The intensity of an antibiotic stewardship intervention to achieve clinical impact is not known. We conducted a multisite dissemination project of an intervention to reduce treatment of asymptomatic bacteriuria (ASB) and studied: (1) the association between implementation metrics and clinical outcomes and (2) the cost of implementation.

A central site facilitated a multimodality intervention to decrease unnecessary urine cultures and antibiotic treatment in patients with ASB at 4 Veterans Affairs medical centers.

The intervention consisted of a decision support aid algorithm and interactive teaching cases that provided in the moment audit and feedback on how to manage ASB. Implementation outcomes included minutes spent in intervention delivery, number of healthcare professionals reached, and number of sessions delivered. Clinical outcomes included days of antibiotic therapy (DOT), length of antibiotic therapy (LOT), and number of urine cultures ordered per 1000 bed days. Personnel reported weekly time logs.

Minutes spent in intervention delivery were inversely correlated with two clinical outcomes, DOT (R −0.3, P = .04) and LOT (R −0.3, P = .02). Number of healthcare professionals reached and number of sessions delivered were not correlated with clinical outcomes of DOT (R –0.003, P = .98, R = −0.059, P = .69) or LOT (R +0.073, P = .62, R −0.102, P = .49). Physician champions spent an average of 3.8% of effort on the intervention. The implementation cost was USD 22,299/year per site on average.

The amount of time local teams spent in delivery of an antibiotic stewardship intervention was correlated with the desired decrease in antibiotic use. Implementing this successful antibiotic stewardship intervention required minimal time.

Despite significant advancements in healthcare technology, digital health solutions – especially those for serious mental illnesses – continue to fall short of their potential across both clinical practice and efficacy. The utility and impact of medicine, including digital medicine, hinges on relationships, trust, and engagement, particularly in the field of mental health. This paper details results from Phase 1 of a two-part study that seeks to engage people with schizophrenia, their family members, and clinicians in co-designing a digital mental health platform for use across different cultures and contexts in the United States and India.

Each site interviewed a mix of clinicians, patients, and their family members in focus groups (n = 20) of two to six participants. Open-ended questions and discussions inquired about their own smartphone use and, after a demonstration of the mindLAMP platform, specific feedback on the app's utility, design, and functionality.

Our results based on thematic analysis indicate three common themes: increased use and interest in technology during coronavirus disease 2019 (COVID-19), concerns over how data are used and shared, and a desire for concurrent human interaction to support app engagement.

People with schizophrenia, their family members, and clinicians are open to integrating technology into treatment to better understand their condition and help inform treatment. However, app engagement is dependent on technology that is complementary – not substitutive – of therapeutic care from a clinician.

Hypoxic ischemic encephalopathy (HIE) is a condition that occurs when the entire brain is deprived of an adequate oxygen supply, and is often a complication of cardiac arrest or profound hypotension. This can result in poor outcomes including significant impairments in memory, cognition, and attention.

In the context of sparse literature reports on chronic delirum following cardiac arrest related HIE, we report a case of a 59 year old male patient with normal premorbid functioning who developed chronic confusional state following a hypoxic insult to the brain subsequent to cardiac arrest and try to highlight the challenges encountered during his clinical course and management.

This case highlights the presence of chronic delirium following hypoxic ischaemic encephalopathy, an unfortunate consequence of cardiac arrest. It also highlights the problems encountered in managing such patients.

In preparation for a multisite antibiotic stewardship intervention, we assessed knowledge and attitudes toward management of asymptomatic bacteriuria (ASB) plus teamwork and safety climate among providers, nurses, and clinical nurse assistants (CNAs).

Prospective surveys during January–June 2018.

All acute and long-term care units of 4 Veterans’ Affairs facilities.

The survey instrument included 2 previously tested subcomponents: the Kicking CAUTI survey (ASB knowledge and attitudes) and the Safety Attitudes Questionnaire (SAQ).

A total of 534 surveys were completed, with an overall response rate of 65%. Cognitive biases impacting management of ASB were identified. For example, providers presented with a case scenario of an asymptomatic patient with a positive urine culture were more likely to give antibiotics if the organism was resistant to antibiotics. Additionally, more than 80% of both nurses and CNAs indicated that foul smell is an appropriate indication for a urine culture. We found significant interprofessional differences in teamwork and safety climate (defined as attitudes about issues relevant to patient safety), with CNAs having highest scores and resident physicians having the lowest scores on self-reported perceptions of teamwork and safety climates (P < .001). Among providers, higher safety-climate scores were significantly associated with appropriate risk perceptions related to ASB, whereas social norms concerning ASB management were correlated with higher teamwork climate ratings.

Our survey revealed substantial misunderstanding regarding management of ASB among providers, nurses, and CNAs. Educating and empowering these professionals to discourage unnecessary urine culturing and inappropriate antibiotic use will be key components of antibiotic stewardship efforts.

There are few longitudinal studies about South Asians (SAs) and little information about recruitment and retention approaches for this ethnic group.

We followed 906 SAs enrolled in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort for 5 years. Surviving participants were invited for a second clinical exam from 2015 to 2018. A new wave of participants was recruited during 2017–2018. We assessed the yields from different methods of recruitment and retention.

A total of 759 (83%) completed the second clinical exam, and 258 new participants were enrolled. Providing a nearby community hospital location for the study exam, offering cab/shared ride reimbursement, and conducting home visits were the most effective methods for enhancing retention. New participant recruitment targeted women and individuals with lower socioeconomic status, and we found that participant referrals and active community engagement were most effective. Mailing invitational letters to those identified by electronic health records had very low yield.

Recruitment and retention strategies that address transportation barriers and increase community engagement will help increase the representation of SAs in health research.

