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To develop a risk score for deep sternal wound infection (DSWI) after isolated coronary artery bypass grafting (CABG).
Multicenter, prospective study.
Tertiary-care referral hospitals.
The study included 7,352 patients from the European multicenter coronary artery bypass grafting (E-CABG) registry.
An additive risk score (the E-CABG DSWI score) was estimated from the derivation data set (66.7% of patients), and its performance was assessed in the validation data set (33.3% of patients).
DSWI occurred in 181 (2.5%) patients and increased 1-year mortality (adjusted hazard ratio, 4.275; 95% confidence interval [CI], 2.804–6.517). Female gender (odds ratio [OR], 1.804; 95% CI, 1.161–2.802), body mass index ≥30 kg/m2 (OR, 1.729; 95% CI, 1.166–2.562), glomerular filtration rate <45 mL/min/1.73 m2 (OR, 2.410; 95% CI, 1.413–4.111), diabetes (OR, 1.741; 95% CI, 1.178–2.573), pulmonary disease (OR, 1.935; 95% CI, 1.178–3.180), atrial fibrillation (OR, 1.854; 95% CI, 1.096–3.138), critical preoperative state (OR, 2.196; 95% CI, 1.209–3.891), and bilateral internal mammary artery grafting (OR, 2.088; 95% CI, 1.422–3.066) were predictors of DSWI (derivation data set). An additive risk score was calculated by assigning 1 point to each of these independent risk factors for DSWI. In the validation data set, the rate of DSWI increased along with the E-CABG DSWI scores (score of 0, 1.0%; score of 1, 1.8%; score of 2, 2.2%; score of 3, 6.9%; score ≥4: 12.1%; P < .0001). Net reclassification improvement, integrated discrimination improvement, and decision curve analysis showed that the E-CABG DSWI score performed better than other risk scores.
DSWI is associated with poor outcome after CABG, and its risk can be stratified using the E-CABG DSWI score.
Studies suggest that alcohol consumption and alcohol use disorders have distinct genetic backgrounds.
We examined whether polygenic risk scores (PRS) for consumption and problem subscales of the Alcohol Use Disorders Identification Test (AUDIT-C, AUDIT-P) in the UK Biobank (UKB; N = 121 630) correlate with alcohol outcomes in four independent samples: an ascertained cohort, the Collaborative Study on the Genetics of Alcoholism (COGA; N = 6850), and population-based cohorts: Avon Longitudinal Study of Parents and Children (ALSPAC; N = 5911), Generation Scotland (GS; N = 17 461), and an independent subset of UKB (N = 245 947). Regression models and survival analyses tested whether the PRS were associated with the alcohol-related outcomes.
In COGA, AUDIT-P PRS was associated with alcohol dependence, AUD symptom count, maximum drinks (R2 = 0.47–0.68%, p = 2.0 × 10−8–1.0 × 10−10), and increased likelihood of onset of alcohol dependence (hazard ratio = 1.15, p = 4.7 × 10−8); AUDIT-C PRS was not an independent predictor of any phenotype. In ALSPAC, the AUDIT-C PRS was associated with alcohol dependence (R2 = 0.96%, p = 4.8 × 10−6). In GS, AUDIT-C PRS was a better predictor of weekly alcohol use (R2 = 0.27%, p = 5.5 × 10−11), while AUDIT-P PRS was more associated with problem drinking (R2 = 0.40%, p = 9.0 × 10−7). Lastly, AUDIT-P PRS was associated with ICD-based alcohol-related disorders in the UKB subset (R2 = 0.18%, p < 2.0 × 10−16).
AUDIT-P PRS was associated with a range of alcohol-related phenotypes across population-based and ascertained cohorts, while AUDIT-C PRS showed less utility in the ascertained cohort. We show that AUDIT-P is genetically correlated with both use and misuse and demonstrate the influence of ascertainment schemes on PRS analyses.
Quality improvement and patient safety (QIPS) competencies are increasingly important in emergency medicine (EM) and are now included in the CanMEDS framework. We conducted a survey aimed at determining the Canadian EM residents’ perspectives on the level of QIPS education and support available to them.
