To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Several recent reports have raised concern that infected coworkers may be an important source of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) acquisition by healthcare personnel. In a suspected outbreak among emergency department personnel, sequencing of SARS-CoV-2 confirmed transmission among coworkers. The suspected 6-person outbreak included 2 distinct transmission clusters and 1 unrelated infection.
Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.
This is the first report on the association between trauma exposure and depression from the Advancing Understanding of RecOvery afteR traumA(AURORA) multisite longitudinal study of adverse post-traumatic neuropsychiatric sequelae (APNS) among participants seeking emergency department (ED) treatment in the aftermath of a traumatic life experience.
We focus on participants presenting at EDs after a motor vehicle collision (MVC), which characterizes most AURORA participants, and examine associations of participant socio-demographics and MVC characteristics with 8-week depression as mediated through peritraumatic symptoms and 2-week depression.
Eight-week depression prevalence was relatively high (27.8%) and associated with several MVC characteristics (being passenger v. driver; injuries to other people). Peritraumatic distress was associated with 2-week but not 8-week depression. Most of these associations held when controlling for peritraumatic symptoms and, to a lesser degree, depressive symptoms at 2-weeks post-trauma.
These observations, coupled with substantial variation in the relative strength of the mediating pathways across predictors, raises the possibility of diverse and potentially complex underlying biological and psychological processes that remain to be elucidated in more in-depth analyses of the rich and evolving AURORA database to find new targets for intervention and new tools for risk-based stratification following trauma exposure.
Background: Antibiotics are the most prescribed medicines worldwide, accounting for 20%–30% of total drug expenditures in most settings. Antimicrobial stewardship activities can provide guidance for the most appropriate antibiotic use. Objective: In an effort to generate baseline data to guide antimicrobial stewardship recommendations, we conducted point-prevalence surveys at 3 hospitals in Kenya. Methods: Sites included referral hospitals located in Nairobi (2,000 beds), Eldoret (900 beds) and Mombasa (700 beds). [Results are presented in this order.] Hospital administrators, heads of infection prevention and control units, and laboratory department heads were interviewed about ongoing antimicrobial stewardship activities, existing infection prevention and control programs, and microbiology diagnostic capacities. Patient-level data were collected by a clinical or medical officer and a pharmacist. A subset of randomly selected, consenting hospital patients was enrolled, and data were abstracted from their medical records, treatment sheets, and nursing notes using a modified WHO point-prevalence survey form. Results: Overall, 1,071 consenting patients were surveyed from the 3 hospitals (n = 579, n = 263, and n = 229, respectively) of whom >60% were aged >18 years and 53% were female. Overall, 489 of 1,071 of patients (46%) received ≥1 antibiotic, of whom 254 of 489 (52%) received 1 antibiotic, 201 of 489 (41%) received 2 antibiotics, 31 of 489 (6%) received 3 antibiotics, and 3 of 489 (1%) received 4 antibiotics. Antibiotic use was higher among those aged <5 years: 150 of 244 (62%) compared with older individuals (337 of 822, 41%). Amoxicillin/clavulanate was the most commonly used antibiotic (66 of 387, 17%) at the largest hospital (in Nairobi) whereas ceftriaxone was the most common at the other 2 facilities: 57 of 184 (31%) in Eldoret and 55 of 190 (29%) in Mombasa. Metronidazole was the next most commonly prescribed antibiotic (15%–19%). Meropenem was the only carbapenem reported: 22 of 387 patients (6%) in Nairobi, 2 of 190 patients (1%) in Eldoret, and 8 of 184 patients (4%) in Mombasa. Stop dates or review dates were not indicated for 106 of 390 patients (27%) in Nairobi, 75 of 190 patients (40%) in Eldoret, and 113 of 184 patients (72%) in Mombasa receiving antibiotics. Of 761 antibiotic prescriptions, 45% had a least 1 missed dose. Culture and antibiotic susceptibility tests were limited to 50 of 246 patients (20%) in Nairobi, 17 of 124 patients (14%) in Eldoret, and 23 of 119 patients (19%) in Mombasa who received antibiotics. The largest hospital had an administratively recognized antimicrobial stewardship committee. Conclusions: The prevalence of antibiotic use found by our study was 46%, generally lower than the rates reported in 3 similar studies from other African countries, which ranged from 56% to 65%. However, these survey findings indicate that ample opportunities exist for improving antimicrobial stewardship efforts in Kenya considering the high usage of empiric therapy and low microbiologic diagnostic utilization.
