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To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention.
Tertiary-care pediatric intensive care unit (PICU).
Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists.
This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey.
The number of cultures collected per day of service varied between attending physicians (range, 2.2–27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group “default” practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making.
We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.
The COVID-19 pandemic changed early care and education (ECE) mealtimes. Feeding practices that support children’s emerging autonomy may support children’s healthy eating, but it is unknown whether and how COVID-19 changed feeding practices. This paper describes caregiver feeding practices in ECE centres in Florida during COVID-19.
A mixed-methods design was used to understand mealtime feeding practices. Survey and interview questions were developed based on the Trust Model. More than 7000 surveys were sent to ECE centres. Analysis included descriptive statistics for survey data and thematic analysis for interview data.
This statewide study included teachers in all licensed and license-exempt ECE centres.
Four hundred and thirty-one teachers completed a survey, and twenty-nine participated in follow-up interviews.
Surveys showed most teachers engaged in autonomy-supportive behaviours, such as letting children eat until they were finished (90 %). The most common controlling behaviour was praising children for cleaning their plates (70 %). The most common responses about changes to mealtimes were keeping physical distance and serving healthy food. Interview themes were Autonomy Support, Controlling Feeding Practices, Interactions are the Same, Interactions are Different, Physical Distancing and Healthy Eating.
Mealtimes are a central part of the day for young children and teachers in ECE environments. COVID-19 continues to influence ECE routines as behaviour change remains the primary method of reducing the risk of COVID-19 in the absence of a vaccine for young children. Understanding teachers’ practices and perspectives is important for reducing the risk of COVID-19 and supporting children’s autonomy and healthy eating.
As part of a quality improvement project beginning in October 2011, our centre introduced changes to reduce radiation exposure during paediatric cardiac catheterisations. This led to significant initial decreases in radiation to patients. Starting in April 2016, we sought to determine whether these initial reductions were sustained.
After a 30-day trial period, we implemented (1) weight-based reductions in preset frame rates for fluoroscopy and angiography, (2) increased use of collimators and safety shields, (3) utilisation of stored fluoroscopy and virtual magnification, and (4) hiring of a devoted radiation technician. We collected patient weight (kg), total fluoroscopy time (min), and procedure radiation dosage (cGy-cm2) for cardiac catheterisations between October, 2011 and September, 2019.
A total of 1889 procedures were evaluated (196 pre-intervention, 303 in the post-intervention time period, and 1400 in the long-term group). Fluoroscopy times (18.3 ± 13.6 pre; 19.8 ± 14.1 post; 17.11 ± 15.06 long-term, p = 0.782) were not significantly different between the three groups. Patient mean radiation dose per kilogram decreased significantly after the initial quality improvement intervention (39.7% reduction, p = 0.039) and was sustained over the long term (p = 0.043). Provider radiation exposure was also significantly decreased from the onset of this project through the long-term period (overall decrease of 73%, p < 0.01) despite several changes in the interventional cardiologists who made up the team over this time period.
Introduction of technical and clinical practice changes can result in a significant reduction in radiation exposure for patients and providers in a paediatric cardiac catheterisation laboratory. These reductions can be maintained over the long term.
This report describes how stakeholder groups informed a web-based care planning tool’s development for addressing root causes of poor health. Stakeholders included community members (n = 6), researchers (n = 6), community care providers (n = 9), and patients (n = 17). Feedback was solicited through focus groups, semi-structured interviews, and user experience observations and then qualitatively analyzed to identify themes. Each group contributed a unique perspective. Researchers wanted evidence-based content; community members and providers focused on making goals manageable; patients wanted care team support and simple action-oriented language. Our findings highlight the benefits of stakeholder input. Blending perspectives from multiple groups results in a more robust intervention design.
Psychotherapy is an overarching term for any type of professional treatment for psychological and physical distress using verbal and nonverbal communication. Talking together, the patient and therapist engage collaboratively to understand the source of a dysfunction or suffering in order to reverse either maladaptive self-regulatory processes or to adapt and develop psychological strengths to cope with pathological conditions, developmental concerns, or trauma. Psychotherapy addresses multiple levels of functioning, including the neurobiology of the brain itself, the perception of the self to itself, the relationship of the self to others, the role of the individual in the social world, and the conceptual frameworks and beliefs that also may affect emotions and behavior.