An electronic survey was distributed to all Canadian EM residents from the Royal College and Family Medicine training streams. The survey consisted of multiple-choice, Likert, and free-text entry questions aimed at understanding familiarity with QIPS, local opportunities for QIPS projects and mentorship, and the desire for further QIPS education and involvement.
Of 535 EM residents, 189 (35.3%) completed the survey, representing all 17 medical schools; 77.2% of respondents were from the Royal College stream; 17.5% of respondents reported that QIPS methodologies were formally taught in their residency program; 54.7% of respondents reported being “somewhat” or “very” familiar with QIPS; 47.2% and 51.5% of respondents reported either “not knowing” or “not having readily available” opportunities for QIPS projects and QIPS mentorship, respectively; 66.9% of respondents indicated a desire for increased QIPS teaching; and 70.4% were interested in becoming involved with QIPS training and initiatives.
Many Canadian EM residents perceive a lack of QIPS educational opportunities and support in their local setting. They are interested in receiving more QIPS education, as well as project and mentorship opportunities. Supporting residents with a robust QIPS educational and mentorship framework may build a cohort of providers who can enhance the local delivery of care.
This study examined the long-term effects of a randomized controlled trial of the Family Check-Up (FCU) intervention initiated at age 2 on inhibitory control in middle childhood and adolescent internalizing and externalizing problems. We hypothesized that the FCU would promote higher inhibitory control in middle childhood relative to the control group, which in turn would be associated with lower internalizing and externalizing symptomology at age 14. Participants were 731 families, with half (n = 367) of the families assigned to the FCU intervention. Using an intent-to-treat design, results indicate that the FCU intervention was indirectly associated with both lower internalizing and externalizing symptoms at age 14 via its effect on increased inhibitory control in middle childhood (i.e., ages 8.5–10.5). Findings highlight the potential for interventions initiated in toddlerhood to have long-term impacts on self-regulation processes, which can further reduce the risk for behavioral and emotional difficulties in adolescence.
Describe common pathogens and antimicrobial resistance patterns for healthcare-associated infections (HAIs) that occurred during 2015–2017 and were reported to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN).
Data from central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), and surgical site infections (SSIs) were reported from acute-care hospitals, long-term acute-care hospitals, and inpatient rehabilitation facilities. This analysis included device-associated HAIs reported from adult location types, and SSIs among patients ≥18 years old. Percentages of pathogens with nonsusceptibility (%NS) to selected antimicrobials were calculated for each HAI type, location type, surgical category, and surgical wound closure technique.
Overall, 5,626 facilities performed adult HAI surveillance during this period, most of which were general acute-care hospitals with <200 beds. Escherichia coli (18%), Staphylococcus aureus (12%), and Klebsiella spp (9%) were the 3 most frequently reported pathogens. Pathogens varied by HAI and location type, with oncology units having a distinct pathogen distribution compared to other settings. The %NS for most pathogens was significantly higher among device-associated HAIs than SSIs. In addition, pathogens from long-term acute-care hospitals had a significantly higher %NS than those from general hospital wards.
This report provides an updated national summary of pathogen distributions and antimicrobial resistance among select HAIs and pathogens, stratified by several factors. These data underscore the importance of tracking antimicrobial resistance, particularly in vulnerable populations such as long-term acute-care hospitals and intensive care units.
One-on-one structured Montessori-based activities conducted with people with dementia can improve agitation and enhance engagement. These activities may however not always be implemented by nursing home staff. Family members may present an untapped resource for enabling these activities. This study aimed to evaluate the impact of the Montessori activities implemented by family members on visitation experiences with people who have dementia.
Cluster-randomized crossover design.
General and psychogeriatric nursing homes in the state of Victoria, Australia.
Forty participants (20 residents and 20 carers) were recruited.
During visits, family members interacted with their relative either through engaging in Montessori-based activities or reading a newspaper (the control condition) for four 30-minute sessions over 2 weeks.