In 2007, the American Heart Association modified the infective endocarditis prophylaxis guidelines by limiting the use of antibiotics in patients with cardiac conditions associated with the highest risk of adverse outcomes after infective endocarditis. Our objective was to evaluate current practice for infective endocarditis prophylaxis among paediatric cardiologists.

A web-based survey focussing on current practice, describing the use of antibiotics for infective endocarditis prophylaxis in various congenital and acquired heart diseases, was distributed via e-mail to paediatric cardiologists. The survey was kept anonymous and was distributed twice.

Data from 253 participants were analysed. Most paediatric cardiologists discontinued infective endocarditis prophylaxis in patients with simple lesions such as small ventricular septal defect, patent ductus arteriosus, and bicuspid aortic valve without stenosis or regurgitation; however, significant disagreement persists in prescribing infective endocarditis prophylaxis in certain conditions such as rheumatic heart disease, Fontan palliation without fenestration, and the Ross procedure. Use of antibiotic prophylaxis in certain selected conditions for which infective endocarditis prophylaxis has been indicated as per the current guidelines varies from 44 to 83%. Only 44% follow the current guidelines exclusively, and 34% regularly discuss the importance of oral hygiene with their patients at risk for infective endocarditis.

Significant heterogeneity still persists in recommending infective endocarditis prophylaxis for several cardiac lesions among paediatric cardiologists. More than half of the participants (56%) do not follow the current guidelines exclusively in their practice. Counselling for optimal oral health in patients at risk for infective endocarditis needs to be optimised in the current practice.

Depressive and anxiety disorders (common mental disorders) are the most common psychiatric condition encountered in primary healthcare.

To test the effectiveness of an intervention led by lay health counsellors in primary care settings (the MANAS intervention) to improve the outcomes of people with common mental disorders.

Twenty-four primary care facilities (12 public, 12 private) in Goa (India) were randomised to provide either collaborative stepped care or enhanced usual care to adults who screened positive for common mental disorders. Participants were assessed at 2, 6 and 12 months for presence of ICD-10 common mental disorders, the severity of symptoms of depression and anxiety, suicidal behaviour and disability levels. All analyses were intention to treat and carried out separately for private and public facilities and adjusted for the design. The trial has been registered with clinicaltrials.gov (NCT00446407).

A total of 2796 participants were recruited. In public facilities, the intervention was consistently associated with strong beneficial effects over the 12 months on all outcomes. There was a 30% decrease in the prevalence of common mental disorders among those with baseline ICD-10 diagnoses (risk ratio (RR) = 0.70, 95% CI 0.53–0.92); and a similar effect among the subgroup of participants with depression (RR = 0.76, 95% CI 0.59–0.98). Suicide attempts/plans showed a 36% reduction over 12 months (RR = 0.64, 95% CI 0.42–0.98) among baseline ICD-10 cases. Strong effects were observed on days out of work and psychological morbidity, and modest effects on overall disability. In contrast, there was little evidence of impact of the intervention on any outcome among participants attending private facilities.

Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders, suicidal behaviour, psychological morbidity and disability days among those attending public primary care facilities.

To determine if instituting an Emergency Department (ED) fast-track area would increase efficiency in patient flow, improve utilization of limited resources, and identify critical versus non-critical patients during disaster relief in Port au Prince, Haiti.

A survey was conducted at L'Hôpital de l'Université d'Etat d'Haïti (HUEH) in Port au Prince, Haiti by Emergency physicians and nurses from SUNY Downstate Medical Center on a disaster relief mission following the 2010 earthquake. The following variables were obtained to assess ED effectiveness: number of patients, acuity level, chief complaints, critical interventions, waiting times, length of stay, specialty service coverage and physical plant space. Additionally, existing practitioners were surveyed regarding existing ED practices. ED operation flow maps were created.

The assessment revealed a large volume of low-acuity patients mixed with high-acuity patients without identification of acuity level, time of arrival, or designated area for treatment. Although literature reports routine use of START triage, this was not being implemented in this setting. Results of implementing a fast track area included: (1) Improved identification of patients needing immediate treatment. (2) Increased flow of low acuity patients in designated fast track areas. (3) Improved triage protocols maximized appropriate use of resources, and expedited subspecialty consultation.

By instituting well-accepted, validated patient flow systems and reinforcing communication regarding resources available and the use of geographic space, better management of incoming emergency patients was achieved.

Upon arrival of the SUNY Downstate Medical Center team for their disaster relief mission in Port au Prince, Haiti, it was observed that obstacles to patient care were directly related to difficulty in locating supplies and medications in a timely manner. In addition, staffing schedules had not been correlated to patient flow patterns.

A survey was conducted at L'Hôpital de l'Université d'Etat d'Haïti (HUEH) in Port au Prince, Haiti by Emergency physicians and nurses from SUNY Downstate Medical Center. The following variables were obtained to assess existing resources: number and types of providers available, provider staffing schedules, medication/supply inventories and management systems. Basic ED operation and supply system flow maps were created.

The assessment revealed a large volume of patients presenting in the early morning. Night shifts were inconsistently staffed with ED physicians. Although medications and supplies were reported to be available on-site, they were not tracked, inventoried, or centrally managed. As a result, this increased time to treatment and practitioner fatigue. Process improvements included: (1) Institution of swing and night shifts accommodated peak patient volumes, decreased waiting times, provided care for critical patients during off-peak hours, and decreased physician fatigue. (2) Identification and labeling of existing medications/supplies facilitated more accurate management of inventories and decreased time to treatment and disposition.

Process improvement through systematic analysis led to better disaster resource utilization in this tent hospital.