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The purpose of this study is to explore physicians’ knowledge, attitudes, and perceptions toward antibiograms and identify perceived barriers and facilitators to their implementation in a low-resource setting in Sri Lanka.
Design:
A qualitative study utilizing semi-structured interviews and thematic analysis.
Setting:
A public tertiary care hospital in southern Sri Lanka.
Participants:
Thirty physicians working in pediatric and adult medical wards were purposively sampled and interviewed between June and August 2023.
Results:
Most physicians had limited prior knowledge or experience with antibiograms. However, after receiving a brief explanation, 29 out of 30 participants expressed strong support for implementing antibiograms, citing potential benefits such as improved antibiotic prescribing, reduced antimicrobial resistance (AMR), and enhanced patient outcomes. Approximately one-third of participants expressed concerns about feasibility due to time constraints, limited laboratory infrastructure, and personnel shortages. Participants recommended delivering antibiogram training through small-group sessions led by a multidisciplinary team. Thematic analysis identified three core themes: (1) limited baseline knowledge of antibiograms, (2) perceived clinical value and enthusiasm for implementation, and (3) barriers related to healthcare system constraints.
Conclusions:
Physicians in this LMIC setting demonstrated high interest in using antibiograms to guide empiric antibiotic therapy and address AMR. Despite logistical and infrastructural challenges, tailored training and stakeholder engagement may facilitate the successful development and use of antibiograms in similar resource-limited settings.
Distinguishing viral versus bacterial lower respiratory tract infection (LRTI) is challenging. We previously developed a rapid, host response-based test (Biomeme HR-B/V assay) using peripheral blood samples to identify viral versus bacterial infection. We assessed the performance of this assay when using nasopharyngeal (NP) samples.
Methods:
Patients with LRTI were enrolled, and a NP swab sample was run using the HR-B/V assay (assessing 24 gene targets) on the FranklinTM platform. The performance of the prior classifier at identifying viral versus bacterial infection was assessed. A novel predictive model was generated for NP samples using the same 24 targets. Results were validated using external datasets with nasal/NP RNA sequence data.
Results:
Nineteen patients (median age 62 years, 52.1% male) were included. When using the prior HR-B/V classifier on NP samples of 19 patients with LRTI (12 viral, 7 bacterial), the area under the receiver operator curve (AUC) for viral versus bacterial infection was 0.786 (0.524–1), with accuracy 0.79 (95% CI 0.57–0.91), positive percent agreement (PPA) 0.43 (95% CI 0.16–0.75), and negative percent agreement (NPA) 1.00 (95% CI 0.76–1). The novel model had AUC 0.881 (95% CI 0.726–1), accuracy 0.84 (95% CI 0.62–0.94), PPA 0.86 (95% CI 0.49–0.97), and NPA 0.83 (95% CI 0.55–0.95) for bacterial infection. Validation in two external datasets showed AUC of 0.932 (95% CI 0.90–0.96) and 0.915 (95% CI 0.88–0.95).
Conclusions:
We show that host response in the nasopharynx can distinguish viral versus bacterial LRTI. These findings need to be replicated in larger cohorts with diverse LRTI etiologies.
Tight focusing with very small f-numbers is necessary to achieve the highest at-focus irradiances. However, tight focusing imposes strong demands on precise target positioning in-focus to achieve the highest on-target irradiance. We describe several near-infrared, visible, ultraviolet and soft and hard X-ray diagnostics employed in a ∼1022 W/cm2 laser–plasma experiment. We used nearly 10 J total energy femtosecond laser pulses focused into an approximately 1.3-μm focal spot on 5–20 μm thick stainless-steel targets. We discuss the applicability of these diagnostics to determine the best in-focus target position with approximately 5 μm accuracy (i.e., around half of the short Rayleigh length) and show that several diagnostics (in particular, 3$\omega$ reflection and on-axis hard X-rays) can ensure this accuracy. We demonstrated target positioning within several micrometers from the focus, ensuring over 80% of the ideal peak laser intensity on-target. Our approach is relatively fast (it requires 10–20 laser shots) and does not rely on the coincidence of low-power and high-power focal planes.
Processing speed declines with age and is a strong predictor of age-related cognitive decline in other domains, and in predicting who will need help with tasks of daily living in later years. Higher cardiorespiratory fitness (CRF) reflects better cardiopulmonary health and is related to maintenance of processing speed and cognition into late life. On the other hand, white matter lesions (WML) are reflective of age-related brain network disconnections from damage to white matter tracts in the brain. Lower CRF and higher WML burden have each been related to poorer cognitive performance. Although higher CRF provides a protective effect on cognition, the combined effects of CRF and WML on processing speed have yet to be determined. Specifically, whether CRF and WML independently affect processing speed or if WML moderates the effect of CRF on processing speed is yet to be established. We predicted WML may moderate CRF benefits on cognitive aging if CRF-related cognitive benefits are weakened by high WML load. Here, we test this question with the gold-standard measure of CRF, maximal exercise oxygen uptake (relative VO2 max, mL/kg/min) during a graded exercise test, and a validated neuropsychological measure of processing speed, the Digit Symbol Substitution Test (DSST).
