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Newly arriving Syrian refugees can present with specific health characteristics and medical conditions when entering the United States. Given the lack of epidemiological data available for the refugee populations, our study examined the demographic features of Syrian refugees resettled in the state of Kentucky. Specifically, we examined mental and physical health clinical data in both pre-departure health screenings and domestic Refugee Health Assessments (RHA; Kentucky Office for Refugees, n.d.) performed after resettlement.
Method:
The current study adopted a cross-sectional research design. We analyzed outcome data collected from participants from 2013 and 2015. Specifically, a comparative cross-sectional analysis was performed using clinical data from Syrian refugees who underwent an RHA as part of the resettlement process between January 2015 and August 2016. Those data were compared to data derived from refugees from other countries who resettled in Kentucky between 2013 and 2015.
Results:
Mental health screenings using the Refugee Health Screener (RHS-15; Hollifield et al., 2013) found that 19.5% (n = 34) of adult Syrian refugees reported signs and symptoms from posttraumatic stress, depressive symptoms, and/or anxiety, and nearly 40% (n = 69) reported personal experiences of imprisonment or violence, and/or having witnessed someone experiencing torture or violence. Intestinal parasites and lack of immunity to varicella were the most prevalent communicable diseases among Syrian refugees. Dental abnormalities and decreased visual acuity account for the first and second most prevalent non-communicable conditions. When comparing these results to all refugees arriving during the same years, significant differences arose in demographic variables, social history, communicable diseases, and non-communicable diseases.
Conclusion:
This study provides an initial health profile of Syrian refugees resettling in Kentucky, which reflects mental health as a major healthcare concern. Posttraumatic stress and related symptoms are severe mental health conditions among Syrian refugees above and beyond other severe physical problems.
Yarkoni's analysis clearly articulates a number of concerns limiting the generalizability and explanatory power of psychological findings, many of which are compounded in infancy research. ManyBabies addresses these concerns via a radically collaborative, large-scale and open approach to research that is grounded in theory-building, committed to diversification, and focused on understanding sources of variation.
A policy mandating the completion of an online learning module for healthcare workers intending to decline influenza immunization was associated with a nearly 25% relative increase in immunization and significant reduction in healthcare-associated influenza. In the absence of mandatory vaccination, this model may help to augment severe acute respiratory coronavirus virus 2 (SARS-CoV-2) vaccine efforts.
An accurate estimate of the average number of hand hygiene opportunities per patient hour (HHO rate) is required to implement group electronic hand hygiene monitoring systems (GEHHMSs). We sought to identify predictors of HHOs to validate and implement a GEHHMS across a network of critical care units.
Design:
Multicenter, observational study (10 hospitals) followed by quality improvement intervention involving 24 critical care units across 12 hospitals in Ontario, Canada.
Methods:
Critical care patient beds were randomized to receive 1 hour of continuous direct observation to determine the HHO rate. A Poisson regression model determined unit-level predictors of HHOs. Estimates of average HHO rates across different types of critical care units were derived and used to implement and evaluate use of GEHHMS.
Results:
During 2,812 hours of observation, we identified 25,417 HHOs. There was significant variability in HHO rate across critical care units. Time of day, day of the week, unit acuity, patient acuity, patient population and use of transmission-based precautions were significantly associated with HHO rate. Using unit-specific estimates of average HHO rate, aggregate HH adherence was 30.0% (1,084,329 of 3,614,908) at baseline with GEHHMS and improved to 38.5% (740,660 of 1,921,656) within 2 months of continuous feedback to units (P < .0001).
Conclusions:
Unit-specific estimates based on known predictors of HHO rate enabled broad implementation of GEHHMS. Further longitudinal quality improvement efforts using this system are required to assess the impact of GEHHMS on both HH adherence and clinical outcomes within critically ill patient populations.
The First Episode Rapid Early Intervention for Eating Disorders (FREED) service model is associated with significant reductions in wait times and improved clinical outcomes for emerging adults with recent-onset eating disorders. An understanding of how FREED is implemented is a necessary precondition to enable an attribution of these findings to key components of the model, namely the wait-time targets and care package.
