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Background: Antibiotic time outs (ABTOs), formal reassessments of all new antimicrobial regimens by the care team, can optimize antimicrobial regimens, reducing antimicrobial overuse and potentially improving outcomes. Implementation of ABTOs is a substantial challenge. We used quality improvement methods to implement robust, meaningful, team-driven ABTOs in general medicine ward services. Methods: We identified and engaged stakeholders to serve as champions for the quality improvement initiative. On October 1, 2018, 2 internal medicine teaching services (services A and B), began conducting ABTOs on all patients admitted to their services receiving systemic antimicrobials for at least 36 hours. Eligible patients were usually identified by the team pharmacist. ABTOs were completed within 72 hours of antibiotic initiation and were documented in the electronic medical record (EMR) by providers using a template. The process was modified as necessary in response to feedback from frontline clinicians using plan-do-study-act (PDSA) methods. We subsequently spread the project to 2 additional internal medicine services (services C and D); 2 family medicine teams (services E and F); and 1 general pediatric service (service G). The project is ongoing. We collected data for the following metrics: (1) proportion of ABTO-eligible patients with an ABTO; (2) proportion of ABTOs conducted within the recommended time frame; (3) documented plan changes as a result of ABTO (eg, change IV antibiotics to PO); (4) proportion of documented plan changes actually completed within 24 hours. Results: Within 12 weeks, services A and B were successfully completing time outs in >80% of their patients. This target was consistently reached by services C, D, E, F, and G almost immediately following launch on those services. As of June 29, 2019, >80% of eligible patients across all participating services have had a time out conducted for 16 consecutive weeks. ABTOs have resulted in a change in management in 35% of cases, including IV-to-PO change in 19% of cases and discontinuation in 5%. Overall, 77% of time outs occurred during the 36–72-hour window. Ultimately, 95% of documented plan changes were completed within 24 hours. Conclusions: ABTOs are effective but implementation is challenging. We achieved high compliance with ABTOs without using electronic reminders. Our results suggest that ABTOs were impactful in the non–critical-care general medicine setting. Next steps include (1) development of EMR-based tools to facilitate identifying eligible patients and ABTO documentation; (2) continued spread through our health care system; and (3) analysis of ABTO impact using ABTO-unexposed patients as a control group.
A large proportion of antibiotic use associated with hospitalization occurs immediately after discharge, representing an important focus for antimicrobial stewardship programs. This review identified few studies evaluating the effect of interventions aimed at improving discharge antibiotic prescribing. Antimicrobial stewardship to improve postdischarge antibiotic prescribing is an unmet need warranting further study.
Leukocyte DNA methylation patterns associated with habitual diet may reveal molecular mechanisms involved in the pathogenesis of diet-related chronic diseases and highlight targets for prevention and treatment. We aimed to examine peripheral blood derived leukocyte DNA methylation signatures associated with diet quality. We meta-analyzed epigenome-wide associations between diet quality and DNA methylation levels at over 400,000 cytosine-guanine dinucleotides (CpGs). We conducted analysis primarily in 6,662 European ancestry (EA) participants and secondarily in a group additionally including 3,062 participants of non-European ancestry from five population-based cohort studies. DNA methylation profiles were measured in whole blood, CD4 + T-cells, or CD14 + monocytes. We used food frequency questionnaires to assess habitual intake and constructed two diet quality scores: the Mediterranean-style diet score (MDS) and Alternative Healthy Eating Index (AHEI). Our primary analysis identified 32 diet-associated CpGs, 12 CpGs for MDS and 24 CpGs for AHEI (at FDR < 0.05, corresponding p-values = 1.2×10-6 and 3.1×10-6, respectively) in EA participants. Four of these CpGs were associated with both MDS and AHEI. In addition, Mendelian randomization analysis indicated that seven diet-associated CpGs were causally linked to at least one of the CVD risk factors. For example, hypermethylation of cg11250194 (FADS2), which was associated with higher diet quality scores, was also associated with lower fasting triglycerides concentrations (p-value = 1.5×10-14) and higher high-density lipoprotein cholesterol concentrations (p-value = 1.7×10-8). Transethnic meta-analysis identified nine additional CpGs associated with diet quality (either MDS or AHEI) at FDR < 0.05. Overall quality of habitual diet was associated with differential peripheral leukocyte DNA methylation levels of 32 CpGs in EA participants. The diet-associated CpGs may serve as biomarkers and targets for preventive measures in CVD health. Future studies are warranted to examine diet-associated DNA methylation patterns in larger, ethnically diverse study samples.