Background: Contaminated hands are the most important source for transmission of pathogens in healthcare settings. It has been proposed that replacing the handshake with alternative greetings such as the fist bump might reduce the risk for pathogen transmission. Methods: In a cohort of 50 patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization, we compared the frequency of transfer of MRSA by handshake versus fist bump versus cruise tap (ie, a modified fist bump involving knuckle-to-knuckle contact with a single finger). MRSA-colonized patients performed each greeting with research personnel wearing sterile gloves, and cultures were obtained to determine the number of colonies transferred. Transfer by handshake was also assessed after MRSA-colonized patients used alcohol-based hand sanitizer. Quantitative cultures were obtained to compare the burden of MRSA on the palm versus dorsum of the hands of the MRSA carriers. Results: As shown in Fig. 1, there was a significant reduction in the frequency of MRSA transfer for the cruise tap compared to the handshake, but not for the fist bump. Use of alcohol-based hand sanitizer by MRSA carriers also significantly reduced the risk for transfer of MRSA. There was no significant difference in the burden of MRSA on the dorsum versus the palm of the hands (mean +SE colonies recovered, 32.7+12.3 vs 27.3+12.7; P > .05). Conclusions: The fist-bump greeting did not transfer less MRSA than a handshake. However, transfer was significantly reduced by a cruise-tap greeting or by handshake after the use of hand sanitizer. Modified greetings and patient hand hygiene are potential strategies to reduce transmission of healthcare-associated pathogens.
Background: Stollery Children’s Hospital (SCH) is a tertiary-care pediatric hospital with a complex infrastructure: 3 NICUs located at 3 different hospitals, and all of the pediatric inpatient beds, PICU, PCICU, and a medical-surgical NICU at the main SCH site shared buildings with an academic adult hospital. We describe a collaborative process used to develop standardized SCH Infection Prevention and Control (IPC) recommendations. Methods: The SCH IPC formed a working group with Patient and Family-Centered Care (PFCC) and family representatives in 2014 to enhance the engagement of families in regards to IPC issues and initiatives. The working group identified inconsistent messages provided to families when a child was admitted as a patient requiring additional precautions (PRAP). The working group then developed a framework of key questions to be answered for family care providers of PRAP. The working group held several consultative meetings with frontline staff followed by a review of published guidelines and consultations with other pediatric hospitals about contentious issues. A consensus meeting with all key stakeholders was held to finalize IPC recommendations. Results: The key contentious issues included (1) whether personal protective equipment is required for family care providers who stay overnight with PRAP and (2) whether family care providers of PRAP are allowed to access nutrition centers on clinical units and family lounges in PCICU–PICU–NICU that were stocked with free hot meals for the families. No directly applicable recommendation was available IPC guidelines on these issues. Discussions of these topics were directed by PFCC at family councils of various clinical programs with efforts to seek opinions from more family representatives. Expert opinions and current practice were also obtained from Canadian hospitals through emails and from US hospitals through SHEA Open Forum by ICP. A final consensus meeting revisiting all available information was held, and a new Stollery IPC guideline was created with families as partners sharing the IPC vision of minimizing transmission risk at SCH. Conclusions: A consultative engagement and consensus process was successful in the development of IPC recommendations for family care providers for PRAP for implementation at a tertiary-care pediatric hospital with a complex infrastructure. The next step is to develop family-friendly educational and resource materials with clear and concise messages.