Aims
This study evaluated fidelity to the FREED service model during the multicentre FREED-Up study.
Method
Participants were 259 emerging adults (aged 16–25 years) with an eating disorder of <3 years duration, offered treatment through the FREED care pathway. Patient journey records documented patient care from screening to end of treatment. Adherence to wait-time targets (engagement call within 48 h, assessment within 2 weeks, treatment within 4 weeks) and care package, and differences in adherence across diagnosis and treatment group were examined.
Results
There were significant increases (16–40%) in adherence to the wait-time targets following the introduction of FREED, irrespective of diagnosis. Receiving FREED under optimal conditions also increased adherence to the targets. Care package use differed by component and diagnosis. The most used care package activities were psychoeducation and dietary change. Attention to transitions was less well used.
Conclusions
This study provides an indication of adherence levels to key components of the FREED model. These adherence rates can tentatively be considered as clinically meaningful thresholds. Results highlight aspects of the model and its implementation that warrant future examination.
The goal of the present study was to investigate the association between PTSD and the onset of hypertension in previously normotensive individuals in a population living in the stressful environment of the urban slums while controlling for risk factors for cardiovascular disease (CVD).
Methods
Participants were 320 normotensive individuals who lived in slums and were attending a family doctor program. Measurements included a questionnaire covering sociodemographic characteristics, clinical status and life habits, the Posttraumatic Stress Disorder Checklist – Civilian Version, and the Beck Depression Inventory. Incident hypertension was defined as the first occurrence at the follow-up review of the medical records of (1) systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher, (2) the participant started taking antihypertensive medication, or (3) a new diagnosis of hypertension made by a physician. Differences in sociodemographic, clinical, and lifestyle characteristics between hypertensive and non-hypertensive individuals were compared using the χ2 and t tests. Multivariate Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI).
Results
Six variables – age, educational level, body mass, smoking, diabetes, and PTSD diagnosis – showed a statistically significant (p ≤ 0.20) association with the hypertensive status. In the Cox regression, only PTSD diagnosis was significantly associated with incident hypertension (multivariate HR = 1.94; 95% CI 1.11–3.40).
Conclusions
The present findings highlight the importance of considering a diagnostic hypothesis of PTSD in the prevention and treatment of cardiovascular diseases.
Diversity remains low among US colleges faculty, with only 3% identifying as Black or Hispanic. Moreover, underrepresented racial minority faculty often face unique challenges and are less likely than their white counterparts to earn higher academic rank, tenure, and funding, especially those who study health equity. We developed a novel program for health-equity focused pre-docs and junior faculty. The Disparities Researchers Equalizing Access for Minorities (DREAM) Scholars is a 24-month career development program led by the Center for Clinical and Translational Science (CCTS) that provides pilot and travel funding, career development seminars, mentoring, and writing retreats. We report the outcomes of the first Scholar cohort (N = 10), pre-docs n = 6; assistant professors, n = 4; seven were Black, one Hispanic, two White, one who identified as non-binary. At the end of the program, Scholars coauthored 34 manuscripts, 9 abstracts and 8 grants. Semi-structured interviews revealed seven major program strengths: funding, support and sense of community, accountability, exposure to translational science, network expansion, and exposure to multidisciplinary peers. Scholars provided feedback useful for subsequent cohorts. The DREAM program provided accountability and fostered a sense of community, expanded professional networks and enhanced scholarly productivity. The program serves as a model for implementation throughout the CCTSs.