Participants and Methods:
CRF, DSST scores, and WML volumes of cognitively normal adults (n=91) aged 55-80 years were included in this analysis. The WML data was corrected for total intracranial volume and was log transformed. A linear regression model included the number of accurately completed items on the DSST as the dependent variable and age, sex, relative VO2 max, WML volumes and the interaction between relative VO2 max and WML volume as the predictor variables.
Results:
Main effects of age, sex, VO2 max and WML volume on the DSST were observed. Greater age, higher WML volume, and lower relative VO2 max were associated with poorer performance on the DSST. In addition, females (n=55) performed better than males (n=36) on the DSST. No significant interaction was observed between VO2 max and WML volume on DSST scores.
Conclusions:
Our results show that 1) WML and relative VO2 max independently contribute to processing speed performance in older adults as measured by the DSST, and 2) WML do not moderate the relation between VO2 max and the DSST. Strengths of this study include gold-standard measurement of CRF and WML volumes as predictors of performance on the DSST in older adults. Further research is warranted to understand how vascular aging and brain health indicators interactively or interdependently impact cognition in aging.
The impact of engineered products is a topic of concern in society. Product impact may fall under the categories of economic, environmental or social impact, with the last category defined as the effect of a product on the day-to-day life of people. Design teams lack sufficient tools to estimate the social impact of products, and the combined impacts of economic, environmental and social impacts for the products they are designing. This paper aims to provide a framework for the estimation of product impact during product design. To estimate product impact, models of both the product and society are required. This framework integrates models of the product, scenario, society and impact into an agent-based model to estimate product impact. Although this paper demonstrates the framework using only social impact, the framework can also be applied to economic or environmental impacts individually or all three concurrently. Agent-based modelling has been used previously for product adoption models, but it has not been extended to estimate product impact. Having tools for impact estimation allows for optimising the product design parameters to increase the potential positive impact and reduce potential negative impact.
The impact of products is becoming a topic of concern in society. Product impact may fall under the categories of economic, environmental, or social impact and is defined by the effect of a product on day-to-day life. Design teams lack sufficient tools to predict the impact of products they are designing. In this paper we present a framework for the prediction of product impact during product design. This framework integrates models of the product, scenario, society, and impact into an agent-based model to predict product impact. Although this paper focuses on social impact, the framework can also be applied to economic or environmental impacts. An illustration of using the framework is also presented. Agent-based modeling has been used previously for adoption models, but it has not been extended to predict product impact. Having tools for impact prediction allows for optimizing the product design parameters to increase potential positive impact and reduce potential negative impact.
The goal of this chapter is to establish an overview of the patterns of conflict in the border counties. The purpose here is, as far as possible, to make a quantitative analysis of conflict derived from court evidence. The first section below presents the records which underpin the analysis that follows. The archives of the court of king’s bench are useful for establishing a chronology of affairs at law. Private litigation among landowners features predominantly on the coram rege side this court, and on the rex side it heard most crown and private charges against gentry and nobility. It also heard quite a lot of crown charges of felony or trespass against perpetrators from the lower social orders, but even so such cases were frequently associated with disputes among landed antagonists. Thus, litigation in king’s bench should be an important indicator of tensions in political society. The itinerant gaol delivery court records focus, by contrast, much more on crown prosecutions of felonies perpetrated by culprits of yeoman status or lower; accordingly, they point towards more local social tensions and concerns of a much less politically significant flavour. There are no surviving records of the warden courts to examine by way of comparison. By tracing a chronology of conflict derived from legal records and matching this with major events, especially political upheavals, the second section below examines the extent to which the border counties were affected by the wider national context, including what local effects were caused by greater disputes among magnates. King’s bench records provide the main pool of evidence used in this section. Third, the chapter considers the effect of Anglo-Scottish war and truce on patterns of conflict and litigation in order to continue to address the question of whether the military aspect of the frontier had the effect of making the marches more prone to conflict, especially violent conflict, than elsewhere. This will be done with the king’s bench data and the gaol delivery data separately, and here the gaol delivery evidence will be more fully discussed. Fourth, the chapter will assess, where possible, the level and nature of violence. Finally, it will consider the role of the border liberties in local conflict. In these final two sections the evidence from both king’s bench and gaol delivery will be employed. Further supplementary evidence will be used throughout this chapter where relevant. Of course, where we are concerned with ‘violence’ it should be recalled that this is a broad heading under which can be grouped a number of aggressive actions involving the use of force, both against the person (including physical assault, rape, abduction, detention and killing) and against property (including plundering of goods and livestock and burning or destroying buildings, boundary-markers, crops or the like). Yet no objective measure of such behaviour exists; historians must rely upon the subjective accounts of those who bothered to record it; and it should be taken as read that legal records complicate analysis considerably. As will be noted below, cases begun with the general-purpose writs of trespass vi et armis are not treated on their own as encompassing genuine violence unless they feature more specific allegations. It should also be observed that, although they have not been excluded from the comprehensive figures enumerated in this chapter, those cases with specifically cross-border dimensions (which are more often to be found in gaol delivery than in king’s bench records) will be a focus of Chapter 8.