Residents’ predominant affect and engagement were rated for each 30-second interval using the Philadelphia Geriatric Center Affect Rating Scale and the Menorah Park Engagement Scale. The Pearlin Mastery Scale was used to rate carers satisfaction with visits. The 15-item Mutuality Scale measured the carers quality of their relationship with the resident. Carers’ mood and overall quality of life were measured using the Center for Epidemiological Studies Depression Scale and Carer-QoL questionnaires, respectively.
Linear regressions within the generalized estimating equations approach assessed residents’ and carers’ outcomes. Relative to the control condition, the Montessori condition resulted in more positive engagement (b = 13.0, 95%CI 6.3–19.7, p < 0.001) and affect (b = 0.4, 95%CI 0.2–0.6, p < 0.001) for the residents and higher satisfaction with visits for carers (b = 1.7, 95%CI 0.45–3.00, p = 0.008). No correction was applied to p-values for multiple comparisons.
This study strengthens the evidence base for the use of the Montessori programs in increasing well-being in nursing home residents. The findings also provide evidence that family members are an additional valuable resource in implementing structured activities such as the Montessori program with residents.
To describe common pathogens and antimicrobial resistance patterns for healthcare-associated infections (HAIs) among pediatric patients that occurred in 2015–2017 and were reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN).
Antimicrobial resistance data were analyzed for pathogens implicated in central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonias (VAPs), and surgical site infections (SSIs). This analysis was restricted to device-associated HAIs reported from pediatric patient care locations and SSIs among patients <18 years old. Percentages of pathogens with nonsusceptibility (%NS) to selected antimicrobials were calculated by HAI type, location type, and surgical category.
Overall, 2,545 facilities performed surveillance of pediatric HAIs in the NHSN during this period. Staphylococcus aureus (15%), Escherichia coli (12%), and coagulase-negative staphylococci (12%) were the 3 most commonly reported pathogens associated with pediatric HAIs. Pathogens and the %NS varied by HAI type, location type, and/or surgical category. Among CLABSIs, the %NS was generally lowest in neonatal intensive care units and highest in pediatric oncology units. Staphylococcus spp were particularly common among orthopedic, neurosurgical, and cardiac SSIs; however, E. coli was more common in abdominal SSIs. Overall, antimicrobial nonsusceptibility was less prevalent in pediatric HAIs than in adult HAIs.
This report provides an updated national summary of pathogen distributions and antimicrobial resistance patterns among pediatric HAIs. These data highlight the need for continued antimicrobial resistance tracking among pediatric patients and should encourage the pediatric healthcare community to use such data when establishing policies for infection prevention and antimicrobial stewardship.
The Green et al., Paranoid Thoughts Scale (GPTS) – comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) – was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation.
In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted.
The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09–3.67) and Persecution (a = 2.37–4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0–9; Persecution: 0–4); elevated (Reference: 10–15; Persecution: 5–10); moderately severe (Reference: 16–20; Persecution:11–17); severe (Reference: 21–24; Persecution: 18–27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion.
The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.
Deployment to war is associated with disruptions to emotion regulation and parenting. Using data from a randomized controlled trial, we examined whether fathers with poorer emotion regulation would differentially benefit from the After Deployment, Adaptive Parenting Tools program, a 14-session group-based parenting intervention. Prior analyses of the intervention demonstrated benefits to observed couple parenting and children's adjustment, but not to fathers’ observed parenting. In this study we examined whether intervention effects on fathers’ observed distress avoidance were moderated by baseline emotion regulation, and whether reduced distress avoidance was associated with improved observed parenting and reduced children's internalizing symptoms. A subset of the full randomized controlled trial sample (181 families with a father who had returned from deployment to war in Iraq or Afghanistan, a nondeployed mother, and a target child aged 4–13) completed measures at baseline, 12-months, and 24-months postbaseline. Results indicated that fathers high in baseline emotion regulation difficulties assigned to the intervention group showed reductions in observed distress avoidance at 12 months compared to controls, which were subsequently associated with improvements in observed parenting practices and reductions in children's internalizing symptoms at 24 months. The results suggest a role for personalizing parenting programs for fathers high in emotion dysregulation.