Background:Candida auris is an emerging pathogen that has recently disseminated globally and caused challenging outbreaks in healthcare facilities (HCFs), in part because it is commonly multidrug-resistant. Candida auris remains rare in Canada, with ~20 known cases to date. We describe the emergence of a novel subclade of C. auris in Ontario, Canada, using whole-genome sequencing (WGS). Methods: In Ontario, many HCFs submit yeast isolates from sterile sites requiring species-level characterization and antifungal susceptibility testing (AFST) to the provincial reference laboratory. Yeasts were identified using a combination of standard methods (morphology, API 20C, MALDI-ToF MS) including ITS2 sequencing. Sensititre YO9 panels were used for AFST. Genomic analysis of C. auris was performed using an Illumina HiSeq platform with at least 50× coverage; variants were called against the reference genome by using the previously published North Arizona SNP pipeline (NASP). Phylogenetic trees were produced by maximum parsimony method (MEGA7.0). Results: Between 2014 and 2018, yeast isolates from 5 different patients from 4 HCFs in the same region of Ontario were confirmed to be C. auris by ITS2 PCR and sequence analysis (Table 1). Based on interim CDC criteria for antifungal drug break points, all isolates were pansusceptible to common antifungals. WGS analysis demonstrated that the C. auris isolates were part of the South American clade (IV) and formed an isolated subclade that is well supported by bootstrap analysis, indicating clonal relationships among these isolates (Fig. 1). Conclusions: Although C. auris isolates are usually drug resistant, all 5 initial Ontario isolates were pansusceptible. WGS determined that these isolates clustered within clade IV and were clonal. This cluster of C. auris appears to represent a new subclade of the South American clade that has been transmitted among patients within a region of Ontario. C. auris may have been present in Ontario for some time, escaping earlier detection due to lack of screening programs in HCFs, historical challenges with microbiologic detection of C. auris, and the antifungal susceptibility of the circulating isolates. Investigations are underway to determine clinical features and epidemiologic relatedness among patients in this cluster.
Funding: None
Disclosures: Susy Hota, Contracted Research - Finch Therapeutics
Background: The current approach to measuring hand hygiene (HH) relies on human auditors who capture <1% of HH opportunities and rapidly become recognized by staff, resulting in inflation in performance. Our goal was to assess the impact of group electronic monitoring coupled with unit-led quality improvement on HH performance and prevention of healthcare-associated transmission and infection. Methods: A stepped-wedge cluster randomized quality improvement study was undertaken across 5 acute-care hospitals in Ontario, Canada. Overall, 746 inpatient beds were electronically monitored across 26 inpatient medical and surgical units. Daily HH performance as measured by group electronic monitoring was reported to inpatient units who discussed results to guide unit-led improvement strategies. The primary outcome was monthly HH adherence (%) between baseline and intervention. Secondary outcomes included transmission of antibiotic resistant organisms such as methicillin resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections. Results: After adjusting for the correlation within inpatient units, there was a significant overall improvement in HH adherence associated with the intervention (IRR, 1.73; 95% CI, 1.47–1.99; P < .0001). Monthly HH adherence relative to the intervention increased from 29% (1,395,450 of 4,544,144) to 37% (598,035 of 1,536,643) within 1 month, followed by consecutive incremental increases up to 53% (804,108 of 1,515,537) by 10 months (P < .0001). We identified a trend toward reduced healthcare-associated transmission of MRSA (0.74; 95% CI, 0.53–1.04; P = .08). Conclusions: The introduction of a system for group electronic monitoring led to rapid, significant, and sustained improvements in HH performance within a 2-year period.
Objective:
We investigated whether whole-genome sequencing (WGS) data altered interpretations of clonal transmission as determined by conventional epidemiology and pulsed-field gel electrophoresis (PFGE) at a tertiary-care hospital (hospital Z, HZ). Methods: We included all carbapenemase-producing Enterobacterales (CPE)–colonized or –infected patients identified via population-based surveillance from 2007 through 2018, who were admitted to HZ during and/or in the year prior to or following CPE detection. HZ reported clonal transmission clusters using epidemiology and PFGE for CPE identified at HZ or reported to HZ by other hospitals as potentially acquired at HZ. We assessed single-nucleotide polymorphism (SNP) phylogenies and case epidemiology. Results: Overall, 85 CPE-colonized or -infected patients were included: 50 were detected at HZ and 35 were detected at another local hospital but were admitted to HZ in the previous or following year. HZ reported 6 transmission clusters (Table 1). SNP analyses confirmed clusters B, C, E, and F. In cluster A, SNP analyses cast doubt on 2 of 9 cases (possibly representing plasmid transmission) but also identified 2 additional cases with isolates highly related (0–3 SNP differences) to other isolates. One case may be the index case: a travel-related case who stayed on the same unit as case 1, 4 months before case 1 detection. The second case stayed in a room previously occupied by 5 cluster A cases. In cluster D, SNP analyses found 1 additional case whose isolate was highly related (ie, 17–19 SNP differences) to other isolates. This case was identified a year before cluster D at another hospital that shares patients with HZ; however, the case’s admission to HZ was after all cluster D cases were detected and no direct epidemiologic link was identified. Conclusions: WGS data can identify cases belonging to transmission clusters that conventional epidemiologic methods missed.
