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Despite recommendations to discontinue prophylactic antibiotics after incision closure or <24 hours after surgery, prophylactic antibiotics are continued after discharge by some clinicians. The objective of this study was to determine the prevalence and factors associated with postdischarge prophylactic antibiotic use after spinal fusion.
Multicenter retrospective cohort study.
This study included patients aged ≥18 years undergoing spinal fusion or refusion between July 2011 and June 2015 at 3 sites. Patients with an infection during the surgical admission were excluded.
Prophylactic antibiotics were identified at discharge. Factors associated with postdischarge prophylactic antibiotic use were identified using hierarchical generalized linear models.
In total, 8,652 spinal fusion admissions were included. Antibiotics were prescribed at discharge in 289 admissions (3.3%). The most commonly prescribed antibiotics were trimethoprim/sulfamethoxazole (22.1%), cephalexin (18.8%), and ciprofloxacin (17.1%). Adjusted for study site, significant factors associated with prophylactic discharge antibiotics included American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 1.31; 95% CI, 1.00–1.70), lymphoma (OR, 2.57; 95% CI, 1.11–5.98), solid tumor (OR, 3.63; 95% CI, 1.62–8.14), morbid obesity (OR, 1.64; 95% CI, 1.09–2.47), paralysis (OR, 2.38; 95% CI, 1.30–4.37), hematoma/seroma (OR, 2.93; 95% CI, 1.17–7.33), thoracic surgery (OR, 1.39; 95% CI, 1.01–1.93), longer length of stay, and intraoperative antibiotics.
Postdischarge prophylactic antibiotics were uncommon after spinal fusion. Patient and perioperative factors were associated with continuation of prophylactic antibiotics after hospital discharge.
For nearly 30 years, the business and scientific press has featured a constant stream of stories about the changing nature of work. While some organizations and occupations have changed substantially in recent years, the belief that such changes are relatively recent or relatively widespread is not well founded. First, the nature and organization of work has evolved continuously over time and the current changes are especially large. Second, there are very large sectors of the economy in which the changes in technology and the organization of work have been minimal. The belief that the nature of work is changing is in large part rooted in the tendency to mistake the brief period of economic stability and highly valued employment in the United Stats that followed the Second World War as the normal state rather than an anomaly. The nature of work is changing and will continue to change, but these changes are part of a long-term set of evolutionary changes, not a sudden or recent innovation.
This study evaluated the quality of YouTube content focusing on common paediatric otolaryngology procedures, as this content can influence the opinions and medical decisions of patients.
A total of 120 YouTube videos were compiled to review using the terms ‘adenoid removal’, ‘adenoidectomy’, ‘ear tubes’, ‘tympanostomy’, ‘tonsil removal’ and ‘tonsillectomy’. The Discern criteria was used to rate the quality of health information presented in each video.
The mean bias Discern score was 3.18 and the mean overall Discern score was 2.39. Videos including US board certified physicians were rated significantly higher (p < 0.001) than videos without (bias Discern score = 3.00 vs 2.38; overall Discern score = 3.79 vs 1.55). The videos had been viewed a total of 176 769 549 times.
Unbiased, high quality videos on YouTube are lacking. As patients may rely on this information when making medical decisions, it is important that practitioners continually evaluate and improve this video content. Otolaryngologists should be prepared to discuss YouTube content with patients.
To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices.
Retrospective before-and-after study.
A 1,250-bed academic tertiary-care referral center.
Hospitalized adults who had ≥1 urine culture performed during their stay.
The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets, and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before the intervention (January 2015 to April 2016) and after the intervention (May 2016 to August 2017), adjusting for temporal trends.
During the study period, 18,954 inpatients (median age, 62 years; 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Overall, 6,662 urine cultures (27%) were positive. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention; P < .001), clean catch (30.0 vs 18.7; P < .001) and catheterized urine (7.8 vs 1.9; P < .001). Using an interrupted time series model, urine culture rates decreased for all specimen types (P < .05).
Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.
Introduction: Continued smoking by cancer patients causes adverse cancer treatment outcomes, but few patients receive evidence-based smoking cessation as a standard of care.
Aim: To evaluate practical strategies to promote wide-scale dissemination and implementation of evidence-based tobacco cessation services within state cancer centers.
Methods: A Collaborative Learning Model (CLM) for Quality Improvement was evaluated with three community oncology practices to identify barriers and facilitate practice change to deliver evidence-based smoking cessation treatments to cancer patients using standardized assessments and referrals to statewide smoking cessation resources. Patients were enrolled and tracked through an automated data system and received follow-up cessation support post-enrollment. Monthly quantitative reports and qualitative data gathered through interviews and collaborative learning sessions were used to evaluate meaningful quality improvement changes in each cancer center.
Results: Baseline practice evaluation for the CLM identified the lack of tobacco use documentation, awareness of cessation guidelines, and awareness of services for patients as common barriers. Implementation of a structured assessment and referral process demonstrated that of 1,632 newly registered cancer patients,1,581 (97%) were screened for tobacco use. Among those screened, 283 (18%) were found to be tobacco users. Of identified tobacco users, 207 (73%) were advised to quit. Referral of new patients who reported using tobacco to an evidence-based cessation program increased from 0% at baseline across all three cancer centers to 64% (range = 30%–89%) during the project period.
Conclusions: Implementation of quality improvement learning collaborative models can dramatically improve delivery of guideline-based tobacco cessation treatments to cancer patients.
We compared sepsis “time zero” and Centers for Medicare and Medicaid Services (CMS) SEP-1 pass rates among 3 abstractors in 3 hospitals. Abstractors agreed on time zero in 29 of 80 (36%) cases. Perceived pass rates ranged from 9 of 80 cases (11%) to 19 of 80 cases (23%). Variability in time zero and perceived pass rates limits the utility of SEP-1 for measuring quality.
Mentorship is perceived to be an important component of residency education. However, evidence of the impact of mentorship on professional development in Emergency Medicine (EM) is lacking.
Online survey distributed to attending physician members of the Canadian Association of Emergency Physicians (CAEP), using a modified Dillman method. Survey contained questions about mentorship during residency training, and perceptions of the impact of mentorship on career development.
The response rate was 23.5% (309/1314). 63.6% reported having at least one mentor during residency. The proportion of participants with a formal mentorship component during residency was higher among those with mentors (44.5%) compared to those without any formal mentorship component during residency (8.0%, p<0.001). The most common topics discussed with mentors were career planning and work-life balance. The least common topics included research and finances. While many participants consulted their mentor regarding their first job (56.5%), fewer consulted their mentor regarding subspecialty training (45.1%) and research (41.1%). 71.8% chose to work in a similar centre as their mentor, but few completed the same subspecialty (24.8%), or performed similar research (30.4%). 94.1% stated that mentorship was important to success during residency. Participants in a formal mentorship program did not rate their experience of mentorship higher than those without a formal program.
Among academic EM physicians with an interest in mentorship, mentorship during EM residency may have a greater association with location of practice than academic scholarship or subspecialty choice. Formal mentorship programs increase the likelihood of obtaining a mentor, but do not appear to improve reported mentorship experiences.
A theoretical study is carried out for bubble oscillation in a compressible liquid with significant acoustic radiation based on the Keller–Miksis equation using a multi-scaled perturbation method. The leading-order analytical solution of the bubble radius history is obtained to the Keller–Miksis equation in a closed form including both compressible and surface tension effects. Some important formulae are derived including: the average energy loss rate of the bubble system for each cycle of oscillation, an explicit formula for the dependence of the oscillation frequency on the energy, and an implicit formula for the amplitude envelope of the bubble radius as a function of the energy. Our theory shows that the frequency of oscillation does not change on the inertial time scale at leading order, the energy loss rate on the long compressible time scale being proportional to the Mach number. These asymptotic predictions have excellent agreement with experimental results and the numerical solutions of the Keller–Miksis equation over very long times. A parametric analysis is undertaken using the above formula for the energy of the bubble system, frequency of oscillation and minimum/maximum bubble radii in terms of the dimensionless initial pressure of the bubble gases (or, equivalently, the dimensionless equilibrium radius), Weber number and polytropic index of the bubble gas.