This paper examines the misalignment between modern human society and certain male phenotypes, a misalignment that has been highlighted and explored in great detail in the work of Tom Dishion. We begin by briefly enumerating the ongoing developmental difficulties of many boys and young men and how these difficulties affect them and those around them. We then suggest that the qualities that have been advantageous for men and their families in our earlier evolution but that are often no longer functional in modern society are a source of these problems. Finally, we provide a brief review of prevention programs that can contribute to preventing this type of problematic development and eliciting more prosocial behavior from at-risk boys and men. We conclude with an overview of research and policy priorities that could contribute to reducing the proportion of boys and young men who experience developmental difficulties in making their way in the world.
Maltreatment during childhood is associated with difficult interpersonal relationships throughout the life course. The aim of the current study was to investigate differential pathways from child maltreatment to emerging adult relationship dysfunction. Specifically, we prospectively tested whether child maltreatment initiates a developmental cascade resulting in coercive negative romantic and friend interactions in emerging adulthood via childhood antisocial tendencies and via childhood relational aggression. Utilizing a longitudinal sample of emerging adult participants (N = 392; mean age = 20 years old) who took part in a summer research camp program as children (mean age = 11 years old), results supported pathways via both childhood antisocial behavior and childhood relational aggression. We found specificity within these pathways such that childhood antisocial behavior was a mediator of child maltreatment effects on emerging adult negative romantic interactions, whereas childhood relational aggression was a mediator of child maltreatment effects on emerging adult negative friend interactions. Taken together, results indicate that children exposed to maltreatment face significant interpersonal challenges in emerging adulthood, within both the friend and the romantic domains, and point to distinct childhood pathways to these negative interactions. Our findings are consistent with Dishion's (2016) theoretical framework for understanding the development of coercion in relationships and highlight the criticality of early intervention with maltreating families.
Decades of research have highlighted the significance of parenting in children's development, yet few studies have focused specifically on the development of parental monitoring strategies in diverse families living in at-risk neighborhoods. The current study investigated the development of active (i.e., parental discussions and curfew rules) and passive (i.e., child communication with parents) parental monitoring strategies across different developmental periods (middle childhood and adolescence; Grades 4–5 and 7–11) as well as individual (child, parent), family, and contextual antecedents (measured in kindergarten) of this parenting behavior. Using an ecological approach, this study evaluated longitudinal data from 753 participants in the Fast Track Project, a multisite study directed at the development and prevention of conduct problems in at-risk children. Latent trajectory modeling results identified little to no mean growth in these monitoring strategies over time, suggesting that families living in at-risk environments may engage in consistent levels of monitoring strategies to ensure children's safety and well-being. Findings also identified several kindergarten antecedents of the growth factors of these parental monitoring strategies including (a) early child conduct problems; (b) parental warmth/involvement, satisfaction, and efficacy; and (c) parent–child relationship quality. These predictive effects largely highlighted the important role of early parenting behaviors on later levels of and growth in parental monitoring strategies. These findings have important implications for potential prevention and intervention targets to promote the development of parental monitoring strategies among families living in more at-risk contexts.
In interventions for at-risk children, Tom Dishion strongly exhorted programs that are short term, cost-effective, and delivered in families’ own communities, just as resilience researchers underscore the need for programs that provide ongoing support for children's primary caregivers, and are implementable on a large scale. Presented here are preliminary results on a short-term intervention for mothers, the Authentic Connections Virtual Groups. A previous randomized trial of the in-person version of this program, conducted with mothers at high risk for stress and burnout, showed significant benefits. There had been zero dropouts across the 3-month program, and participants showed significant improvements on psychological indices as well as cortisol, even 3 months after the program ended. In the present study, virtual groups were conducted with five sets of women, all white-collar professionals with highly stressful, exacting careers, and most also primary caregivers of their children. Again, there were zero dropouts. Mean satisfaction ratings were 9.6 of 10, and the Net Promoter Score (promoters vs. detractors) fell in the “world class” range. To illuminate mechanisms of change, participants’ responses to open-ended questions on the groups’ value are presented verbatim. Recurrently mentioned were the development of new, authentic connections and invaluable ongoing support. These results, with the low costs and ease of women's attendance, attest to the value of expanding offerings such as these, toward benefiting even more highly stressed mothers themselves as well as the children for whose care they are responsible.