Background: Sink drainage systems are a potential reservoir for the dissemination of gram-negative bacilli but are not amenable to standard methods of cleaning and disinfection. Pouring liquid disinfectants down drains has only a limited and transient effect on drain colonization, presumably due to inadequate disinfectant contact time and suboptimal penetration into areas harboring biofilm-associated organisms. Methods: We compared the antimicrobial efficacy of 2 novel sink disinfection methods intended to enhance disinfectant contact time and penetration. Healthcare facility sinks were randomly assigned to disinfection with 300 mL hydrogen peroxide-based disinfectant applied either as a foam (N = 13 sinks) or instilled for 30 minutes behind a temporary obstruction created by an inflated urinary catheter balloon (N = 12 sinks). Swabs were used to collect quantitative cultures from the proximal sink drain to depth of 2.5 cm (1 inch) below the strainer before treatment and at 15 minutes and 1, 2, 3, 5, and 7 days after treatment. Repeated measures analysis of variance was performed to compare the efficacy of the 2 treatments. Results: As shown in Fig. 1, both methods yielded an initial reduction of >3 log10 CFU of gram-negative bacilli. Over the 7-day follow-up period, disinfectant instillation resulted in significantly greater reduction than the foam application (P < .01). Recovery of sink colonization to >2 log per swab occurred at day 3 for both treatments, whereas recovery to >3 log per swab occurred on day 3 for the foam treatment versus day 7 for disinfectant instillation. Conclusions: Two novel disinfection methods were effective in reducing sink drain colonization for several days. The instillation method was more effective than the foam method in maintaining reductions over 7 days.
Background: A robust infection prevention infrastructure is critical for creating a safe resident environment in nursing homes. The CDC NHSN provides a standardized approach to infection surveillance and analysis, which can drive internal quality improvement efforts in nursing homes and could serve as an indicator of facilities’ infection prevention aptitude. The purpose of this study was to compare the characteristics of nursing homes enrolled to those not enrolled in the NHSN, including interfacility communication methods, as an essential part of reducing resident infection-related risks. Methods: Over a 2-year period, 50 nursing homes participated in a 12-month program designed to reduce healthcare-associated infections (HAIs) by enhancing relationships between nursing homes and hospitals. Overall, 11 demographic surveys were administered to nursing homes prior to the start of the phase 1 pilot year between January and March 2018, and another 39 were administered prior to beginning phase 2 in January–February 2019. The survey consisted of 36 questions on facility characteristics, including NHSN enrollment, infection prevention and control (IPC) program and infection preventionist characteristics, and communication methods related to interfacility transfer of care. We compared facility, IPC program characteristics, and communication methods between nursing homes stratified based on NHSN enrollment. These were compared using the Fisher exact test. Results: In total, 50 nursing homes, varying in size and services provided, completed the demographic survey (Table 1). Of these 50 nursing homes, 11 (22%) were enrolled in the NHSN. Nursing homes enrolled in the NHSN were more likely to use a telephone report prior to resident transfer in and out of the facility (P = .04) and to disseminate infection data to all facility nursing staff (P = .02). Overall, less than half of nursing homes included a telephone report as part of their routine hand-off communication, and most nursing homes relied only on written transfer forms or discharge documentation. Moreover, 65% of the nursing homes reported use of a standardized method to accept new residents with history of multidrug-resistant organism (MDRO), including a review of infection or MDRO type, antibiotic orders, and ambulation status. NHSN-enrolled nursing homes were also more likely to have an antibiotic stewardship program and to use the electronic health record (EHR) to facilitate infection surveillance, though these differences were not statistically significant. Conclusions: A higher percentage of nursing homes enrolled in the NHSN engaged in activities connected with resident safety including verbal report prior to interfacility transfer and antimicrobial stewardship programs. Dedicating resources for nursing homes to enhance their IPC program including NHSN enrollment should be encouraged.