General practices play an important role in the detection and treatment of depressive symptoms in older adults. An adapted version of the indicated preventive life review therapy group intervention called Looking for Meaning (LFM) was developed for general practice and a pilot evaluation was conducted.
A pretest-posttest design was used. One week before and one week after the intervention participants filled out questionnaires.
In six general practices in the Netherlands the adapted intervention was given.
Inclusion criteria were > 60 years and a score of 5 or higher on the Center for Epidemiological Studies Depression Scale (CES-D).
The length and number of LFM sessions were shortened and the intervention was given by one mental health care nurse practitioner (MHCNP).
The impact on mental health was analyzed by depressive symptoms (CES-D) as the primary outcome and anxiety symptoms (HADS-A), psychological well-being (PGCMS) and mastery (PMS) as secondary outcomes. An evaluative questionnaire was included to evaluate the feasibility and acceptability.
Most participants were satisfied with the adaptations of the number (72%) and length (72%) of sessions. The overall sample showed a significant decrease in depressive symptoms after the intervention. No impact was found on psychological well-being, anxiety symptoms and mastery.
The intervention is feasible and acceptable for older adults with depressive symptoms and has an impact on their depressive symptoms.
The author, a health insurance industry leader and a prominent voice in the national reform debate, shares his perspective on attempts to transform health care over nearly a decade. He advocates for a bipartisan solution to stabilize the health insurance market in the near term, and for private sector innovation in partnership with government to create sustainable long-term change. He encourages ASLME members to continue to lend their expertise to the process of transformation.
There is much discourse and focus on the social determinants of health, but undergirding these multiple intersecting and interacting determinants are legal and political determinants that have operated at every level and impact the entire life continuum. The United States has long grappled with advancing health equity via public law and policy. Seventy years after the country was founded, lawmakers finally succeeded in passing the first comprehensive and inclusive law aimed at tackling the social determinants of health, but that effort was short-lived. Today the United States is faced with another fork in the road relative to the advancement of health equity. This article draws on lessons from history and law to argue that researchers, providers, payers, lawmakers and the legal community have a moral, economic and national security imperative to address not only the negative outcomes of health disparities, but also the imbalance of inputs resulting from laws and policies which fail to employ an equity lens.
Whether or not a replication attempt counts as “direct” often cannot be determined definitively after the fact as a result of flexibility in how procedural differences are interpreted. Specifying constraints on generality in original articles can eliminate ambiguity in advance, thereby leading to a more cumulative science.
Prior optical coherence tomography (OCT) studies of schizophrenia have identified thinning of retinal layers. However, findings have varied across reports, and most studies have had serious methodological limitations. To address unresolved issues, we determined whether: (1) retinal thinning in schizophrenia occurs independently of comorbid medical conditions that affect the retina; (2) thinning is independent of antipsychotic medication dose; (3) optic nerve parameters are abnormal in schizophrenia; and (4) OCT indices are related to visual and cognitive impairments common in schizophrenia.
A total of 32 people with schizophrenia and 32 matched controls participated. Spectral domain OCT generated data on retinal nerve fiber layer (RNFL), macula, and ganglion cell-inner plexiform layer (GCL-IPL) thickness, in addition to cup volume and the cup-to-disc ratio at the optic nerve head. Subjects with schizophrenia also completed measures of symptoms, visual processing, and IQ.
The groups did not differ on RNFL, macula, or GCL-IPL thickness. However, thinning of these layers was related to the presence of diabetes or hypertension across the sample as a whole. The schizophrenia group demonstrated enlarged cup volume and an enlarged cup-to-disc ratio in both eyes, which were unrelated to medical comorbidity, but were related to increased cognitive symptoms.
Past reports of retinal thinning may be artifacts of medical comorbidity that is over-represented in schizophrenia, or other confounds. However, optic nerve head abnormalities may hold promise as biomarkers of central nervous system abnormality, including cognitive decline, in schizophrenia.
This piece explores legal, ethical, and policy arguments associated with using interventions that leverage feelings of shame and social exclusion to promote uptake of childhood immunizations by parents.