Funding: None
Disclosures: Allison McGeer reports funds to her institution from Pfizer and Merck for projects for which she is the principal investigator. She also reports consulting fees from Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara
Background:
Annual influenza immunization of healthcare workers (HCWs) is widely recommended to reduce the risk of healthcare-associated influenza (HAI). Although there is a clear association between higher HCW immunization and reduced incidence of HAI, data in acute care are lacking compared to the nursing home setting. Objective: Our goal was to assess the association between HCW influenza immunization and the incidence of HAI across 2 acute-care facilities. Methods: A multicenter prospective cohort study was undertaken at 2 acute-care hospitals including 1 university and 1 community-based academic hospital. Any patient prospectively identified with HAI was included between 2013–2014 and 2018–2019, whereas 2017–2018 was excluded due to vaccine mismatch. The HCW influenza immunization rate was defined as the proportion of HCWs (nurses and other allied and support staff but excluding physicians) immunized prior to December 15. A case of HAI was defined as laboratory-confirmed influenza A or B with symptom onset >72 hours after admission. The association between inpatient ward HCW influenza immunization rate and the incidence of HAI was compared using a Poisson regression analysis adjusting for hospital and influenza season. Results: Over 5 influenza seasons, the incidences of HAI at either facility were 0.24 and 0.22 per 1,000 patient days, whereas the median HCW influenza immunization rates were 57.3% (IQR, 42.5%–66.4%) and 66.6% (IQR, 50.6%–76.8%), respectively. When adjusting for hospital and influenza season in the multivariate analysis, HCW influenza immunization rates of 65% and 70% were not associated with HAI incidence. In contrast, HCW influenza immunization rates ≥75% was associated with a trend toward reduced HAI (IRR, 0.65; 95% CI, 0.39–1.08; P = .096) whereas inpatient wards above 80% immunization had significantly lower risk of HAI (IRR, 0.28; 95% CI, 0.089–0.89; P = .03). Conclusions: The risk of HAI across 2 acute-care hospitals was significantly lower among inpatient wards achieving HCW influenza immunization rates >80%. Acute-care facilities should aim for this minimum HCW immunization rate to protect patients from the complications of HAI.
The class forcing theorem, which asserts that every class forcing notion
${\mathbb {P}}$
admits a forcing relation
$\Vdash _{\mathbb {P}}$
, that is, a relation satisfying the forcing relation recursion—it follows that statements true in the corresponding forcing extensions are forced and forced statements are true—is equivalent over Gödel–Bernays set theory
$\text {GBC}$
to the principle of elementary transfinite recursion
$\text {ETR}_{\text {Ord}}$
for class recursions of length
$\text {Ord}$
. It is also equivalent to the existence of truth predicates for the infinitary languages
$\mathcal {L}_{\text {Ord},\omega }(\in ,A)$
, allowing any class parameter A; to the existence of truth predicates for the language
$\mathcal {L}_{\text {Ord},\text {Ord}}(\in ,A)$
; to the existence of
$\text {Ord}$
-iterated truth predicates for first-order set theory
$\mathcal {L}_{\omega ,\omega }(\in ,A)$
; to the assertion that every separative class partial order
${\mathbb {P}}$
has a set-complete class Boolean completion; to a class-join separation principle; and to the principle of determinacy for clopen class games of rank at most
$\text {Ord}+1$
. Unlike set forcing, if every class forcing notion
${\mathbb {P}}$
has a forcing relation merely for atomic formulas, then every such
${\mathbb {P}}$
has a uniform forcing relation applicable simultaneously to all formulas. Our results situate the class forcing theorem in the rich hierarchy of theories between
$\text {GBC}$
and Kelley–Morse set theory
$\text {KM}$
.