Objectives: Glioblastoma is a lethal disease in the elderly population. We aimed to evaluate disease and treatment outcomes in the oldest-old patients. Methods: Patients >80 years old with histologically confirmed glioblastoma treated between 2004 and 2009 were identified. We included patients managed with best supportive care (BSC), temozolomide (TMZ) alone, radiotherapy (RT) alone, or concomitantly with TMZ (CRT). Survival outcomes were analyzed using the Kaplan–Meier method. Results: Ultimately, 48 patients were analyzed. Median age and Eastern Cooperative Oncology Group (ECOG) Performance Status were 82 years and 2, respectively. The median Age-Adjusted Charlson Index (AAC) was 6. Gross total and subtotal resections were performed in 16.7% and 18.8% of patients, respectively. Biopsy followed by RT alone was the treatment modality for 23/48 (47.9%), while 17/48 (35.4%) received surgery followed by RT alone or CRT. A total of 8 (16.7%) were managed with BSC after biopsy. Median overall survival (OS) and progression-free survival (PFS) were 4.1 (95% confidence interval [95% CI] 3.3-4.9) and 2.7 (95% CI 1.5-3.9) months, respectively. Improved median OS was observed in those treated with surgical resection followed by RT alone or CRT (7.1 months), compared to biopsy followed by RT alone (4.2 months) or BSC (2.0 months; p=0.002). Surgical resection, age≤85, and AAC<6 were associated with better OS (p=0.032, p=0.031, and p=0.02, respectively). Cause of death was neurological progression in 56% of cases. RT was well-tolerated. Conclusions: PFS and OS outcomes remain poor in the oldest-old patients (>80 years old). Younger age, lower AAC, surgical resection, and adjuvant treatment were associated with improved OS.
This paper reports on a project conducted with representatives of indigenous Māori organizations that are active in New Zealand land-based sectors. The primary aim of the research was to assist these organizations in thinking about their current and future positioning with regard to climate change. Using Peter Checkland’s Soft Systems Methodology as a broad framework for the research, the paper first seeks to capture some of the likely issues that enable and constrain strategic activity in the climate change arena. It then uses various soft systems modelling tools to research and structure a debate to consider the desirability and feasibility of particular interventions.
Customary land is commonly perceived as a barrier to economic development and indigenous entrepreneurship in Pacific Island countries. We turn this proposition on its head, arguing that customary land provides a solid foundation for indigenous entrepreneurs who wish to achieve social, cultural and environmental, as well as economic, goals for their businesses. Furthermore, we assert that appropriate tools are needed to measure the success of indigenous businesses on customary land, as conventional tools have a narrow focus on economics that fails to capture the more holistic, sustainable development goals that indigenous people hope to achieve through their businesses. The indicators we utilise relate to socio-cultural, economic and environmental sustainability. The tool’s usefulness was scrutinized through pre-testing on two indigenous businesses in Fiji; this revealed that culturally oriented tools are essential if the sustainability of indigenous business is to be measured in terms that are meaningful to Pacific communities.
