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Two sentiments governed the postwar world: fear and hope. These two feelings dominated the debates that gave birth to both the Charter of the United Nations and the Universal Declaration of Human Rights. The League of Nations had failed. Leaders had expressed the desire for a world grounded in human rights but could not agree on what that meant or whether individual rights trumped the sovereign rights of nations. The UN Charter reflected these concerns, recognizing human rights but leaving their scope undefined. No precedents existed to guide the work. A committee of eighteen nations, chaired by Eleanor Roosevelt, accepted the unprecedented assignment of defining basic rights for all people everywhere. After consulting with noted jurists, philosophers, and social justice organizations, the committee set out to draft a document that would recognize the horrors of war and engender a commitment to peace. They envisioned a world governed more by hope than by fear. It was hard work. The debate was punctuated by escalating Cold War politics. A legally binding document seemed out of reach. All efforts turned instead to securing a declaration of human rights, which ultimately paved the way for legally binding commitments and energized a budding human rights movement.
To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period.
Interrupted time series.
The study was conducted in an 865-bed academic medical center.
Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) “contact plus” isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018).
Environmental cleaning interventions and enhanced “contact plus” isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470).
Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.
Family caregivers of people with dementia can experience loss and grief before death. We hypothesized that modifiable factors indicating preparation for end of life are associated with lower pre-death grief in caregivers.
Caregivers of people with dementia living at home or in a care home.
In total, 150 caregivers, 77% female, mean age 63.0 (SD = 12.1). Participants cared for people with mild (25%), moderate (43%), or severe dementia (32%).
Primary outcome: Marwit-Meuser Caregiver Grief Inventory Short Form (MMCGI-SF). We included five factors reflecting preparation for end of life: (1) knowledge of dementia, (2) social support, (3) feeling supported by healthcare providers, (4) formalized end of life documents, and (5) end-of-life discussions with the person with dementia. We used multiple regression to assess associations between pre-death grief and preparation for end of life while controlling for confounders. We repeated this analysis with MMCGI-SF subscales (“personal sacrifice burden”; “heartfelt sadness”; “worry and felt isolation”).
Only one hypothesized factor (reduced social support) was strongly associated with higher grief intensity along with the confounders of female gender, spouse, or adult child relationship type and reduced relationship closeness. In exploratory analyses of MMCGI-SF subscales, one additional hypothesized factor was statistically significant; higher dementia knowledge was associated with lower “heartfelt sadness.”
We found limited support for our hypothesis. Future research may benefit from exploring strategies for enhancing caregivers’ social support and networks as well as the effectiveness of educational interventions about the progression of dementia (ClinicalTrials.gov ID: NCT03332979).
Major depressive disorder (MDD) has been ranked among the top causes worldwide of years lived with disability. In this study we assessed meaningful change for the PHQ-9 and the SDS and determined the meaningful change threshold (MCT) using anchor-based methods, which could be used to compare meaningful differences in patients within different treatment arms.
TRANSFORM-1 (NCT02417064) and -2 (NCT0241858) were Phase 3 trials that evaluated the efficacy and safety of fixed and flexible doses of esketamine nasal spray (56 mg or 84 mg) in combination with newly initiated oral antidepressant (ESK+AD) vs oral antidepressant + placebo nasal spray (AD+PBO) in TRD patients. Patient Reported Outcomes (PROs) were integrated into these trials to evaluate the patient perspective of treatment using instruments capturing concepts of importance to patients. The 9-item Patient Health Questionnaire (PHQ-9) is a PRO instrument used to assess self-reported depression symptoms and the Sheehan Disability Scale (SDS) is a PRO for self-reported function and disability. Blinded trial data (combined treatment groups) from TRANSFORM-1 was used for the anchor-based analysis. The Clinical Global Impression - Severity (CGI-S) was used as an anchor and patients were classified into response groups depending on their level of change over the course of the study. Patients were classified among all possible change categories (15 levels, ranging from -7 to 7 where negative change scores indicate improvement). Cumulative Distribution Function (CDF) curves of change from baseline to day 28 were generated using unblinded data from TRANSFORM-2 to visualize the range of responses demonstrated in the respective treatment groups for the PHQ-9 and SDS. MCT values were used to as thresholds to evaluate percentage of responders in each treatment group.
