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To determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on healthcare-associated infection (HAI) incidence in US hospitals, national- and state-level standardized infection ratios (SIRs) were calculated for each quarter in 2020 and compared to those from 2019.
Central–line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), select surgical site infections, and Clostridioides difficile and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia laboratory-identified events reported to the National Healthcare Safety Network for 2019 and 2020 by acute-care hospitals were analyzed. SIRs were calculated for each HAI and quarter by dividing the number of reported infections by the number of predicted infections, calculated using 2015 national baseline data. Percentage changes between 2019 and 2020 SIRs were calculated. Supporting analyses, such as an assessment of device utilization in 2020 compared to 2019, were also performed.
Significant increases in the national SIRs for CLABSI, CAUTI, VAE, and MRSA bacteremia were observed in 2020. Changes in the SIR varied by quarter and state. The largest increase was observed for CLABSI, and significant increases in VAE incidence and ventilator utilization were seen across all 4 quarters of 2020.
This report provides a national view of the increases in HAI incidence in 2020. These data highlight the need to return to conventional infection prevention and control practices and build resiliency in these programs to withstand future pandemics.
This paper reports findings of a pilot survey of adolescent sexual and reproductive health (ASRH) knowledge and behaviour in Homabay County of western Kenya. The study was based on a cross-sectional survey of 523 male and female adolescents aged 10–19 years from 32 Community Health Units (CHUs). Bivariate analysis of gender differences and associations between ASRH knowledge and behaviour was followed with two-level logistic regression analysis of predictors of ASRH behaviour (sexual activity, unprotected sex, HIV testing), taking individual adolescents as level-1 and CHUs as level-2. The findings reveal important gender differences in ASRH knowledge and behaviour. While male adolescents reported higher sexual activity (ever had sex, unprotected last sex), female adolescents reported higher HIV testing. Despite having lower HIV/AIDS knowledge, female adolescents were more likely to translate their SRH knowledge into appropriate behaviour. Education emerged as an important predictor of ASRH behaviour. Out-of-school adolescents had significantly higher odds of having ever had sex (aOR=3.3) or unprotected last sex (aOR=3.2) than their in-school counterparts of the same age, gender and ASRH knowledge, while those with at least secondary education had lower odds of unprotected sex (aOR=0.52) and higher odds of HIV testing (aOR=5.49) than their counterparts of the same age, gender and SRH knowledge who had primary education or lower. However, being out of school was associated with higher HIV testing (aOR=2.3); and there was no evidence of significant differences between younger (aged 10–14) and older (aged 15–19) adolescents in SRH knowledge and behaviour. Besides individual-level predictors, there were significant community variations in ASRH knowledge and behaviour, with relatively more-deprived CHUs being associated with poorer indicators. The overall findings have important policy/programme implications. There is a need for a comprehensive approach that engages schools, health providers, peers, parents/adults and the wider community in developing age-appropriate ASRH interventions for both in-school and out-of-school adolescents in western Kenya.
Most tobacco treatment efforts target healthcare settings, because about 75% of smokers in the United States visit a primary care provider annually. Yet, 25% of patients may be missed by such targeting.
To describe patients who smoke but infrequently visit primary care – their characteristics, rates of successful telephone contact, and acceptance of tobacco treatment.
Tobacco Cessation Outreach Specialists ‘cold-called’ those without a primary care visit in the past year, offering tobacco dependence treatment. Age, sex, insurance status, race, ethnicity, electronic health record (EHR) patient-portal status and outreach outcomes were reported.
Of 3,407 patients identified as smokers in a health system registry, 565 (16.6%) had not seen any primary care provider in the past year. Among 271 of those called, 143 (53%) were successfully reached and 33 (23%) set a quit date. Those without visits tended to be younger, male, some-day versus every-day smokers (42 vs. 44 years, P = 0.004; 48% vs. 40% female, P = 0.0002, and 21% vs. 27% some-day, P = 0.003), and less active on the EHR patient portal (33% vs. 40%, P = 0.001).
A substantial proportion of patients who smoke are missed by traditional tobacco treatment interventions that require a primary care visit, yet many are receptive to quit smoking treatment offers.
Classical stewardship efforts have targeted immunocompetent patients; however, appropriate use of antimicrobials in the immunocompromised host has become a target of interest. Cytomegalovirus (CMV) infection is one of the most common and significant complications after solid-organ transplant (SOT). The treatment of CMV requires a dual approach of antiviral drug therapy and reduction of immunosuppression for optimal outcomes. This dual approach to CMV management increases complexity and requires individualization of therapy to balance antiviral efficacy with the risk of allograft rejection. In this review, we focus on the development and implementation of CMV stewardship initiatives, as a component of antimicrobial stewardship in the immunocompromised host, to optimize the management of prevention and treatment of CMV in SOT recipients. These initiatives have the potential not only to improve judicious use of antivirals and prevent resistance but also to improve patient and graft survival given the interconnection between CMV infection and allograft function.