Point-prevalence surveys for infection or colonization with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae (CREs), and for Clostridium difficile infection (CDI) were conducted in Canadian hospitals in 2010 and 2012 to better understanding changes in the epidemiology of antimicrobial-resistant organisms (AROs), which is crucial for public health and care management.
Methods
A third survey of the same AROs in adult inpatients in Canadian hospitals with ≥50 beds was performed in February 2016. Data on participating hospitals and patient cases were obtained using standard criteria and case definitions. Associations between ARO prevalence and institutional characteristics were assessed using logistic regression models.
Results
In total, 160 hospitals from 9 of the 10 provinces with 35,018 adult inpatients participated in the survey. Median prevalence per 100 inpatients was 4.1 for MRSA, 0.8 for VRE, 1.1 for CDI, 0.8 for ESBLs, and 0 for CREs. No significant change occurred compared to 2012. CREs were reported from 24 hospitals (15%) in 2016 compared to 10 hospitals (7%) in 2012. Routine universal or targeted admission screening for VRE decreased from 94% in 2010 to 74% in 2016. Targeted screening for MRSA on admission was associated with a lower prevalence of MRSA infection. Large hospitals (>500 beds) had higher prevalences of CDI.
Conclusion
This survey provides national prevalence rates for AROs in Canadian hospitals. Changes in infection control and prevention policies might lead to changes in the epidemiology of AROs and our capacity to detect them.
The Pediatric Heart Network designed a career development award to train the next generation of clinician scientists in paediatric-cardiology-related research, a historically underfunded area. We sought to identify the strengths/weaknesses of the programme and describe the scholars’ academic achievements and the network’s return on investment.
Methods
Survey questions designed to evaluate the programme were sent to applicants – 13 funded and 19 unfunded applicants – and 20 mentors and/or principal investigators. Response distributions were calculated. χ2 tests of association assessed differences in ratings of the application/selection processes among funded scholars, unfunded applicants, and mentors/principal investigators. Scholars reported post-funding academic achievements.
Results
Survey response rates were 88% for applicants and 100% for mentor/principal investigators. Clarity and fairness of the review were rated as “clear/fair” or “very clear/very fair” by 98% of respondents, but the responses varied among funded scholars, unfunded applicants, and mentors/principal investigators (clarity χ2=10.85, p=0.03; fairness χ2=16.97, p=0.002). Nearly half of the unfunded applicants rated feedback as “not useful” (47%). “Expanding their collaborative network” and “increasing publication potential” were the highest-rated benefits for scholars. Mentors/principal investigators found the programme “very” valuable for the scholars (100%) and the network (75%). The 13 scholars were first/senior authors for 97 abstracts and 109 manuscripts, served on 22 Pediatric Heart Network committees, and were awarded $9,673,660 in subsequent extramural funding for a return of ~$10 for every scholar dollar spent.
Conclusions
Overall, patient satisfaction with the Scholar Award was high and scholars met many academic markers of success. Despite this, programme challenges were identified and improvement strategies were developed.
Staff training in positive behaviour support (PBS) is a widespread treatment approach for challenging behaviour in adults with intellectual disability.
Aims
To evaluate whether such training is clinically effective in reducing challenging behaviour during routine care (trial registration: NCT01680276).
Method
We carried out a multicentre, cluster randomised controlled trial involving 23 community intellectual disability services in England, randomly allocated to manual-assisted staff training in PBS (n = 11) or treatment as usual (TAU, n = 12). Data were collected from 246 adult participants.
Results
No treatment effects were found for the primary outcome (challenging behaviour over 12 months, adjusted mean difference = −2.14, 95% CI: −8.79, 4.51) or secondary outcomes.
