, non use values cannot be attributed to the major part of existing commercial forestry area but to spatially restricted schemes such as additional afforestation or preservation of ancient natural woodlands.

The impact of antibiotic use on the incidence and resistance pattern of extended-spectrum beta-lactamase-producing bacteria in primary and secondary healthcare settings

Aims: The objective of the present study was to study the relationship between hospital antibiotic use, community antibiotic use and the incidence of extended-spectrum beta-lactamase (ESBL)-producing bacteria in hospitals, while assessing the impact of a fluoroquinolone restriction policy on ESBL-producing bacteria incidence rates. METHODS: The study was retrospective and ecological in design. A multivariate autoregressive integrated moving average (ARIMA) model was built to relate antibiotic use to ESB-producing bacteria incidence rates and resistance patterns over a 5 year period (January 2005-December 2009). Results: Analysis showed that the hospital incidence of ESBLs had a positive relationship with the use of fluoroquinolones in the hospital (coefficient = 0.174, P= 0.02), amoxicillin-clavulanic acid in the community (coefficient = 1.03, P= 0.03) and mean co-morbidity scores for hospitalized patients (coefficient = 2.15, P= 0.03) with various time lags. The fluoroquinolone restriction policy was implemented successfully with the mean use of fluoroquinolones (mainly ciprofloxacin) being reduced from 133 to 17 defined daily doses (DDDs)/1000 bed days (P <0.001) and from 0.65 to 0.54 DDDs/1000 inhabitants/day (P= 0.0007), in both the hospital and its surrounding community, respectively. This was associated with an improved ciprofloxacin susceptibility in both settings [ciprofloxacin susceptibility being improved from 16% to 28% in the community (P <0.001)] and with a statistically significant reduction in ESBL-producing bacteria incidence rates. Discussion: This study supports the value of restricting the use of certain antimicrobial classes to control ESBL, and demonstrates the feasibility of reversing resistance patterns post successful antibiotic restriction. The study also highlights the potential value of the time-series analysis in designing efficient antibiotic stewardship. © 2011 The Authors. British Journal of Clinical Pharmacology © 2011 The British Pharmacological Society.

The Value of Reducing Cancer Risks at Contaminated Sites: Are More Knowledgeable People Willing to Pay More?

We use conjoint choice questions to investigate people's tastes for cancer risk reductions and income in the context of public programs that would provide for remediation at abandoned industrial contaminated sites. Our survey was self-administered using the computer by persons living in the vicinity of an important contaminated site on the Italian National Priority List. The value of a prevented case of cancer is €2.6 million, but this figure does vary with income, perceived exposure to contaminants, and respondent opinions about priorities that should be pursued by cleanup programs. © 2011 Society for Risk Analysis.

Physical activity assessment in practice: a mixed methods study of GPPAQ use in primary care

Background: Insufficient physical activity (PA) levels which increase the risk of chronic disease are reported by almost two-thirds of the population. More evidence is needed about how PA promotion can be effectively implemented in general practice (GP), particularly in socio-economically disadvantaged communities. One tool recommended for the assessment of PA in GP and supported by NICE (National Institute for Health and Care Excellence) is The General Practice Physical Activity Questionnaire (GPPAQ) but details of how it may be used and of its acceptability to practitioners and patients are limited. This study aims to examine aspects of GPPAQ administration in non-urgent patient contacts using different primary care electronic recording systems and to explore the views of health professionals regarding its use.

Methods: Four general practices, selected because of their location within socio-economically disadvantaged areas, were invited to administer GPPAQs to patients, aged 35-75 years, attending non-urgent consultations, over two-week periods. They used different methods of administration and different electronic medical record systems (EMIS, Premiere, Vision). Participants’ (general practitioners (GPs), nurses and receptionists) views regarding GPPAQ use were explored via questionnaires and focus groups.

Results: Of 2,154 eligible consultations, 192 (8.9%) completed GPPAQs; of these 83 (43%) were categorised as inactive. All practices were located within areas ranked as being in the tertile of greatest socio-economic deprivation in Northern Ireland. GPs/nurses in two practices invited completion of the GPPAQ, receptionists did so in two. One practice used an electronic template; three used paper copies of the questionnaires. End-of-study questionnaires, completed by 11 GPs, 3 nurses and 2 receptionists and two focus groups, with GPs (n = 8) and nurses (n = 4) indicated that practitioners considered the GPPAQ easy to use but not in every consultation. Its use extended consultation time, particularly for patients with complex problems who could potentially benefit from PA promotion.