ABSTRACT IMPACT: Identifying factors associated with opioid overdoses will enable better resource allocation in communities most impacted by the overdose epidemic. OBJECTIVES/GOALS: Opioid overdoses often occur in hotspots identified by geographic and temporal trends. This study uses principles of community engaged research to identify neighborhood and community-level factors associated with opioid overdose within overdose hotspots which can be targets for novel intervention design. METHODS/STUDY POPULATION: We conducted an environmental scan in three overdose hotspots’‘ two in an urban center and one in a small city’‘ identified by the Rhode Island Department of Health as having the highest opioid overdose burden in Rhode Island. We engaged hotspot community stakeholders to identify neighborhood factors to map within each hotspot. Locations of addiction treatment, public transportation, harm reduction programs, public facilities (i.e., libraries, parks), first responders, and social services agencies were converted to latitude and longitude and mapped in ArcGIS. Using Esri Service Areas, we will evaluate the service areas of stationary services. We will overlay overdose events and use logistic regression identify neighborhood factors associated with overdose by comparing hotspot and non-hotspot neighborhoods. RESULTS/ANTICIPATED RESULTS: We anticipate that there will be differing neighborhood characteristics associated with overdose events in the densely populated urban area and those in the smaller city. The urban area hotspots will have overlapping social services, addiction treatment, and transportation service areas, while the small city will have fewer community resources without overlapping service areas and reduced public transportation access. We anticipate that overdoses will occur during times of the day when services are not available. Overall, overdose hotspots will be associated with increased census block level unemployment, homelessness, vacant housing, and low food security. DISCUSSION/SIGNIFICANCE OF FINDINGS: Identifying factors associated with opioid overdoses will enable better resource allocation in communities most impacted by the overdose epidemic. Study results will be used for novel intervention design to prevent opioid overdose deaths in communities with high burden of opioid overdose.
To evaluate whether incorporating mandatory prior authorization for Clostridioides difficile testing into antimicrobial stewardship pharmacist workflow could reduce testing in patients with alternative etiologies for diarrhea.
Single center, quasi-experimental before-and-after study.
Tertiary-care, academic medical center in Ann Arbor, Michigan.
Adult and pediatric patients admitted between September 11, 2019 and December 10, 2019 were included if they had an order placed for 1 of the following: (1) C. difficile enzyme immunoassay (EIA) in patients hospitalized >72 hours and received laxatives, oral contrast, or initiated tube feeds within the prior 48 hours, (2) repeat molecular multiplex gastrointestinal pathogen panel (GIPAN) testing, or (3) GIPAN testing in patients hospitalized >72 hours.
A best-practice alert prompting prior authorization by the antimicrobial stewardship program (ASP) for EIA or GIPAN testing was implemented. Approval required the provider to page the ASP pharmacist and discuss rationale for testing. The provider could not proceed with the order if ASP approval was not obtained.
An average of 2.5 requests per day were received over the 3-month intervention period. The weekly rate of EIA and GIPAN orders per 1,000 patient days decreased significantly from 6.05 ± 0.94 to 4.87 ± 0.78 (IRR, 0.72; 95% CI, 0.56–0.93; P = .010) and from 1.72 ± 0.37 to 0.89 ± 0.29 (IRR, 0.53; 95% CI, 0.37–0.77; P = .001), respectively.
We identified an efficient, effective C. difficile and GIPAN diagnostic stewardship approval model.
To assess relationships between mothers’ feeding practices (food as a reward, food for emotion regulation, modelling of healthy eating) and mothers’ willingness to purchase child-marketed foods and fruits/vegetables (F&V) requested by their children during grocery co-shopping.
Cross-sectional. Mothers completed an online survey that included questions about feeding practices and willingness (i.e. intentions) to purchase child-requested foods during grocery co-shopping. Feeding practices scores were dichotomized at the median. Foods were grouped as nutrient-poor or nutrient-dense (F&V) based on national nutrition guidelines. Regression models compared mothers with above-the-median v. at-or-below-the-median feeding practices scores on their willingness to purchase child-requested food groupings, adjusting for demographic covariates.
Participants completed an online survey generated at a public university in the USA.
Mothers (n 318) of 2- to 7-year-old children.
Mothers who scored above-the-median on using food as a reward were more willing to purchase nutrient-poor foods (β=0·60, P<0·0001), mothers who scored above-the-median on use of food for emotion regulation were more willing to purchase nutrient-poor foods (β=0·29, P<0·0031) and mothers who scored above-the-median on modelling of healthy eating were more willing to purchase nutrient-dense foods (β=0·22, P<0·001) than were mothers with at-or-below-the-median scores, adjusting for demographic covariates.
Mothers who reported using food to control children’s behaviour were more willing to purchase child-requested, nutrient-poor foods. Parental feeding practices may facilitate or limit children’s foods requested in grocery stores. Parent–child food consumer behaviours should be investigated as a route that may contribute to children’s eating patterns.