Governmental development strategies focus on entrepreneurship as a major resource for the economic development of indigenous peoples. While initiatives and programs are locally based, there is a debate in the academic literature about how contextual factors affect the identification of indigenous entrepreneurship. The purpose of this paper is to analyze and integrate indigenous entrepreneurship literature to identify the main indigenous entrepreneurship models. Thus, a systematic literature review was conducted. In total, 25 relevant articles were identified in selected electronic databases and manual searches of Australian Business Deans Council ranked journals from January 1, 1995 to the end of 2016. Using a systematic analysis of sociocultural contexts and locations, the paper proposed that a typology of contextualized indigenous entrepreneurship models was possible, that were classified as urban, remote and rural. The parameters of these models, and their potential theoretical and practical applications to the study and practice of indigenous entrepreneurship ecosystems were also outlined.
This paper explores the influence of institutions on indigenous entrepreneurship within the muttonbird economy of Ngāi Tahu (a New Zealand Māori tribe). It determines that colonisation removed the traditional Ngāi Tahu institution of executive authority which once regulated muttonbird exchange. Without this regulatory function whānau (family) birders compete against each other at their own expense and to the benefit of traders. As a consequence the birders are constrained in applying their birding knowledge and abilities to realise market opportunity. Furthermore, declining returns and harvesting pressure is in some cases reducing the financial and natural capital of whānau, whilst threats to continuing birding culture potentially undermines the socio-human capital contained within inherited traditions and the maintaining of kinship connections. It is argued that the development of a contemporary executive authority to regulate exchange and market product may reinvigorate entrepreneurial birding activities.
Art centres fulfil many functions in remote regions as a source of Indigenous identity and creativity; as a link to the global art market; as centres for community engagement and participation; and as a source of social capital providing a range of services for local communities. They are dependent on funding from State and Federal authorities and they are identified as one of the success stories in remote community development. However, they face an uncertain future in the light of their multiple functions and their position as both a source of traditional identity and a link to an external art market. The article highlights the challenges faced by government in the evaluation of their effectiveness and contribution; and in particular discusses the suitability of the hybrid economy model as a representation of their functions.
With the widespread shift from models of welfare to business-led development, capacity development offers a useful lens from which to consider the emergence of Indigenous social enterprise as a business-led development approach. We explore capacity development from the international development literature and identify capacity development principles in the context of an Indigenous social enterprise in remote northeast Arnhem Land. Here, Aboriginal Australians continue to experience poverty and marginalisation. This paper provides an ethnographic example of the relationship between Indigenous social enterprise and capacity development. Identifying principles of capacity development in this rich context reveals the remit of the Indigenous social enterprise privileges environmental stewardship and cultural maintenance.
This paper explores the emancipatory impulse of Indigenous social innovation and social enterprise. Indigenous approaches to solving social disparities reflect a perpetual search for innovative ways to change the circumstances of Māori. Power is an understudied dimension of social innovation and social enterprise. This paper explores the power dynamics that structure the disadvantage and marginalisation that cause populations to be underserved by markets and that limit their access to resources. We highlight that it is not power per se that enables social change: rather, it is power shifts. Through a single, richly contextualised case study of a well-known Māori social innovator, Dr Lance O’Sullivan, we reveal and illustrate the nuances of Indigenous entrepreneurship in the Far North of Aotearoa New Zealand. The case epitomises the transformative impact a social entrepreneur can have on the provision of healthcare amid market and policy failures.
Indigenous entrepreneurs represent a growing segment of the business community in many countries, but face sometimes stark challenges in starting and running enterprises. The success of indigenous entrepreneurs matters because they draw upon their indigeneity as sources of inspiration and innovation, contribute to the collective wellbeing of indigenous peoples, and some represent world class exemplars of sustainable ways of doing business. While enterprise assistance for entrepreneurs is widely accepted as a worthwhile use of public funds few guidelines exist to help policy makers and providers understand the needs of indigenous entrepreneurs and how best to respond. In this paper, we use the theoretical lens of entrepreneurial identity to provide insight into this challenging context. Taking an identity perspective may enable us to tease out how identifying as a Māori entrepreneur can enable and also hinder change in this community context. In doing so we lay foundations for future empirical work.