In anchor-based analyses using TRANSFORM-1 combined treatment groups, the correlation between change on the CGI-S and change on the PHQ-9 at Day 28 was high (> 0.60) with anchor-based MCTs ranging from 5 to 8 points. The magnitude of change (standardized effect size estimate within-subject change) for patients improving was exceptionally high (> 0.80). Similar results were observed on the SDS: high correlation of CGI-S and SDS at Day 28 (0.75), moderate SES (0.66), with suggested MCT ranging from 3 to 7 with an MCT value of 5 pts. CDF curves from TRANSFORM-2 showed clear separation between the ESK+AD vs AD+PBO across a number of responder definitions inclusive of those identified with the anchor-based analyses.
The current study is the first to derive an MCT on the PHQ-9 and SDS in TRD to measure meaningful change from the perspective of the patient using regulatory-preferred psychometric anchor-based methodology. These analyses assist with interpretation of meaningfulness of esketamine phase 3 clinical trial results from the patient perspective.
Behaviour that challenges in people with intellectual disability is associated with higher healthcare, social care and societal costs. Although behavioural therapies are widely used, there is limited evidence regarding the cost and quality-adjusted life-years (QALYs).
We aimed to assess the incremental cost per QALY gained of therapist training in positive behaviour support (PBS) and treatment as usual (TAU) compared with TAU using data from a cluster randomised controlled trial (Clinical Trials.gov registration: NCT01680276).
We conducted a cost-utility analysis (cost per QALY gained) of 23 teams randomised to PBS or TAU, with a total of 246 participants followed up over 36 months. The primary analysis was from a healthcare cost perspective with a secondary analysis from a societal cost perspective.
Over 36 months the intervention resulted in an additional 0.175 QALYs (discounted and adjusted 95% CI −0.068 to 0.418). The total cost of training in and delivery of PBS is £1598 per participant plus an additional cost of healthcare of £399 (discounted and adjusted 95% CI −603 to 1724). From a healthcare cost perspective there is an 85% probability that the intervention is cost-effective compared with TAU at a £30 000 willingness to pay for a QALY threshold.
There was a high probability that training in PBS is cost-effective as the cost of training and delivery of PBS is balanced out by modest improvements in quality of life. However, staff training in PBS is not supported given we found no evidence for clinical effectiveness.
In New York City, a multi-disciplinary Mass Casualty Consultation team is proposed to support prioritization of patients for coordinated inter-facility transfer after a large-scale mass casualty event. This study examines factors that influence consultation team prioritization decisions.
As part of a multi-hospital functional exercise, 2 teams prioritized the same set of 69 patient profiles. Prioritization decisions were compared between teams. Agreement between teams was assessed based on patient profile demographics and injury severity. An investigator interviewed team leaders to determine reasons for discordant transfer decisions.
The 2 teams differed significantly in the total number of transfers recommended (49 vs 36; P = 0.003). However, there was substantial agreement when recommending transfer to burn centers, with 85.5% agreement and inter-rater reliability of 0.67 (confidence interval: 0.49–0.85). There was better agreement for patients with a higher acuity of injuries. Based on interviews, the most common reason for discordance was insider knowledge of the local community hospital and its capabilities.
A multi-disciplinary Mass Casualty Consultation team was able to rapidly prioritize patients for coordinated secondary transfer using limited clinical information. Training for consultation teams should emphasize guidelines for transfer based on existing services at sending and receiving hospitals, as knowledge of local community hospital capabilities influence physician decision-making.
We document a positive and strong correlation between speciation and extinction rates in the Paleozoic zooplankton graptoloid clade, between 481 and 419 Ma. This correlation has a magnitude of ~0.35–0.45 and manifests at a temporal resolution of <50 kyr and, for part of our data set, <25 kyr. It cannot be explained as an artifact of the method used to measure rates, sampling bias, bias resulting from construction of the time series, autocorrelation, underestimation of species durations, or undetected phyletic evolution. Correlations are approximately equal during the Ordovician and Silurian, despite the very different speciation and extinction regimes prevailing during these two periods, and correlation is strongest in the shortest-lived cohorts of species.
We infer that this correlation reflects approximately synchronous coupling of speciation and extinction in the graptoloids on timescales of a few tens of thousands of years. Almost half of graptoloid species in our data set have durations of <0.5 Myr, and previous studies have demonstrated that, during times of background extinction, short-lived species were selectively targeted by extinction. These observations may be consistent with the model of ephemeral speciation, whereby new species are inferred to form constantly and at high rate, but most of them disappear rapidly through extinction or reabsorption into the ancestral lineage. Diversity dependence with a lag of ~1 Myr, also documented elsewhere, may reflect a subsequent and relatively slow, competitive dynamic that governed those species that dispersed beyond their originating water mass and escaped the ephemeral species filter.