The concern of this chapter is some fundamental elements of the structure of local society in the marches. At the outset we highlighted the theoretical importance of kinship and lordship in conflict management, and now we return to these themes with the goal to address directly the vague generalisations that have been made concerning ‘the clannish loyalties of border society’, and which build on certain (and enduring) assumptions about the strength of kinship in the region and its correlation with weak governmental structures. By evaluating the importance of social relationships of lordship and kinship, the aim is to build the ground upon which to assess local conflict in the marches. More broadly, it is to explore how kinship was conceived and expressed at different social levels, beginning with landed society and then extending the analysis to encompass common inhabitants of the border shires. This discussion relies heavily for its source materials on court records, which will be introduced in the course of discussion below and more fully in a subsequent chapter.
Before proceeding any further with our analysis, this short chapter offers an overview of the landowners of the northern marches. By 1399, the greatest border lords were relative newcomers. Fourteenth-century warfare had eliminated the cross-border landownership which been prevalent in the thirteenth century and had led to an increasing level of seigneurial absenteeism. The Percy earls of Northumberland (created 1377, and who suffered forfeitures in 1405–16 and 1461–70) were the only magnates frequently resident in the far north-east. However, as great magnates, their other responsibilities meant they were seldom in the marches for long. The family had gained extensive lands in Northumberland during the fourteenth century (including the baronies of Alnwick, Warkworth, Beanley, Langley and Prudhoe, and the manors of Rothbury, Corbridge, Newburn, Thirston, Newham, Ellingham and Newstead). Their territories included the ‘Talbot Lands’ within northern Tynedale, which alone extended to nearly 6,000 acres. In Cumberland, they had also acquired Egremont and Cockermouth. The sons of the second earl of Northumberland maintained a family presence in the marches: Thomas (Lord Egremont from 1449) was active on the family’s Cumberland estates in the 1450s; Henry (Lord Poynings from 1446 and third earl from 1455) was warden of the east march and keeper of Berwick from 1440; Sir Ralph (d. 1464), was active in the 1450s and early 1460s as deputy and later constable of Dunstanburgh Castle.
This book has two main aims. Its subject is the far north in the fifteenth century, in a time period significant for the region in being much less well understood than either the preceding century (dominated by Anglo-Scottish warfare) or the following one (in which the so-called border reivers were so well documented by Tudor administrators and their Scottish counterparts). The first aim is to investigate the far north in light of its prevailing reputation as different from the rest of England: an alien, turbulent and exceptional ‘periphery’ distant from the realm’s heartland. The question to be pursued is how local society governed itself, in particular, how it sought to manage conflict, in the northern marches. The second aim is the more ambitious. While drawing local, national and international comparisons where relevant and helpful, it is to raise questions from this example about the geography of power and the nature of conflict in the English kingdom as a whole.
If the preceding chapter set out a conceptual apparatus with which to understand the northern marches, then this chapter examines two topics which have been salient in historical interpretations of the region. The first relates to the view of the far north as an ‘embattled frontier society’, defended by strings of garrisoned fortresses. It is this particular emblem of the supposed exceptional militarisation of the region, its towers and castles, which shall be investigated. The second topic concerns the landscape of the ‘northe parties’ and its corresponding patterns of human activity and settlement. In both popular and academic accounts, the far north is often a wild country, remote, mountainous, dominated by difficult hill farming and rugged hill tribes. Such interpretations are shaped in part by modern assumptions about human geography; they are also partly informed by the rhetorical efforts of medieval borderers themselves. Marchers crafted petitions and turns of phrase in their dealings with the hierarchy of the king’s government and with that of the church which (as should be no occasion for surprise) emphasised aspects of border life which played to their advantage and benefit. If what follows tends to offer an appraisal of existing work in a range of specialisms (including especially architectural and landscape history) more than a digestion of raw historical evidence, it does so seeking to engage the current historiography of the Anglo-Scottish marches with a view to provoking some critical debate and to opening up to scrutiny some of the prevailing assumptions about the exceptional character of this area. The argument to be advanced here is that the towers and castles of the marches should not be understood solely, or even primarily, as a symptom of war and a pressing need for security. The point will also be pursued that the landscapes of the medieval far north cannot be reduced in any satisfactory way to a single category of ‘upland’ terrain, and so the diversity of farming practices and corresponding patterns of human habitation in the region require more nuanced appreciation if they are to be understood meaningfully.