Conclusions
Staff training in PBS, as applied in this study, did not reduce challenging behaviour. Further research should tackle implementation issues and endeavour to identify other interventions that can reduce challenging behaviour.
Children with hypoplastic left heart syndrome are at a risk for neurodevelopmental delays. Current guidelines recommend systematic evaluation and management of neurodevelopmental outcomes with referral for early intervention services. The Single Ventricle Reconstruction Trial represents the largest cohort of children with hypoplastic left heart syndrome ever assembled. Data on life events and resource utilisation have been collected annually. We sought to determine the type and prevalence of early intervention services used from age 1 to 4 years and factors associated with utilisation of services.
Methods
Data from 14-month neurodevelopmental assessment and annual medical history forms were used. We assessed the impact of social risk and geographic differences. Fisher exact tests and logistic regression were used to evaluate associations.
Results
Annual medical history forms were available for 302 of 314 children. Greater than half of the children (52–69%) were not receiving services at any age assessed, whereas 20–32% were receiving two or more therapies each year. Utilisation was significantly lower in year 4 (31%) compared with years 1–3 (with a range from 40 to 48%) (p<0.001). Social risk factors were not associated with the use of services at any age but there were significant geographic differences. Significant delay was reported by parents in 18–43% of children at ages 3 and 4.
Conclusion
Despite significant neurodevelopmental delays, early intervention service utilisation was low in this cohort. As survival has improved for children with hypoplastic left heart syndrome, attention must shift to strategies to optimise developmental outcomes, including enrolment in early intervention when merited.
It has been suggested that offspring of parents with bipolar disorder are at increased risk for disruptive mood dysregulation disorder (DMDD), but the specificity of this association has not been established.
Aims
We examined the specificity of DMDD to family history by comparing offspring of parents with (a) bipolar disorder, (b) major depressive disorder and (c) a control group with no mood disorders.
Method
We established lifetime diagnosis of DMDD using the Schedule for Affective Disorders and Schizophrenia for School Aged Children for DSM-5 in 180 youth aged 6–18 years, including 58 offspring of parents with bipolar disorder, 82 offspring of parents with major depressive disorder and 40 control offspring.
Results
Diagnostic criteria for DMDD were met in none of the offspring of parents with bipolar disorder, 6 of the offspring of parents with major depressive disorder and none of the control offspring. DMDD diagnosis was significantly associated with family history of major depressive disorder.
Conclusions
Our results suggest that DMDD is not specifically associated with a family history of bipolar disorder and may be associated with parental depression.
A few studies have evaluated the impact of clinical trial results on practice in paediatric cardiology. The Infant Single Ventricle (ISV) Trial results published in 2010 did not support routine use of the angiotensin-converting enzyme inhibitor enalapril in infants with single-ventricle physiology. We sought to assess the influence of these findings on clinical practice.
Methods
A web-based survey was distributed via e-mail to over 2000 paediatric cardiologists, intensivists, cardiothoracic surgeons, and cardiac advance practice nurses during three distribution periods. The results were analysed using McNemar’s test for paired data and Fisher’s exact test.
Results
The response rate was 31.5% (69% cardiologists and 65% with >10 years of experience). Among respondents familiar with trial results, 74% reported current practice consistent with trial findings versus 48% before trial publication (p<0.001); 19% used angiotensin-converting enzyme inhibitor in this population “almost always” versus 36% in the past (p<0.001), and 72% reported a change in management or improved confidence in treatment decisions involving this therapy based on the trial results. Respondents familiar with trial results (78%) were marginally more likely to practise consistent with the trial results than those unfamiliar (74 versus 67%, p=0.16). Among all respondents, 28% reported less frequent use of angiotensin-converting enzyme inhibitor over the last 3 years.
Conclusions
Within 5 years of publication, the majority of respondents was familiar with the Infant Single Ventricle Trial results and reported less frequent use of angiotensin-converting enzyme inhibitor in single-ventricle infants; however, 28% reported not adjusting their clinical decisions based on the trial’s findings.