The Crisis Intervention Team (CIT) model is a law enforcement strategy that aims to build alliances between the law enforcement and mental health communities. Despite its success in the United States, CIT has not been used in low- and middle-income countries. This study assesses the immediate and 9-month outcomes of CIT training on trainee knowledge and attitudes.
Twenty-two CIT trainees (14 law enforcement officers and eight mental health clinicians) were evaluated using pre-developed measures assessing knowledge and attitudes related to mental illness. Evaluations were conducted prior to, immediately after, and 9 months post training.
The CIT training produced improvements both immediately and 9 months post training in knowledge and attitudes, suggesting that CIT can benefit law enforcement officers even in extremely low-resource settings with limited specialized mental health service infrastructure.
These findings support further exploration of the benefits of CIT in highly under-resourced settings.
The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.
Interest in electronic hand hygiene monitoring systems (EHHMSs) is now widespread throughout the infection control community. We tested 2 types of EHHMS for accuracy. The type B EHHMS captured more HH events with superior accuracy. Hospitals considering an EHHMS should assess the technology’s ability to accurately capture HH performance in the clinical workflow.
Children, who comprise 25% of the US population, are frequently victims of disasters and have special needs during these events.
To prepare NYC for a large-scale pediatric disaster, NYCPDC has worked with an increasing number of providers that initially included a small number of hospitals and agencies. Through a cooperative team approach, stakeholders now include public health, emergency management, and emergency medical services, 28 hospitals, community-based providers, and the Medical Reserve Corps.
The NYCPDC utilized an inclusive iterative process model whereby a desired plan was achieved by stakeholders reviewing the literature and current practice through discussion and consensus building. NYCPDC used this model in developing a comprehensive regional pediatric disaster plan.
The Plan included disaster scene triage (adapted for pediatric use) to transport (with prioritization) to surge and evacuation. Additionally, site-specific plans utilizing Guidelines and Templates now include Pediatric Long-Term Care Facilities, Hospital Pediatric Departments, Pediatric and Ob/Newborn/Neonatal Intensive Care Services and Outpatient/Urgent Care Centers. A force multiplier course in critical care for non-intensivists is provided. An extensive Pediatric Exercise program has been used to develop, operationalize and revise plans based on lessons learned. This includes pediatric tabletop, functional and full-scale exercises at individual hospitals leading to citywide exercises at 13 and subsequently all 28 hospitals caring for children.
The NYCPDC has comprehensively planned for the special needs of children during disasters utilizing a pediatric coalition based regional approach that matches pediatric resources to needs to provide best outcomes.
The NYCPDC has responded to real-time events (H1N1, Haiti Earthquake, Superstorm Sandy, Ebola), and participated in local (NYC boroughs and executive leadership) and nationwide coalitions (National Pediatric Disaster Coalition). The NYCPDC has had the opportunity to present their Pediatric Disaster Planning and Response efforts at local, national and International conferences.
Children are frequently victims of disasters, however important gaps remain in pediatric disaster planning. This includes a lack of resources for pediatric preparedness planning for patients in outpatient/urgent-care facilities. The New York City Pediatric Disaster Coalition (NYCPDC) is funded by the NYC Department of Health and Mental Hygiene (DOHMH) to improve NYC’s pediatric disaster preparedness and response.
After creating planning resources in Pediatric Long-Term Care Facilities, Hospital Pediatric Departments, Pediatric and Neonatal Intensive Care Units and Obstetric/Newborn Services within NYC hospitals, the NYCPDC partnered with leaders and experts from outpatient/urgent-care facilities caring for pediatric patients and created the Pediatric Outpatient Disaster Planning Committee (PODPC). PODPC’s goal was to create guidelines and templates for use in disaster planning for pediatric patients at outpatient/urgent-care facilities.
The PODPC includes physicians, nurses, administrators, and emergency planning experts who have experience working with outpatient facilities. There were 21 committee members from eight organizations (the NYCPDC, DOHMH, Community Healthcare Association of NY State, NY State DOH, NYC Health and Hospitals, Maimonides Medical Center and Presbyterian/Columbia University Medical Center). The committee met six times over a four-month period and shared information to create disaster planning tools that meet the specific pediatric challenges in the outpatient setting.
Utilizing an iterative process including literature review, participant presentations, discussions review, and improvement of working documents, the final guidelines and templates for surge and evacuation of pediatric patients in outpatient/urgent care facilities were created in February 2018. Subsequently, model plans were completed and implemented at five NYC outpatient/urgent-care facilities.
An expert committee utilizing an iterative process successfully created disaster guidelines and templates for pediatric outpatient/urgent care facilities. They addressed the importance of matching the special needs of children to available space, staff, and equipment needs and created model plans for site-specific use.