Implementation of genome-scale sequencing in clinical care has significant challenges: the technology is highly dimensional with many kinds of potential results, results interpretation and delivery require expertise and coordination across multiple medical specialties, clinical utility may be uncertain, and there may be broader familial or societal implications beyond the individual participant. Transdisciplinary consortia and collaborative team science are well poised to address these challenges. However, understanding the complex web of organizational, institutional, physical, environmental, technologic, and other political and societal factors that influence the effectiveness of consortia is understudied. We describe our experience working in the Clinical Sequencing Evidence-Generating Research (CSER) consortium, a multi-institutional translational genomics consortium.
A key aspect of the CSER consortium was the juxtaposition of site-specific measures with the need to identify consensus measures related to clinical utility and to create a core set of harmonized measures. During this harmonization process, we sought to minimize participant burden, accommodate project-specific choices, and use validated measures that allow data sharing.
Identifying platforms to ensure swift communication between teams and management of materials and data were essential to our harmonization efforts. Funding agencies can help consortia by clarifying key study design elements across projects during the proposal preparation phase and by providing a framework for data sharing data across participating projects.
In summary, time and resources must be devoted to developing and implementing collaborative practices as preparatory work at the beginning of project timelines to improve the effectiveness of research consortia.
Surgical site infections (SSIs) are among the most common healthcare-associated infections in low- and middle-income countries. To encourage establishment of actionable and standardized SSI surveillance in these countries, we propose simplified surveillance case definitions. Here, we use NHSN reports to explore concordance of these simplified definitions to NHSN as ‘reference standard.’
The Apolipoprotein (APOE) ε4 allele increases the risk for mild cognitive impairment (MCI) and dementia, but not all carriers develop MCI/dementia. The purpose of this exploratory study was to determine if early and subtle preclinical signs of cognitive dysfunction and medial temporal lobe atrophy are observed in cognitively intact ε4 carriers who subsequently develop MCI.
Twenty-nine healthy, cognitively intact ε4 carriers (ε3/ε4 heterozygotes; ages 65–85) underwent neuropsychological testing and MRI-based measurements of medial temporal volumes over a 5-year follow-up interval; data were converted to z-scores based on a non-carrier group consisting of 17 ε3/ε3 homozygotes.
At follow-up, 11 ε4 carriers (38%) converted to a diagnosis of MCI. At study entry, the MCI converters had significantly lower scores on the Mini-Mental State Examination, Rey Auditory Verbal Learning Test (RAVLT) Trials 1–5, and RAVLT Immediate Recall compared to non-converters. MCI converters also had smaller MRI volumes in the left subiculum than non-converters. Follow-up logistic regressions revealed that left subiculum volumes and RAVLT Trials 1–5 scores were significant predictors of MCI conversion.
Results from this exploratory study suggest that ε4 carriers who convert to MCI exhibit subtle cognitive and volumetric differences years prior to diagnosis.
Cybermentoring refers to virtual peer support in which young people themselves are trained as cybermentors and interact with those needing help and advice (cybermentees) online. This article describes the training in, and implementation of, a cross-national cybermentoring scheme, Beatbullying Europe, developed in the United Kingdom. It involved train-the-trainer workshops for partners and life mentors in six European countries (Italy, Spain, Portugal, Romania, Poland and the Czech Republic) in 2013–2014, followed by training sessions for pupil cybermentors aged 11–16 years. Although BeatBullying went into liquidation in November 2014, the project was largely completed. We (1) report an evaluation of the training of the life mentors and mentors, via questionnaire survey; and (2) discuss findings about the implementation of the scheme and its potential at a cross-national level, via partner interviews during and at the end of the project. The training was found to be highly rated in all respects, and in all six countries involved. The overall consensus from the data available is that there was a positive impact for the schools and professionals involved; some challenges encountered are discussed. The BeatBullying Europe project, despite being unfinished, was promising, and a similar approach deserves further support and evaluation in the future.