Funding: This study was supported by a grant from the AHRQ (grant no. RO1HS25451).
Respiratory and enteric viruses are highly contagious pathogens that can be spread by contaminated hands and surfaces. We hypothesized that alternatives to handshake greetings that reduce the time and surface area of hand contact would be associated with decreased transfer of viral particles. Methods: In a simulation of hand-contact greetings, volunteers (N = 22) used a keyboard contaminated with the benign bacteriophage MS2 and then performed a handshake and fist bump with additional volunteers. To assess viral transfer, hands were cultured for MS2, and plaque-forming units (PFU) were compared for the different types of hand contact. Additional simulations (N = 10) were conducted to compare viral transfer with the fist bump versus a cruise tap greeting (ie, a modified fist bump involving single knuckle contact). Results: The handshake greeting resulted in significantly greater transfer of MS2 than the fist bump (1.31 vs 0.54 log10 PFUs, P < .001) (Fig. 1A), but the frequency of transfer of virus was high for both greetings (91% transfer by handshake vs 59% by fist bump). The cruise-tap greeting did not result in reduced transfer of viral particles in comparison to the fist bump (Fig. 1B), and the frequency of transfer remained high (70%). Conclusions: The fist-bump and cruise-tap greetings could potentially reduce transmission of viruses in comparison to the handshake, but transfer occurred frequently, even with these greeting methods. To eliminate hand-to-hand transmission of respiratory and enteric viruses, alternative greeting methods that do not involve physical contact are needed.
Following Canadian estimates of frailty, academic researchers and the Chiefs of Ontario came together to create the first Ontario-wide profile of aging in First Nations people in Ontario. Using self-reported data from First Nations adults who participated in the Ontario First Nations Regional Health Survey Phase 2, we found that First Nations people in Ontario experience higher rates of frailty than the general Canadian population and early onset frailty appears to affect First Nations communities. This is important to consider as communities plan for health care needs of an aging population and is particularly relevant in the face of Covid-19, as we know severity is exacerbated by underlying health conditions.
On coronavirus disease 2019 (COVID-19) wards, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid was frequently detected on high-touch surfaces, floors, and socks inside patient rooms. Contamination of floors and shoes was common outside patient rooms on the COVID-19 wards but decreased after improvements in floor cleaning and disinfection were implemented.
The diagnosis of an advanced cancer in young adulthood can bring one's life to an abrupt halt, calling attention to the present moment and creating anguish about an uncertain future. There is seldom time or physical stamina to focus on forward-thinking, social roles, relationships, or dreams. As a result, young adults (YAs) with advanced cancer frequently encounter existential distress, despair, and question the purpose of their life. We sought to investigate the meaning and function of hope throughout YAs’ disease trajectory; to discern the psychosocial processes YAs employ to engage hope; and to develop a substantive theory of hope of YAs diagnosed with advanced cancer.
Thirteen YAs (ages 23–38) diagnosed with a stage III or IV cancer were recruited throughout the eastern and southeastern United States. Participants completed one semi-structured interview in-person, by phone, or Skype, that incorporated an original timeline instrument assessing fluctuations in hope and an online socio-demographic survey. Glaser's grounded theory methodology informed constant comparative methods of data collection, analysis, and interpretation.
Findings from this study informed the development of the novel contingent hope theoretical framework, which describes the pattern of psychosocial behaviors YAs with advanced cancer employ to reconcile identities and strive for a life of meaning. The ability to cultivate the necessary agency and pathways to reconcile identities became contingent on the YAs’ participation in each of the psychosocial processes of the contingent hope theoretical framework: navigating uncertainty, feeling broken, disorienting grief, finding bearings, and identity reconciliation.
Significance of Results
Study findings portray the influential role of hope in motivating YAs with advanced cancer through disorienting grief toward an integrated sense of self that marries cherished aspects of multiple identities. The contingent hope theoretical framework details psychosocial behaviors to inform assessments and interventions fostering hope and identity reconciliation.