Retrospective voting is a central explanation for voters’ support of incumbents. Yet, despite the variety of conditions facing American cities, past research has devoted little attention to retrospective voting for mayors. This paper first develops hypotheses about how local retrospective voting might differ from its national analog, due to both differing information sources and the presence of national benchmarks. It then analyzes retrospective voting using the largest data set on big-city mayoral elections between 1990 and 2011 to date. Neither crime rates nor property values consistently influence incumbent mayors’ vote shares, nor do changes in local conditions. However, low city-level unemployment relative to national unemployment correlates with higher incumbent support. The urban voter is a particular type of retrospective voter, one who compares local economic performance to conditions elsewhere. Moreover, these effects appear to be present only in cities that dominate their media markets, suggesting media outlets’ role in facilitating retrospective voting.
The fragmented ecosystems along the Niagara Escarpment World Biosphere Reserve provide important habitats for biota including lichens. Nonetheless, the Reserve is disturbed by dense human populations and associated air pollution. Here we investigated patterns of lichen diversity within urban and rural sites at three different locations (Niagara, Hamilton, and Owen Sound) along the Niagara Escarpment in Ontario, Canada. Our results indicate that both lichen species richness and community composition are negatively correlated with increasing human population density and air pollution. However, our quantitative analysis of community composition using canonical correspondence analysis (CCA) indicates that human population density and air pollution is more independent than might be assumed. The CCA analysis suggests that the strongest environmental gradient (CCA1) associated with lichen community composition includes regional pollution load and climatic variables; the second gradient (CCA2) is associated with local pollution load and human population density factors. These results increase the knowledge of lichen biodiversity for the Niagara Escarpment and urban and rural fragmented ecosystems as well as along gradients of human population density and air pollution; they suggest a differential influence of regional and local pollution loads and population density factors. This study provides baseline knowledge for further research and conservation initiatives along the Niagara Escarpment World Biosphere Reserve.
To investigate the association of seasonality with dietary diversity, household food security and nutritional status of pregnant women in a rural district of northern Bangladesh.
A cross-sectional study was conducted from February 2013 to February 2015. Data were collected on demographics, household food security (using the Household Food Insecurity Access Scale), dietary diversity (using the women’s dietary diversity questionnaire) and mid-upper arm circumference. Descriptive statistics were used to explore demographics, dietary diversity, household food security and nutritional status, and inferential statistics were applied to explore the role of seasonality on diversity, household food security and nutritional status.
Twelve villages of Pirganj sub-district, Rangpur District, northern Bangladesh.
Pregnant women (n 288).
Seasonality was found to be associated with dietary diversity (P=0·026) and household food security (P=0·039). Dietary diversity was significantly lower in summer (P=0·029) and spring (P=0·038). Food security deteriorated significantly in spring (P=0·006) and late autumn (P=0·009).
Seasons play a role in women’s household food security status and dietary diversity, with food security deteriorating during the lean seasons and dietary diversity deteriorating during the second ‘lesser’ lean season and the season immediately after. Interventions that aim to improve the diet of pregnant women from low-income, subsistence-farming communities need to recognise the role of seasonality on diet and food security and to incorporate initiatives to prevent seasonal declines.
To identify Choosing Wisely items for the American Board of Internal Medicine Foundation.
The Society for Healthcare Epidemiology of America (SHEA) elicited potential items from a hospital epidemiology listserv, SHEA committee members, and a SHEA–Infectious Diseases Society of America compendium with SHEA Research Network members ranking items by Delphi method voting. The SHEA Guidelines Committee reviewed the top 10 items for appropriateness for Choosing Wisely. Five final recommendations were approved via individual member vote by committees and the SHEA Board.
Ninety-six items were proposed by 87 listserv members and 99 SHEA committee members. Top 40 items were ranked by 24 committee members and 64 of 226 SHEA Research Network members. The 5 final recommendations follow: 1. Don’t continue antibiotics beyond 72 hours in hospitalized patients unless patient has clear evidence of infection. 2. Avoid invasive devices (including central venous catheters, endotracheal tubes, and urinary catheters)and, if required, use no longer than necessary. They pose a major risk for infections. 3. Don’t perform urinalysis, urine culture, blood culture, or Clostridium difficile testing unless patients have signs or symptoms of infection. Tests can be falsely positive leading to overdiagnosis and overtreatment. 4. Do not use antibiotics in patients with recent C. difficile without convincing evidence of need. Antibiotics pose a high risk of C. difficile recurrence. 5. Don’t continue surgical prophylactic antibiotics after the patient has left the operating room. Five runner-up recommendations are included.