Weed management is a major challenge in organic crop production, and organic farms generally harbor larger weed populations and more diverse communities compared with conventional farms. However, little research has been conducted on the effects of different organic management practices on weed communities and crop yields. In 2014 and 2015, we measured weed community structure and soybean [Glycine max (L.) Merr.] yield in a long-term experiment that compared four organic cropping systems that differed in nutrient inputs, tillage, and weed management intensity: (1) high fertility (HF), (2) low fertility (LF), (3) enhanced weed management (EWM), and (4) reduced tillage (RT). In addition, we created weed-free subplots within each system to assess the impact of weeds on soybean yield. Weed density was greater in the LF and RT systems compared with the EWM system, but weed biomass did not differ among systems. Weed species richness was greater in the RT system compared with the EWM system, and weed community composition differed between RT and other systems. Our results show that differences in weed community structure were primarily related to differences in tillage intensity, rather than nutrient inputs. Soybean yield was lower in the EWM system compared with the HF and RT systems. When averaged across all four cropping systems and both years, soybean yield in weed-free subplots was 10% greater than soybean yield in the ambient weed subplots that received standard management practices for the systems in which they were located. Although weed competition limited soybean yield across all systems, the EWM system, which had the lowest weed density, also had the lowest soybean yield. Future research should aim to overcome such trade-offs between weed control and yield potential, while conserving weed species richness and the ecosystem services associated with increased weed diversity.
The first episode of psychosis is a critical period in the emergence of cardiometabolic risk.
We set out to explore the influence of individual and lifestyle factors on cardiometabolic outcomes in early psychosis.
This was a prospective cohort study of 293 UK adults presenting with first-episode psychosis investigating the influence of sociodemographics, lifestyle (physical activity, sedentary behaviour, nutrition, smoking, alcohol, substance use) and medication on cardiometabolic outcomes over the following 12 months.
Rates of obesity and glucose dysregulation rose from 17.8% and 12%, respectively, at baseline to 23.7% and 23.7% at 1 year. Little change was seen over time in the 76.8% tobacco smoking rate or the quarter who were sedentary for over 10 h daily. We found no association between lifestyle at baseline or type of antipsychotic medication prescribed with either baseline or 1-year cardiometabolic outcomes. Median haemoglobin A1c (HbA1c) rose by 3.3 mmol/mol in participants from Black and minority ethnic (BME) groups, with little change observed in their White counterparts. At 12 months, one-third of those with BME heritage exceeded the threshold for prediabetes (HbA1c >39 mmol/mol).
Unhealthy lifestyle choices are prevalent in early psychosis and cardiometabolic risk worsens over the next year, creating an important window for prevention. We found no evidence, however, that preventative strategies should be preferentially directed based on lifestyle habits. Further work is needed to determine whether clinical strategies should allow for differential patterns of emergence of cardiometabolic risk in people of different ethnicities.
The U.S. Food and Drug Administration (FDA) traditionally has kept confidential significant amounts of information relevant to the approval or non-approval of specific drugs, devices, and biologics and about the regulatory status of such medical products in FDA’s pipeline.
To develop practical recommendations for FDA to improve its transparency to the public that FDA could implement by rulemaking or other regulatory processes without further congressional authorization. These recommendations would build on the work of FDA’s Transparency Task Force in 2010.
In 2016-2017, we convened a team of academic faculty from Harvard Medical School, Brigham and Women’s Hospital, Yale Medical School, Yale Law School, and Johns Hopkins Bloomberg School of Public Health to develop recommendations through an iterative process of reviewing FDA’s practices, considering the legal and policy constraints on FDA in expanding transparency, and obtaining insights from independent observers of FDA.
The team developed 18 specific recommendations for improving FDA’s transparency to the public. FDA could adopt all these recommendations without further congressional action.
The development of the Blueprint for Transparency at the U.S. Food and Drug Administration was funded by the Laura and John Arnold Foundation.