Chondrichthyan teeth from a new locality in the Scottish Borders supply additional evidence of Early Carboniferous chondrichthyans in the UK. The interbedded dolostones and siltstones of the Ballagan Formation exposed along Whitrope Burn are interpreted as representing a restricted lagoonal environment that received significant amounts of land-derived sediment. This site is palynologically dated to the latest Tournaisian–early Viséan. The diverse dental fauna documented here is dominated by large crushing holocephalan toothplates, with very few, small non-crushing chondrichthyan teeth. Two new taxa are named and described. Our samples are consistent with worldwide evidence that chondrichthyan crushing faunas are common following the Hangenberg extinction event. The lagoonal habitat represented by Whitrope Burn may represent a temporary refugium that was host to a near-relict fauna dominated by large holocephalan chondrichthyans with crushing dentitions. Many of these had already become scarce in other localities by the Viséan and become extinct later in the Carboniferous. This fauna provides evidence of early endemism or niche separation within European chondrichthyan faunas at this time. This evidence points to a complex picture in which the diversity of durophagous chondrichthyans is controlled by narrow spatial shifts in niche availability over time.
Auxinic herbicides, such as 2,4-D and dicamba, that act as plant growth regulators are commonly used for broadleaf weed control in cereal crops (e.g., wheat, barley), grasslands, and noncroplands. If applied at late growth stages, while cereals are developing reproductive parts, the herbicides can reduce seed production. We tested whether growth regulators have this same effect on the invasive annual grass Japanese brome. The herbicides 2,4-D, dicamba, and picloram were applied at typical field use rates to Japanese brome at various growth stages in a greenhouse. Picloram reduced seed production nearly 100% when applied at the internode elongation, boot, or heading stages of growth, whereas dicamba appeared to be slightly less effective and 2,4-D was much less effective. Our results indicate it may be possible to control Japanese brome by using growth regulator herbicides to reduce its seed production, thereby depleting its short-lived seed bank.
The past two decades have seen a significant advancement in the detection, classification and understanding of exoplanets and binary star systems. The vast majority of these systems consist of stars on the main sequence or on the giant branch, leading to a dearth of knowledge of properties at early times (<50 Myr). Only one transiting planet candidate and a dozen eclipsing binaries are known among pre-main sequence objects, yet these are the systems that can provide the best constraints on stellar and planetary formation models. We have recently completed a photometric survey of 3 young (<50 Myr), nearby (D<150 pc) moving groups with a small-aperture instrument, nicknamed “AggieCam”. We detected 7 candidate Hot Jupiters and over 200 likely pre-main sequence binaries, which are now being followed up photometrically and spectroscopically.
Magnetic resonance imaging (MRI) procedures have been used for over 20 years. This modality is considered relatively safe and holds great promise. Yet, MRI has a number of risks. In order for MRI research to meet the Canadian standard of disclosure, the investigator must communicate and make note of all risks in their research protocols and consent forms. Those creating and reviewing research protocols and consent forms must take notice of the different circumstances under which MRI poses a risk. First, this paper will describe the current standard of disclosure in Canada for research participants. Second, the paper will provide a comprehensive synthesis of the known physical and psychological risks associated with MRI. Third, the paper will provide recommendations concerning areas for further investigation and risk reduction strategies. This information will thus equip researchers and research ethics boards (REBs) with the criteria needed for the composition of research protocols that meet the Canadian disclosure standard.
The 2013 Infection Prevention and Control (IP&C) Guideline for Cystic Fibrosis (CF) was commissioned by the CF Foundation as an update of the 2003 Infection Control Guideline for CF. During the past decade, new knowledge and new challenges provided the following rationale to develop updated IP&C strategies for this unique population:
1. The need to integrate relevant recommendations from evidence-based guidelines published since 2003 into IP&C practices for CF. These included guidelines from the Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC), the World Health Organization (WHO), and key professional societies, including the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). During the past decade, new evidence has led to a renewed emphasis on source containment of potential pathogens and the role played by the contaminated healthcare environment in the transmission of infectious agents. Furthermore, an increased understanding of the importance of the application of implementation science, monitoring adherence, and feedback principles has been shown to increase the effectiveness of IP&C guideline recommendations.
2. Experience with emerging pathogens in the non-CF population has expanded our understanding of droplet transmission of respiratory pathogens and can inform IP&C strategies for CF. These pathogens include severe acute respiratory syndrome coronavirus and the 2009 influenza A H1N1. Lessons learned about preventing transmission of methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant gram-negative pathogens in non-CF patient populations also can inform IP&C strategies for CF.
