Little is known about the skills involved in clinical formulation. The individual case formulation (ICF) approach, based on functional analysis, employs clinical descriptions that are theory-free and depicts formulations constructed according to a set of basic conventions.

We report a test of whether this method could be taught and if the quality of the resulting diagrams could be reliably rated.

Participants (n=40) participated in a training course in formulation. A draft rating scale was refined in the course of rating formulation diagrams and basic inter-rater reliability established.

Results of the study support further development of the ICF approach.

Imagery rescripting (ImRs) is an experiential therapy technique used to change the content and meaning of intrusive imagery in post-traumatic stress disorder (PTSD) by imagining alternative endings to traumatic events. There is growing evidence that ImRs is an effective treatment for PTSD; however, little is known about how it brings about change.

This study aimed to explore the role of mental simulation as a candidate mechanism of action in ImRs, and, specifically, whether well-simulated imagery rescripts are associated with greater change in symptom severity during ImRs.

Using a single-case experimental design, seven participants receiving cognitive therapy for PTSD were assessed before, during and after sessions of imagery rescripting for one intrusive image. Participants completed continuous symptom severity measures. Sessions were recorded, then coded for goodness of simulation (GOS) as well as additional factors (e.g. rescript believability, vividness).

Participants were divided into high- and low-responders and coding was compared across groups. Correlational analyses were supported by descriptive analysis of individual sessions. High-responders’ rescripts tended to be rated as well-simulated compared with those of low-responders. Specific factors (e.g. intensity of thoughts/emotions related to original and new imagery elements, level of cognitive and emotional shift and belief in the resultant rescript) were also associated with reductions in symptom severity.

There was tentative evidence that well-simulated rescripted images tended to be associated with greater reductions in symptom severity of the target image. Clinical implications and avenues for further research are discussed.

Interfacility patient movement plays an important role in the dissemination of antimicrobial-resistant organisms throughout healthcare systems. We evaluated how 3 alternative measures of interfacility patient sharing were associated with C. difficile infection incidence in Ontario acute-care facilities.

The cohort included adult acute-care facility stays of ≥3 days between April 2003 and March 2016. We measured 3 facility-level metrics of patient sharing: general patient importation, incidence-weighted patient importation, and C. difficile case importation. Each of the 3 patient-sharing metrics were examined against the incidence of C. difficile infection in the facility per 1,000 stays, using Poisson regression models.

The analyzed cohort included 6.70 million stays at risk of C. difficile infection across 120 facilities. Over the 13-year period, we included 62,189 new cases of healthcare-associated CDI (incidence, 9.3 per 1,000 stays). After adjustment for facility characteristics, general importation was not strongly associated with C. difficile infection incidence (risk ratio [RR] per doubling, 1.10; 95% confidence interval [CI], 0.97–1.24; proportional change in variance [PCV], −2.0%). Incidence-weighted (RR per doubling, 1.18; 95% CI, 1.06–1.30; PCV, −8.4%) and C. difficile case importation (RR per doubling, 1.43; 95% CI, 1.29–1.58; PCV, −30.1%) were strongly associated with C. difficile infection incidence.

In this 13-year study of acute-care facilities in Ontario, interfacility variation in C. difficile infection incidence was associated with importation of patients from other high-incidence acute-care facilities or specifically of patients with a recent history of C. difficile infection. Regional infection control strategies should consider the potential impact of importation of patients at high risk of C. difficile shedding from outside facilities.

The goal of this study was to evaluate the ability of semantic (animal naming) and phonemic (FAS) fluency in their ability to discriminate between normal aging, amnestic-Mild Cognitive Impairment (a-MCI), and Alzheimer’s disease (AD).

We used binary logistic regressions, multinomial regressions, and discriminant analysis to evaluate the predictive value of semantic and phonemic fluency in regards to specific diagnostic classifications.

Outpatient geriatric neuropsychology clinic.

232 participants (normal aging = 99, a-MCI = 90, AD = 43; mean age = 65.75 years).

Mini-mental State Examination (MMSE), Controlled Oral Word Association Test

Results indicate that semantic and phonemic fluency were significant predictors of diagnostic classification, and semantic fluency explained a greater amount of the discriminant ability of the model.

These results suggest that verbal fluency, particularly semantic fluency, may be an accurate and efficient tool in screening for early dementia in time-limited medical settings.

Clostridium difficile spores play an important role in transmission and can survive in the environment for several months. Optimal methods for measuring environmental C. difficile are unknown. We sought to determine whether increased sample surface area improved detection of C. difficile from environmental samples.

Samples were collected from 12 patient rooms in a tertiary-care hospital in Toronto, Canada.

Samples represented small surface-area and large surface-area floor and bedrail pairs from single-bed rooms of patients with low (without prior antibiotics), medium (with prior antibiotics), and high (C. difficile infected) shedding risk. Presence of C. difficile in samples was measured using quantitative polymerase chain reaction (qPCR) with targets on the 16S rRNA and toxin B genes and using enrichment culture.

Of the 48 samples, 64·6% were positive by 16S qPCR (geometric mean, 13·8 spores); 39·6% were positive by toxin B qPCR (geometric mean, 1·9 spores); and 43·8% were positive by enrichment culture. By 16S qPCR, each 10-fold increase in sample surface area yielded 6·6 times (95% CI, 3·2–13) more spores. Floor surfaces yielded 27 times (95% CI, 4·9–181) more spores than bedrails, and rooms of C. difficile–positive patients yielded 11 times (95% CI, 0·55–164) more spores than those of patients without prior antibiotics. Toxin B qPCR and enrichment culture returned analogous findings.