OBJECTIVES/SPECIFIC AIMS: The prevention, management, and treatment of HIV, STDs, and HCV requires continuous training that reflects contemporary best-practice and innovative care models. In order to improve the NYS AIDS Institute’s comprehensive web-enabled training program, which enhances the capacity of a diverse healthcare workforce, a needs assessment (NA) of our community of practice (CoP) is needed to better understand their training needs, circumstances, and instructional modalities preferences. The goal of the assessment was to better understand our CoP’s preferences of online trainings, and as a result to develop a “responsive design” system that will enhance user’s learning experience thus improving patient care. METHODS/STUDY POPULATION: We developed and deployed an NA survey using REDCap. The instrument consisted in 27 questions related to providers’ preferences on receiving continuing educational training and their use of technologies, including mobile platforms, online modules, webinars, and telehealth. As part of the recruitment strategy, several resources were deployed over a 1-month recruitment period including sequential email blasts, website promotion, and assessment links included in newsletters and social media. Weekly reminders were also used to promote the participation from our CoP. RESULTS/ANTICIPATED RESULTS: A total of 310 respondents participated in the NA, with 85.8% from NYS. 177 were clinicians (20.5% MD, 2.9% PA, 17.3% NP, and 16.3% RN) and 133 nonclinical providers (case/care managers, social workers, public health professionals, coordinators/administrators, and other). The participants worked in hospitals, community health centers, substance use centers, private practices, and state/local health departments. More than 90% of respondents indicated that they preferred both live/in-person and online training, and participants most strongly indicated that they stayed up-to-date on current developments through CDC, the AIDS Institute, and conferences. More than 60% of respondents considered that receiving CE credit for the training was very important and 28% indicated they would use training materials in Spanish if offered. In terms of technology, over 80% of the respondents preferred computers, but more 50% also used mobile devices (computer at home 61.8%, computer at work 85%, tablet 29.9%, iPhone 20.9%, Android 16.6%, other device 2.3%). DISCUSSION/SIGNIFICANCE OF IMPACT: Accessing an online CoP provided a useful opportunity to assess training needs and preferences of clinical and nonclinical providers. Most providers indicated that they were primarily likely to use a work computer to complete online training or secondarily a home computer. With a significant portion of respondents indicating use of tablets, smartphones, and other devices, online training opportunities should be developed with responsive design to assure flexibility and access. In addition to online training, participants indicated that they also strongly valued live, in-person training. Offering training with CDC and the NYS AIDS Institute branding, in Spanish, together with offering continuing education credit, were all seen as desirable training elements. Accessing this online CoP helped streamline and target training priorities and logistics.
The role of mindfulness, mindful eating and a newer concept of intuitive eating in modulating eating habits is an area of increasing interest. In this structured literature review, a summary of the current evidence is presented, together with details of interventions undertaken and the tools to measure outcomes. It is broad in scope given the emerging evidence base in this area. The review yielded sixty-eight publications: twenty-three interventions in obese/overweight populations; twenty-nine interventions in normal-weight populations; sixteen observational studies, three of which were carried out in overweight/obese populations. Mindfulness-based approaches appear most effective in addressing binge eating, emotional eating and eating in response to external cues. There is a lack of compelling evidence for the effectiveness of mindfulness and mindful eating in weight management. Mindfulness-based approaches may prevent weight gain. Reduced food intake was seen in some of the studies in overweight and obese populations, but this was less apparent in the studies in normal-weight populations. The evidence base for intuitive eating is limited to date and further research is needed to examine its potential in altering eating behaviours. Mindfulness appears to work by an increased awareness of internal, rather than external, cues to eat. Mindfulness and mindful eating have the potential to address problematic eating behaviours and the challenges many face with controlling their food intake. Encouraging a mindful eating approach would seem to be a positive message to be included in general weight management advice to the public.
Despite national guidelines recommending early concurrent palliative care for individuals newly diagnosed with metastatic cancer, few community cancer centers, especially those in underserved rural areas do so. We are implementing an early concurrent palliative care model, ENABLE (Educate, Nurture, Advise, Before Life Ends) in four, rural-serving community cancer centers. Our objective was to develop a “toolkit” to assist community cancer centers that wish to integrate early palliative care for patients with newly diagnosed advanced cancer and their family caregivers.
Guided by the RE-AIM (Reach, Effectiveness–Adoption, Implementation, Maintenance) framework, we undertook an instrument-development process based on the literature, expert and site stakeholder review and feedback, and pilot testing during site visits.
We developed four instruments to measure ENABLE implementation: (1) the ENABLE RE-AIM Self-Assessment Tool to assess reach, adoption, implementation, and maintenance; (2) the ENABLE General Organizational Index to assess institutional implementation; (3) an Implementation Costs Tool; and (4) an Oncology Clinicians' Perceptions of Early Concurrent Oncology Palliative Care survey.
Significance of results:
We developed four measures to determine early palliative care implementation. These measures have been pilot-tested, and will be integrated into a comprehensive “toolkit” to assist community cancer centers to measure implementation outcomes. We describe the lessons learned and recommend strategies for promoting long-term program sustainability.
Fontan survivors have depressed cardiac index that worsens over time. Serum biomarker measurement is minimally invasive, rapid, widely available, and may be useful for serial monitoring. The purpose of this study was to identify biomarkers that correlate with lower cardiac index in Fontan patients.