Conclusions: GPs and nurses reported that the GPPAQ itself was an easy tool with which to assess PA levels in general practice and feasible to use in a range of electronic record systems but integration within routine practice is constrained by time and complex consultations. Further exploration of ways to facilitate PA promotion into practice is needed.

Diagnostic value of increased sensitivity by massively parallel sequencing

Routine molecular diagnostics modalities are unable to confidently detect low frequency mutations (<5-15%) that may indicate response to targeted therapies. We confirm the presence of a low frequency NRAS mutation in a rectal cancer patient using massively parallel sequencing when previous Sanger sequencing results proved negative and Q-PCR testing inconclusive. There is increasing evidence that these low frequency mutations may confer resistance to anti-EGFR therapy. In view of negative/inconclusive Sanger sequencing and Q-PCR results for NRAS mutations in a KRAS wt rectal case, the diagnostic biopsy and 4 distinct subpopulations of cells in the resection specimen after conventional chemo/radiotherapy were massively parallel sequenced using the Ion Torrent PGM. DNA was derived from FFPE rectal cancer tissue and amplicons produced using the Cancer Hotspot Panel V2 and sequenced using semiconductor technology. NRAS mutations were observed at varying frequencies in the patient biopsy (12.2%) and all four subpopulations of cells in the resection with an average frequency of 7.3% (lowest 2.6%). The results of the NGS also provided the mutational status of 49 other genes that may have prognostic or predictive value, including KRAS and PIK3CA. NGS technology has been postulated in diagnostics because of its capability to generate results in large panels of clinically meaningful genes in a cost-effective manner. This case illustrates another potential advantage of this technology: its use for detecting low frequency mutations that may influence therapeutic decisions in cancer treatment.

An Exploration of the Use of Coaching and Mentoring in the Supervision of Doctoral Students in UK University Business Schools

Purpose: to consider and evaluate the student and supervisor experience of doctoral supervision (dyadic and triadic) and specifically the value of using coaching and mentoring approaches (process and relationship) in supervisory practice. Design/methodology/approach: phase one is a mixed methods study exploring the use of coaching and mentoring in doctoral supervision on traditional and taught doctoral programmes in one UK university business school. The focus is on developing a conceptual model for doctoral supervisory practice for the transfer of learning and the improvement of practice. Phase two will be a collaborative action research study in a range of UK university business schools to use, reflect on and refine the conceptual model of supervision. Findings: the initial findings from phase one will be reported on at the conference presentation. Research limitations/implications: we have tentative agreements from four UK university business schools for phase two (subject to ethics approval). Practical implications: students and supervisors participating in the research will benefit from having the opportunity to review and improve their practice; the participating business schools will have the opportunity to review and potentially revise their doctoral student and supervisor training; and a business school’s reputation for high quality doctoral supervision could be enhanced. Social implications: could potentially benefit numerous future students and supervisors across a wide range of UK university business schools. Originality/value: there does not appear to be any previously published research on the use of coaching and mentoring in doctoral supervision in UK university business schools for the transfer of learning and improvement of practice.

(Un)suitability of the use of pH buffers in biological, biochemical and environmental studies and their interaction with metal ions – a review

The use of buffers to maintain the pH within a desired range is a very common practice in chemical, biochemical and biological studies. Among them, zwitterionic N-substituted aminosulfonic acids, usually known as Good’s buffers, although widely used, can complex metals and interact with biological systems. The present work reviews, discusses and updates the metal complexation characteristics of thirty one commercially available buffers. In addition, their impact on biological systems is also presented. The influences of these buffers on the results obtained in biological, biochemical and environmental studies, with special focus on their interaction with metal ions, are highlighted and critically reviewed. Using chemical speciation simulations, based on the current knowledge of the metal–buffer stability constants, a proposal of the most adequate buffer to employ for a given metal ion is presented.

Market value of corruption

This paper studies the impact of the Brazilian anticorruption legislation, PL 6826/2010, on stock returns. I show that, around the law approval date, the greater the link between the corporate and political worlds, the worse is the companies’ performance. Companies awarded with public contracts in 2012 suffer more with the new legislation approval. Firms with above median contract values have 2.9% lower returns than its peers. The negative effect is more pronounced for bigger and more complex entities, associated with higher levels of Corporate Responsibility and Governance and not subject to the US FCPA.

Research in the clinical setting : a qualitative study of the value of play research in the continuing education of occupational therapists.