Retinoblastoma is the most common primary intraocular tumor of childhood with >95% survival rates in the US. Traditional therapy for retinoblastoma often included enucleation (removal of the eye). While much is known about the visual, physical, and cognitive ramifications of enucleation, data are lacking about survivors' perception of how this treatment impacts overall quality of life.
Qualitative analysis of an open-ended response describing how much the removal of an eye had affected retinoblastoma survivors' lives and in what ways in free text, narrative form.
Four hundred and four retinoblastoma survivors who had undergone enucleation (bilateral disease = 214; 52% female; mean age = 44, SD = 11) completed the survey. Survivors reported physical problems (n = 205, 50.7%), intrapersonal problems (n = 77, 19.1%), social and relational problems (n = 98, 24.3%), and affective problems (n = 34, 8.4%) at a mean of 42 years after diagnosis. Three key themes emerged from survivors' responses; specifically, they (1) continue to report physical and intrapersonal struggles with appearance and related self-consciousness due to appearance; (2) have multiple social and relational problems, with teasing and bullying being prominent problems; and (3) reported utilization of active coping strategies, including developing more acceptance and learning compensatory skills around activities of daily living.
Significance of results
This study suggests that adult retinoblastoma survivors treated with enucleation continue to struggle with a unique set of psychosocial problems. Future interventions can be designed to teach survivors more active coping skills (e.g., for appearance-related issues, vision-related issues, and teasing/bullying) to optimize survivors' long-term quality of life.
We examined Clostridioides difficile infection (CDI) prevention practices and their relationship with hospital-onset healthcare facility-associated CDI rates (CDI rates) in Veterans Affairs (VA) acute-care facilities.
From January 2017 to February 2017, we conducted an electronic survey of CDI prevention practices and hospital characteristics in the VA. We linked survey data with CDI rate data for the period January 2015 to December 2016. We stratified facilities according to whether their overall CDI rate per 10,000 bed days of care was above or below the national VA mean CDI rate. We examined whether specific CDI prevention practices were associated with an increased risk of a CDI rate above the national VA mean CDI rate.
All 126 facilities responded (100% response rate). Since implementing CDI prevention practices in July 2012, 60 of 123 facilities (49%) reported a decrease in CDI rates; 22 of 123 facilities (18%) reported an increase, and 41 of 123 (33%) reported no change. Facilities reporting an increase in the CDI rate (vs those reporting a decrease) after implementing prevention practices were 2.54 times more likely to have CDI rates that were above the national mean CDI rate. Whether a facility’s CDI rates were above or below the national mean CDI rate was not associated with self-reported cleaning practices, duration of contact precautions, availability of private rooms, or certification of infection preventionists in infection prevention.
We found considerable variation in CDI rates. We were unable to identify which particular CDI prevention practices (i.e., bundle components) were associated with lower CDI rates.
Early behaviors that differentiate later biomarkers for psychopathology can guide preventive efforts while also facilitating pathophysiological research. We tested whether error-related negativity (ERN) moderates the link between early behavior and later psychopathology in two early childhood phenotypes: behavioral inhibition and irritability. From ages 2 to 7 years, children (n = 291) were assessed longitudinally for behavioral inhibition (BI) and irritability. Behavioral inhibition was assessed via maternal report and behavioral responses to novelty. Childhood irritability was assessed using the Child Behavior Checklist. At age 12, an electroencephalogram (EEG) was recorded while children performed a flanker task to measure ERN, a neural indicator of error monitoring. Clinical assessments of anxiety and irritability were conducted using questionnaires (i.e., Screen for Child Anxiety Related Disorders and Affective Reactivity Index) and clinical interviews. Error monitoring interacted with early BI and early irritability to predict later psychopathology. Among children with high BI, an enhanced ERN predicted greater social anxiety at age 12. In contrast, children with high childhood irritability and blunted ERN predicted greater irritability at age 12. This converges with previous work and provides novel insight into the specificity of pathways associated with psychopathology.