Clostridium difficile spores were identified in most floor and bedrail samples, and increased surface area improved detection. Future research aiming to understand the role of environmental C. difficile in transmission should prefer samples with large surface areas.

Antibiotic use varies widely between hospitals, but the influence of antimicrobial stewardship programs (ASPs) on this variability is not known. We aimed to determine the key structural and strategic aspects of ASPs associated with differences in risk-adjusted antibiotic utilization across facilities.

Observational study of acute-care hospitals in Ontario, Canada

A survey was sent to hospitals asking about both structural (8 elements) and strategic (32 elements) components of their ASP. Antibiotic use from hospital purchasing data was acquired for January 1 to December 31, 2014. Crude and adjusted defined daily doses per 1,000 patient days, accounting for hospital and aggregate patient characteristics, were calculated across facilities. Rate ratios (RR) of defined daily doses per 1,000 patient days were compared for hospitals with and without each antimicrobial stewardship element of interest.

Of 127 eligible hospitals, 73 (57%) participated in the study. There was a 7-fold range in antibiotic use across these facilities (min, 253 defined daily doses per 1,000 patient days; max, 1,872 defined daily doses per 1,000 patient days). The presence of designated funding or resources for the ASP (RRadjusted, 0·87; 95% CI, 0·75–0·99), prospective audit and feedback (RRadjusted, 0·80; 95% CI, 0·67–0·96), and intravenous-to-oral conversion policies (RRadjusted, 0·79; 95% CI, 0·64–0·99) were associated with lower risk-adjusted antibiotic use.

Wide variability in antibiotic use across hospitals may be partially explained by both structural and strategic ASP elements. The presence of funding and resources, prospective audit and feedback, and intravenous-to-oral conversion should be considered priority elements of a robust ASP.

Carbapenem-resistant Enterobacteriaceae (CRE) are a significant clinical and public health concern. Understanding the distribution of CRE colonization and developing a coordinated approach are key components of control efforts. The prevalence of CRE in the District of Columbia is unknown. We sought to determine the CRE colonization prevalence within healthcare facilities (HCFs) in the District of Columbia using a collaborative, regional approach.

Point-prevalence study.

This study included 16 HCFs in the District of Columbia: all 8 acute-care hospitals (ACHs), 5 of 19 skilled nursing facilities, 2 (both) long-term acute-care facilities, and 1 (the sole) inpatient rehabilitation facility.

Inpatients on all units excluding psychiatry and obstetrics-gynecology.

CRE identification was performed on perianal swab samples using real-time polymerase chain reaction, culture, and antimicrobial susceptibility testing (AST). Prevalence was calculated by facility and unit type as the number of patients with a positive result divided by the total number tested. Prevalence ratios were compared using the Poisson distribution.

Of 1,022 completed tests, 53 samples tested positive for CRE, yielding a prevalence of 5.2% (95% CI, 3.9%–6.8%). Of 726 tests from ACHs, 36 (5.0%; 95% CI, 3.5%–6.9%) were positive. Of 244 tests from long-term-care facilities, 17 (7.0%; 95% CI, 4.1%–11.2%) were positive. The relative prevalence ratios by facility type were 0.9 (95% CI, 0.5–1.5) and 1.5 (95% CI, 0.9–2.6), respectively. No CRE were identified from the inpatient rehabilitation facility.

A baseline CRE prevalence was established, revealing endemicity across healthcare settings in the District of Columbia. Our study establishes a framework for interfacility collaboration to reduce CRE transmission and infection.

Infect Control Hosp Epidemiol 2017;38:921–929

Surgical site infections (SSIs) are responsible for significant morbidity and mortality. Preadmission skin antisepsis, while controversial, has gained acceptance as a strategy for reducing the risk of SSI. In this study, we analyze the benefit of an electronic alert system for enhancing compliance to preadmission application of 2% chlorhexidine gluconate (CHG).

Following informed consent, 100 healthy volunteers in an academic, tertiary care medical center were randomized to 5 chlorhexidine gluconate (CHG) skin application groups: 1, 2, 3, 4, or 5 consecutive applications. Participants were further randomized into 2 subgroups: with or without electronic alert. Skin surface concentrations of CHG (μg/mL) were analyzed using a colorimetric assay at 5 separate anatomic sites.

Preadmission application of chlorhexidine gluconate, 2%

Mean composite skin surface CHG concentrations in volunteer participants receiving EA following 1, 2, 3, 4, and 5 applications were 1,040.5, 1,334.4, 1,278.2, 1,643.9, and 1,803.1 µg/mL, respectively, while composite skin surface concentrations in the no-EA group were 913.8, 1,240.0, 1,249.8, 1,194.4, and 1,364.2 µg/mL, respectively (ANOVA, P<.001). Composite ratios (CHG concentration/minimum inhibitory concentration required to inhibit the growth of 90% of organisms [MIC90]) for 1, 2, 3, 4, or 5 applications using the 2% CHG cloth were 208.1, 266.8, 255.6, 328.8, and 360.6, respectively, representing CHG skin concentrations effective against staphylococcal surgical pathogens. The use of an electronic alert system resulted in significant increase in skin concentrations of CHG in the 4- and 5-application groups (P<.04 and P<.007, respectively).

The findings of this study suggest an evidence-based standardized process that includes use of an Internet-based electronic alert system to improve patient compliance while maximizing skin surface concentrations effective against MRSA and other staphylococcal surgical pathogens.

Infect. Control Hosp. Epidemiol. 2016;37(3):254–259