These 5 SHEA Choosing Wisely and 5 runner-up items limit medical overuse.
The challenges presented by traumatic injuries in low-resource communities are especially relevant in South Sudan. This study was conducted to assess whether a 3-day wilderness first aid (WFA) training course taught in South Sudan improved first aid knowledge. Stonehearth Open Learning Opportunities (SOLO) Schools designed the course to teach people with limited medical knowledge to use materials from their environment to provide life-saving care in the event of an emergency.
A pre-test/post-test study design was used to assess first aid knowledge of 46 community members in Kit, South Sudan, according to a protocol approved by the University of New England Institutional Review Board. The course and assessments were administered in English and translated in real-time to Acholi and Arabic, the two primary languages spoken in the Kit region. Descriptive statistics, t-test, ANOVA, and correlation analyses were conducted.
Results included a statistically significant improvement in first aid knowledge after the 3-day training course: t(38)=3.94; P<.001. Although men started with more health care knowledge: (t(37)=2.79; P=.008), men and women demonstrated equal levels of knowledge upon course completion: t(37)=1.56; P=.88.
This research, which may be the first of its kind in South Sudan, provides evidence that a WFA training course in South Sudan is efficacious. These findings suggest that similar training opportunities could be used in other parts of the world to improve basic medical knowledge in communities with limited access to medical resources and varying levels of education and professional experiences.
KatonaLB, DouglasWS, LenaSR, RatnerKG, CrothersD, ZondervanRL, RadisCD. Wilderness First Aid Training as a Tool for Improving Basic Medical Knowledge in South Sudan. Prehosp Disaster Med. 2015;30(6):574–578.
To determine whether use of contact precautions on hospital ward patients is associated with patient adverse events
Individually matched prospective cohort study
The University of Maryland Medical Center, a tertiary care hospital in Baltimore, Maryland
A total of 296 medical or surgical inpatients admitted to non–intensive care unit hospital wards were enrolled at admission from January to November 2010. Patients on contact precautions were individually matched by hospital unit after an initial 3-day length of stay to patients not on contact precautions. Adverse events were detected by physician chart review and categorized as noninfectious, preventable and severe noninfectious, and infectious adverse events during the patient’s stay using the standardized Institute for Healthcare Improvement’s Global Trigger Tool.
The cohort of 148 patients on contact precautions at admission was matched with a cohort of 148 patients not on contact precautions. Of the total 296 subjects, 104 (35.1%) experienced at least 1 adverse event during their hospital stay. Contact precautions were associated with fewer noninfectious adverse events (rate ratio [RtR], 0.70; 95% confidence interval [CI], 0.51–0.95; P=.02) and although not statistically significant, with fewer severe adverse events (RtR, 0.69; 95% CI, 0.46–1.03; P=.07). Preventable adverse events did not significantly differ between patients on contact precautions and patients not on contact precautions (RtR, 0.85; 95% CI, 0.59–1.24; P=.41).
Hospital ward patients on contact precautions were less likely to experience noninfectious adverse events during their hospital stay than patients not on contact precautions.
Infect. Control Hosp. Epidemiol. 2015;36(11):1268–1274
Hospital Ebola preparation is underway in the United States and other countries; however, the best approach and resources involved are unknown.
To examine costs and challenges associated with hospital Ebola preparation by means of a survey of Society for Healthcare Epidemiology of America (SHEA) members.
Electronic survey of infection prevention experts.
A total of 257 members completed the survey (221 US, 36 international) representing institutions in 41 US states, the District of Columbia, and 18 countries. The 221 US respondents represented 158 (43.1%) of 367 major medical centers that have SHEA members and included 21 (60%) of 35 institutions recently defined by the US Centers for Disease Control and Prevention as Ebola virus disease treatment centers. From October 13 through October 19, 2014, Ebola consumed 80% of hospital epidemiology time and only 30% of routine infection prevention activities were completed. Routine care was delayed in 27% of hospitals evaluating patients for Ebola.
Convenience sample of SHEA members with a moderate response rate.
Hospital Ebola preparations required extraordinary resources, which were diverted from routine infection prevention activities. Patients being evaluated for Ebola faced delays and potential limitations in management of other diseases that are more common in travelers returning from West Africa.