Kelly Quesnelle, University of Pittsburgh Medical Center, Pittsburgh, PA, USA,
Jennifer Grandis, University of Pittsburgh Medical Center, Pittsburgh, PA, USA,
Karl Munger, Brigham andWomen’s Hospital, Harvard Medical School, Boston, MA, USA,
Marshall R. Posner, Mount Sinai Medical Center, Tisch Cancer Institute, Icahn School of Medicine, New York, NY, USA
Over the last decade two highly specific, robust molecular targets have proven practical and relevant for therapy and prognosis in squamous cell cancers of the head and neck (HNC): the epidermal growth factor receptor (EGFR) and human papillomavirus (HPV). EGFR and its signaling pathways are key regulators of cell growth. The first experimental studies with anti-EGFR antibodies in human tumor models took place 25 years ago, culminating in the approval of an EGFR targeting agent in 2006 as the first new treatment for HNC in over 45 years. Recent studies have also identified HPV as a causative factor in oropharyngeal HNC. If current trends continue, there will soon be over 20 000 cases of HPV-caused oropharynx cancer in the United States. To date, EGFR and HPV are the most clinically relevant molecular targets in HNC.
EGFR expression in HNC
The epidermal growth factor receptor (EGFR) is a member of the ERBB family of tyrosine kinase receptors. EGFR regulates a variety of cellular functions by activating downstream effectors in cellular growth, differentiation, and survival pathways. Other ERBB family members include ERBB2 (HER2, Neu), ERBB3 (HER3), and ERBB4 (HER4). The family members all contain a unique extra-cellular domain along with a transmembrane domain and a tyrosine kinase domain that is structurally conserved across family members, although HER3 is kinase dead (Figure 42.1).
To examine the use of vitamin D supplements during infancy among the participants in an international infant feeding trial.
Information about vitamin D supplementation was collected through a validated FFQ at the age of 2 weeks and monthly between the ages of 1 month and 6 months.
Infants (n 2159) with a biological family member affected by type 1 diabetes and with increased human leucocyte antigen-conferred susceptibility to type 1 diabetes from twelve European countries, the USA, Canada and Australia.
Daily use of vitamin D supplements was common during the first 6 months of life in Northern and Central Europe (>80 % of the infants), with somewhat lower rates observed in Southern Europe (>60 %). In Canada, vitamin D supplementation was more common among exclusively breast-fed than other infants (e.g. 71 % v. 44 % at 6 months of age). Less than 2 % of infants in the USA and Australia received any vitamin D supplementation. Higher gestational age, older maternal age and longer maternal education were study-wide associated with greater use of vitamin D supplements.
Most of the infants received vitamin D supplements during the first 6 months of life in the European countries, whereas in Canada only half and in the USA and Australia very few were given supplementation.
Habitat use of Manta alfredi and M. birostris was assessed at 20 localities in the Indian and Pacific Oceans based upon 3328 photographic observations. Geographical relationships of the two species were scored as either microallopatry, microparapatry or microsympatry at each locality. Our study revealed a mosaic habitat occupancy by the two species within their macrosympatric range.
Brunilde Gril, National Cancer Institute, United States,
Russell Szmulewitz, The University of Chicago, Committee on Cancer Biology and Pritzker School of Medicine, United States,
Joshua Collins, National Cancer Institute, United States,
Jennifer Taylor, The University of Chicago, Committee on Cancer Biology and Pritzker School of Medicine, United States,
Carrie Rinker-Schaeffer, The University of Chicago, Committee on Cancer Biology and Pritzker School of Medicine, United States,
Patricia Steeg, National Cancer Institute, United States,
Jean-Claude Marshall, National Cancer Institute, United States
In the 1970s and 1980s, clever scientific insight and innovation rapidly advanced our understanding of the molecular mechanisms of cancer biology. The discoveries of oncogenes and tumor suppressors, and the elucidation of their functions, greatly aided in studies aimed at a molecular understanding of the etiology of primary tumors. Despite this, cancer biologists had little understanding of the molecular aspects of metastasis. Considering the devastating consequences, scientists were anxious for a breakthrough. The first clue would come from the study of tumor suppressors.
Tumor suppressor genes were identified when it was discovered that their loss of function was critical to tumorigenesis. Prior to their discovery, researchers were of the mindset that the oncogenic phenotype was always dominant. In other words, a mutation need happen on only a single allele for a normal cell to be transformed into a tumor cell. However, not all disease incidence data seemed to fit neatly into this hypothesis. By studying retinoblastoma case histories, a “two-hit” hypothesis emerged, predicting that for at least some cancers, two mutations must occur (one on each allele) to successfully transform a cell . Indeed, the retinoblastoma gene, or Rb, would become known as the first described tumor suppressor. We now know that the “two hits” need not come in the form of distinct somatic mutations but may be the result of any combination of germinal and/or somatic mutations, mitotic recombinations, gene conversions, and functional inactivation of genes owing to promoter hypermethylation.