Methods and results
This study was a multi-centre case series assessing the correlations between biomarkers and cardiac magnetic resonance-derived cardiac index in Fontan patients ⩾6 years of age with biochemical and haematopoietic biomarkers obtained ±12 months from cardiac magnetic resonance. Medical history and biomarker values were obtained by chart review. Spearman’s Rank correlation assessed associations between biomarker z-scores and cardiac index. Biomarkers with significant correlations had receiver operating characteristic curves and area under the curve estimated. In total, 97 cardiac magnetic resonances in 87 patients met inclusion criteria: median age at cardiac magnetic resonance was 15 (6–33) years. Significant correlations were found between cardiac index and total alkaline phosphatase (−0.26, p=0.04), estimated creatinine clearance (0.26, p=0.02), and mean corpuscular volume (−0.32, p<0.01). Area under the curve for the three individual biomarkers was 0.63–0.69. Area under the curve for the three-biomarker panel was 0.75. Comparison of cardiac index above and below the receiver operating characteristic curve-identified cut-off points revealed significant differences for each biomarker (p<0.01) and for the composite panel [median cardiac index for higher-risk group=2.17 L/minute/m2 versus lower-risk group=2.96 L/minute/m2, (p<0.01)].
Higher total alkaline phosphatase and mean corpuscular volume as well as lower estimated creatinine clearance identify Fontan patients with lower cardiac index. Using biomarkers to monitor haemodynamics and organ-specific effects warrants prospective investigation.
Aging is associated with performance reductions in executive function and episodic memory, although there is substantial individual variability in cognition among older adults. One factor that may be positively associated with cognition in aging is physical activity. To date, few studies have objectively assessed physical activity in young and older adults, and examined whether physical activity is differentially associated with cognition in aging. Young (n=29, age 18–31 years) and older adults (n=31, ages 55–82 years) completed standardized neuropsychological testing to assess executive function and episodic memory capacities. An experimental face-name relational memory task was administered to augment assessment of episodic memory. Physical activity (total step count and step rate) was objectively assessed using an accelerometer, and hierarchical regressions were used to evaluate relationships between cognition and physical activity. Older adults performed more poorly on tasks of executive function and episodic memory. Physical activity was positively associated with a composite measure of visual episodic memory and face-name memory accuracy in older adults. Physical activity associations with cognition were independent of sedentary behavior, which was negatively correlated with memory performance. Physical activity was not associated with cognitive performance in younger adults. Physical activity is positively associated with episodic memory performance in aging. The relationship appears to be strongest for face-name relational memory and visual episodic memory, likely attributable to the fact that these tasks make strong demands on the hippocampus. The results suggest that physical activity relates to cognition in older, but not younger adults. (JINS, 2015, 21, 780–790)
The Antarctic fish fauna from outer continental shelf/upper slope depths is under-sampled compared to that of the inner shelf, and there are limited quantitative data available on absolute abundance and taxonomic change with depth. A photographic survey of demersal fishes was conducted along a depth-gradient of 400–2099 m on the outer shelf and upper slope west of Anvers Island, Palmer Archipelago. A total of 1490 fishes were identified at least to the family level. Notothenioids composed 52.7% of absolute abundance and non-notothenioids 47.3%. The most abundant families were Nototheniidae (39.4%), followed by Macrouridae (28.9%), Zoarcidae (16.9%), and Channichthyidae (12.1%). The most abundant species were the notothenioids Lepidonotothen squamifrons (30.5%) and Chionobathyscus dewitti (11.7%), and the non-notothenioid Macrourus spp. (29.5%). The absolute abundance of all fishes peaked at 400–599 m. Depths of maximum abundance were 400–599 m for L. squamifrons, 700–1499 m for Macrourus spp., and 900–1499 for C. dewitti. At 700–999 m the abundance shifted from primarily notothenioids to the non-notothenioids Macrourus spp. and zoarcids. Fishes of the outer shelf and upper slope are not provincialized like those of the inner shelf and are circum-Antarctic.
This study investigates the development of metalinguistic skills, particularly ambiguity detection, and whether training accelerates this development for prereaders in kindergarten (5;5–6;6). It is the first to compare homophone detection with lexically ambiguous sentence detection in which the same homophones appear. The experimental group received ambiguity detection training; the control group received vocabulary training. Results showed that there is a spontaneous development of homophone detection abilities at the end of kindergarten, and training may accelerate this trajectory. The development of lexical ambiguity detection is not apparent in kindergarteners. However, explicit training improves this trajectory significantly. The knowledge of both meanings of a homophone is not sufficient to report both meanings of a sentence that contains that homophone. We propose that detecting the dual meanings of an ambiguous sentence involves sentence processing operations and an ability to think flexibly about language that may be enhanced with training.