Worldwide, early intervention services for young people with recent-onset psychosis have been associated with improvements in outcomes, including reductions in hospitalization, symptoms, and improvements in treatment engagement and work/school participation. States have received federal mental health block grant funding to implement team-based, multi-element, evidence-based early intervention services, now called coordinated specialty care (CSC) in the USA. New York State’s CSC program, OnTrackNY, has grown into a 23-site, statewide network, serving over 1800 individuals since its 2013 inception. A state-supported intermediary organization, OnTrackCentral, has overseen the growth of OnTrackNY. OnTrackNY has been committed to quality improvement since its inception. In 2019, OnTrackNY was awarded a regional hub within the National Institute of Mental Health-sponsored Early Psychosis Intervention Network (EPINET). The participation in the national EPINET initiative reframes and expands OnTrackNY’s quality improvement activities. The national EPINET initiative aims to develop a learning healthcare system (LHS); OnTrackNY’s participation will facilitate the development of infrastructure, including a systematic approach to facilitating stakeholder input and enhancing the data and informatics infrastructure to promote quality improvement. Additionally, this infrastructure will support practice-based research to improve care. The investment of the EPINET network to build regional and national LHSs will accelerate innovations to improve quality of care.
Sink drainage systems are not amenable to standard methods of cleaning and disinfection. Disinfectants applied as a foam might enhance efficacy of drain decontamination due to greater persistence and increased penetration into sites harboring microorganisms.
To examine the efficacy and persistence of foam-based products in reducing sink drain colonization with gram-negative bacilli.
During a 5-month period, different methods for sink drain disinfection in patient rooms were evaluated in a hospital and its affiliated long-term care facility. We compared the efficacy of a single treatment with 4 different foam products in reducing the burden of gram-negative bacilli in the sink drain to a depth of 2.4 cm (1 inch) below the strainer. For the most effective product, the effectiveness of foam versus liquid-pouring applications, and the effectiveness of repeated foam treatments were evaluated.
A foam product containing 3.13% hydrogen peroxide and 0.05% peracetic acid was significantly more effective than the other 3 foam products. In comparison to pouring the hydrogen peroxide and peracetic acid disinfectant, the foam application resulted in significantly reduced recovery of gram-negative bacilli on days 1, 2, and 3 after treatment with a return to baseline by day 7. With repeated treatments every 3 days, a progressive decrease in the bacterial load recovered from sink drains was achieved.
An easy-to-use foaming application of a hydrogen peroxide- and peracetic acid-based disinfectant suppressed sink-drain colonization for at least 3 days. Intermittent application of the foaming disinfectant could potentially reduce the risk for dissemination of pathogens from sink drains.
The National Institute of Health has mandated good clinical practice (GCP) training for all clinical research investigators and professionals. We developed a GCP game using the Kaizen-Education platform. The GCP Kaizen game was designed to help clinical research professionals immerse themselves into applying International Conference on Harmonization GCP (R2) guidelines in the clinical research setting through case-based questions.
Students were invited to participate in the GCP Kaizen game as part of their 100% online academic Masters during the Spring 2019 semester. The structure of the game consisted of 75 original multiple choice and 25 repeated questions stemming from fictitious vignettes that were distributed across 10 weeks. Each question presented a teachable rationale after the answers were submitted. At the end of the game, a satisfaction survey was issued to collect player satisfaction data on the game platform, content, experience as well as perceptions of GCP learning and future GCP concept application.
There were 71 total players who participated and answered at least one question. Of those, 53 (75%) answered all 100 questions. The game had a high Cronbach’s alpha, and item analyses provided information on question quality, thus assisting us in future quality edits before re-testing and wider dissemination.
The GCP Kaizen game provides an alternative method for mandated GCP training using principles of gamification. It proved to be a reliable and an effective educational method with high player satisfaction.