Occupational therapists have always recognized playas an important part of a child's life. However, until recently play has been viewed as a medium for reaching treatment goals, rather than as an activity that is valuable in and of itself. If occupational therapists think of playas the primary activity or occupation of childhood, then play should be a very important area of focus for paediatric clinicians. In order to assist children to become as independent as possible with play and to have fulfilling play experiences the occupational therapist needs to have a clear understanding of how to assess, set goals which lead towards competence in play, and promote play. Recent play literature has placed importance on play behaviours and looking at the relationship between the child and both the human and nonhuman environment. Believing that play and playfulness can and should be promoted, for children with physical disabilities, requires that therapists learn new assessment and intervention strategies. A new assessment tool, The Test of Playfulness, was developed by Bundy in 1994. It addressed play behaviours and environmental influences. The author, a co-investigator and eight occupational therapists were involved in a playfulness study using this test to compare the playfulness of children with physical disabilities with their able-bodied peers. After the study was completed the author questioned whether or not involvement in the playfulness study was enough of a change agent to bring about transformative learning in order to further the eight occupational therapists' education about play.This study investigated changes in either the therapists' thinking about play or their behaviour in their clinical practice. The study also examined the participants' retention of knowledge about the Test of Playfulness. The eight therapists who had been involved in the playfulness study (participants) were matched with eight therapists who had not been involved (nonparticipants). The therapists were interviewed 9 to 12 months after completion of the playfulness study. They were asked to describe various scenarios of play and open ended prompts were used to elicit the therapists' perceptions of play, good play, the role or value of play, environmental and gender influences on play, play assessment and intervention, and play research, for children with and without disabilities. The participants were also prompted to discuss their experience with the playfulness study. A self-report questionnaire was also completed at the end of the interview. The results of the study demonstrated that: (a) the play research project was a good format for continuing the participants' education about play; (b) their thinking had changed about play; (c) according to self report, they had used this new knowledge in their clinical practice; and (d) the participants remembered the items on the Test of Playfulness and could use them in describing various aspects of play. This study found that participating in a play research project had been an effective method of professional development. It also highlighted the need for increased awareness of the recent literature on play and the developing role of the occupational therapist in the assessment and intervention of play.

Developmental trajectories of marijuana use and psychological distress : exploring the co-occurrence of these phenomena in early adolescence

Le début de l’adolescence est une période de changements rapides où la détresse psychologique et l’expérimentation de la marijuana sont choses fréquentes. Certaines études longitudinales ont démontré que ces deux phénomènes ont tendance à se manifester conjointement tandis que d’autres n’ont pu observer de tel lien. Ces résultats divergents suggèrent que plusieurs questions persistent concernant la nature de cette relation. Cette thèse a pour objectif d’explorer la consommation de marijuana et la détresse psychologique en début d’adolescence afin de mieux saisir les changements à travers le temps, ainsi que d’examiner si ces deux problématiques évoluent conjointement et s’influencent réciproquement. Un échantillon de 448 adolescents garçons et filles fréquentant deux écoles secondaires de Montréal, ont été suivi de secondaire I à secondaire III. De 1999 à 2001, les participants ont complété un questionnaire à chaque année de l’étude incluant des mesures portant sur la consommation de marijuana et la détresse psychologique (IDPESQ-14). Un modèle de mixture semi-paramétrique (Nagin, 2005) a été utilisé afin d’identifier les trajectoires développementales de la consommation de marijuana et de détresse psychologique. Des analyses ont également été effectuées afin d’établir les liens d’appartenance entre chacune des trajectoires de consommation identifiées et la détresse psychologique lors de la première année de l`étude, ainsi qu’entre chacune des trajectoires de détresse psychologique et la consommation de marijuana en première année du secondaire. Finalement, des analyses de trajectoires jointes ont été effectuées afin de déterminer l’interrelation entre la consommation de marijuana et la détresse psychologique. Les résultats de notre étude suggèrent qu’il existe une grande hétérogénéité au niveau de la consommation de marijuana et la détresse psychologique. Trois trajectoires développementales ont été identifiées pour la consommation de marijuana: consommation légère, consommation grandissante et consommation élevée et stable. Trois trajectoires ont également été observées pour la détresse psychologique : basse, moyenne et élevée. Nos résultats démontrent la présence d’un lien entre la détresse psychologique rapportée lors de la première année de l’étude et les trajectoires de consommation problématiques. Ce lien a également été observé entre la consommation de marijuana rapportée lors de première année de l’étude et les trajectoires problématiques de détresse psychologique. Les analyses de trajectoires jointes démontrent la présence d’une concordance entre la consommation de marijuana et la détresse psychologique. Cette interrelation est toutefois complexe puisque les trajectoires de détresse psychologique élevée sont associées à un niveau de consommation de marijuana plus problématique mais l’inverse de cette association est moins probable. Notre étude met en lumière la nature asymétrique de la concordance entre la consommation de marijuana et la détresse psychologique.