Effects of a disaster on a community’s mental health can persist after the physical effects of the event have passed. The pediatric population is often overrepresented in disasters and prone to serious mental health disorders based on their age and parental/community response. Pediatric primary healthcare providers require the psychosocial skills necessary to work in disaster zones and to care for children in disasters.
Pediatric Disaster Mental Health Intervention (PDMHI) was initially developed in response to Superstorm Sandy’s impact on children and their families in New York City. The objective was to develop training for primary care providers in pediatric disaster mental healthcare and to study its impact on the trainees.
A faculty of experts in pediatric mental health, psychiatry, psychology, and disaster preparedness was convened to develop curriculum. The faculty developed a four-hour intervention to equip healthcare providers with the skills and knowledge necessary to care for pediatric patients with mental health problems stemming from a disaster via evaluation, triage, intervention, and referral.
Three PDMHI training sessions were held. A total of 67 providers were trained. Of these, there were 31 pediatricians, 18 nurses, 8 social workers, 4 psychologists, 2 psychiatrists, and 4 others. Pre- and post-tests measured knowledge before and impact 3 months post-intervention. 62.5% of responding primary care providers made changes to their practice. 92% felt better equipped to identify, treat, and refer patients. 81% would be willing to work in a disaster zone and felt prepared to treat patients with disaster mental health issues.
PDMHI covers psychosocial responses to disasters from normal to mental health disorders. Participants gained tools for managing pediatric mental health issues in primary care. Study data showed an increase in the participants perceived knowledge and skills about pediatric disaster mental health, and willingness to participate in future disasters.
Children are frequently victims of disasters. However, gaps remain in disaster planning for pediatric patients. The New York City Pediatric Disaster Coalition (NYCPDC) is funded by the New York City Department of Health and Mental Hygiene (DOHMH) to prepare NYC for mass casualty incidents that involve large numbers of children.
On April 26, 2018, the NYCPDC conducted a first full-scale exercise with the New York Fire Department (FDNY) testing evacuation, patient tracking, communications, and emergency response of the obstetrics, newborn, and neonatal units at Staten Island University Hospital North. The goal of the exercise was to evaluate current obstetrics/newborn/neonatal plans and assess the hospital’s ability to evacuate patients.
The exercise planning process included a review of existing obstetrics/newborn/neonatal plans, four group planning meetings, specific area meetings, and plan revisions. The exercise incorporated scenario-driven, operations-based activities, which challenged participants to employ the facility’s existing evacuation plans during an emergency.
The exercise assessed the following: communication, emergency operation plans, evacuation, patient tracking, supplies, and staffing. Internal and external evaluators rated exercise performance on a scale of 1-4. Evaluators completed an exercise evaluation guide based on the Master Scenario Event List.
An After Action Report was written based on the information from the exercise evaluation guides, participant feedback forms, hot wash session, and after-action review meeting. Strengths included the meaningful improvement of plans before the exercise (including the fire department) and the overall meeting of exercise objectives.
Lessons learned included: addressing gaps in effective internal and external communications, adequate supplies of space, staff, and equipment needed for vertical evacuations in addition to providing staging and alternate care sites with sufficient patient care and electrical power resources. The lessons learned are being utilized to improve existing hospital plans to prepare for future full-scale exercise and or real-time events.
We assessed the impact of an embedded electronic medical record decision-support matrix (Cerner software system) for the reduction of hospital-onset Clostridioides difficile. A critical review of 3,124 patients highlighted excessive testing frequency in an academic medical center and demonstrated the impact of decision support following a testing fidelity algorithm.
Thermal conductivity of uranium dioxide (UO2) is an important nuclear fuel performance property. Radiation- and fission-induced defects and microstructures, such as xenon (Xe) gas bubbles, can degrade the thermal conductivity of UO2 significantly. Here, molecular dynamics simulations are conducted to study the effect of Xe bubble size and pressure on the thermal conductivity of UO2. At a given porosity, thermal conductivity increases with Xe cluster size, then reaches a nearly saturated value at a cluster radius of 0.6 nm, demonstrating that dispersed Xe atoms result in a lower thermal conductivity than clustering them into bubbles. In comparison with empty voids of the same size, Xe-filled bubbles lead to a lower thermal conductivity when the number ratio of Xe atoms to uranium vacancies (Xe:VU ratio) in bubbles is high. Detailed atomic-level analysis shows that the pressure-induced distortion of atoms at bubble surface causes additional phonon scattering and thus further reduces the thermal conductivity.