Overuse of sedation and anesthesia causes delays in gastrojejunostomy tube (GJ) exchanges, increased risk of complications, unnecessary use of resources, preventable hospital admissions, and an ...adverse impact on patient and family experience. Our hospital was over-utilizing sedation and anesthesia, and we aimed to decrease this use from 78% to 20% within two years.
An interdisciplinary quality improvement team comprehensively evaluated current processes for GJ tube exchanges through a retrospective chart review for baseline data with prospective time series analysis after improvement implementation. The primary outcome measure was the percentage of pediatric patients that utilized sedation or anesthesia for routine GJ tube exchanges.
A statistical process control p-chart was used to calculate and show changes over time for patients (n = 45 patients average). The median percent of pediatric GJ tube exchanges performed with sedation or anesthesia decreased from 77.8% to 11.3%. Most patients (76%) were covered by Medicaid programs; with low reimbursement rates, decreased anesthesiologist billing revenue does not have a negative financial impact.
An interprofessional improvement initiative that engaged patients and families, incorporated pediatric-specific staff services, and developed systematic weaning was associated with a significant decrease in the overuse of sedation and anesthesia for GJ tube exchanges.
We believe that this work is highly relevant and impactful for medical centers caring for children who require gastrojejunostomy tubes, an increasingly common approach to management of children with feeding issues. There is very little literature available on the use of sedation or anesthesia for changing these tubes. While large children's medical centers in the USA usually do not utilize sedation or anesthesia, there are likely many serious outliers, especially when children receive care outside of a pediatric specific institution. This paper brings awareness to this serious issue and provides information about how we changed care to achieve higher patient safety and lower medical costs.
In a prospective genomic surveillance study of liver transplant patients, we found that temporal dynamics differed between multidrug-resistant organisms with respect to onset of intestinal ...colonization, clearance, and infections. Whole-genome sequencing revealed an unexpected diversity of carbapenem-resistant Enterobacteriaceae.
Abstract
Background
Multidrug-resistant organisms (MDROs) are an important cause of morbidity and mortality after solid organ transplantation. We aimed to characterize MDRO colonization dynamics and infection in liver transplant (LT) recipients through innovative use of active surveillance and whole-genome sequencing (WGS).
Methods
We prospectively enrolled consecutive adult patients undergoing LT from March 2014 to March 2016. Fecal samples were collected at multiple timepoints from time of enrollment to 12 months posttransplant. Samples were screened for carbapenem-resistant Enterobacteriaceae (CRE), Enterobacteriaceae resistant to third-generation cephalosporins (Ceph-RE), and vancomycin-resistant enterococci. We performed WGS of CRE and selected Ceph-RE isolates. We also collected clinical data including demographics, transplant characteristics, and infection data.
Results
We collected 998 stool samples and 119 rectal swabs from 128 patients. MDRO colonization was detected in 86 (67%) patients at least once and was significantly associated with subsequent MDRO infection (0 vs 19.8%, P = .002). Child-Turcotte-Pugh score at LT and duration of post-LT hospitalization were independent predictors of both MDRO colonization and infection. Temporal dynamics differed between MDROs with respect to onset of colonization, clearance, and infections. We detected an unexpected diversity of CRE colonizing isolates and previously unrecognized transmission that spanned Ceph-RE and CRE phenotypes, as well as a cluster of mcr-1-producing isolates.
Conclusions
Active surveillance and WGS showed that MDRO colonization is a highly dynamic and complex process after LT. Understanding that complexity is crucial for informing decisions regarding MDRO infection control, use of therapeutic decolonization, and empiric treatment regimens.
Cognitive behavior therapy (CBT) has been applied in intervention research in diabetes patients with satisfying results. However, there was no research on type 2 diabetes (T2DM) patients with ...comorbidities. This study aimed to investigate the effectiveness of CBT on psychological variables, behavior variables, quality of life, sleep quality, and physical variables among adult T2DM patients with comorbid metabolic syndrome (MS).
281 patients aged 18-75 years were recruited from Ningbo First Hospital in China from October 2021 to March 2022. Patients were randomized to the intervention group (IG, N = 148) or control group (CG, N = 133). Patients in the IG received 12 CBT-based sessions during a six-month intervention time. Patients in the CG received the usual care only. Univariate General Linear Model was used to analyze the effect of CBT-based interventions. The analysis was conducted by SPSS Version 28.
Results indicated that CBT-based intervention was superior in the following aspects: relieving depression symptoms: IG (4.11 ± 4.35 vs. 1.99 ± 2.12), CG (3.40 ± 3.26 vs. 2.32 ± 1.88), interaction effect (F = 4.074, P = 0.044); enhancing diabetes self-care behaviors: IG (26.79 ± 12.18 vs. 37.49 ± 10.83), CG (25.82 ± 13.71 vs. 31.96 ± 11.72), interaction effect (F = 5.242, P = 0.022); promoting the efficacy of CBT: IG (47.45 ± 6.83 vs. 50.76 ± 4.98), CG (46.74 ± 6.94 vs. 47.87 ± 5.11), interaction effect (F = 5.198, P = 0.023); improving subjective sleep quality: IG (0.93 ± 0.68 vs. 0.69 ± 0.63), CG (1.03 ± 0.72 vs. 1.01 ± 0.68), interaction effect (F = 3.927, P = 0.048).
The CBT-based intervention was beneficial in improving depression symptoms, diabetes self-care behaviors, the efficacy of CBT, and sleep quality in T2DM patients with comorbid MS. The downtrend of body mass index, systolic blood pressure, diastolic pressure, and glycated hemoglobin was larger in the intervention group but not to a significant level.
This study has been prospectively registered at Australia New Zealand Clinical Trials Registry (Registration ID: ACTRN12621001348842 website: https://www.anzctr.org.au/trial/MyTrial.aspx ).
Methicillin-susceptible Staphylococcus aureus (MSSA) is a more prevalent neonatal intensive care unit (NICU) pathogen than methicillin-resistant S. aureus (MRSA). However, the introduction and spread ...of MSSA, the role of systematic decolonization, and optimal infection prevention and control strategies remain incompletely understood. We previously screened infants hospitalized in a university-affiliated level III to IV NICU twice monthly over 18 months for S. aureus colonization and identified several prevalent staphylococcal protein A (
) types. Here, we performed whole-genome sequencing (WGS) and phylogenetic comparisons of 140 isolates from predominant
types t279, t1451, and t571 to examine possible transmission routes and identify genomic and epidemiologic features associated with the spread of dominant clones. We identified two major MSSA clones: sequence type 398 (ST398), common in the local community, and ST1898, not previously encountered in the region. ST398 NICU isolates formed distinct clusters with closely related community isolates from previously published data sets, suggesting multiple sources of acquisition, such as family members or staff, including residents of the local community. In contrast, ST1898 isolates were nearly identical, pointing to clonal expansion within the NICU. Almost all ST1898 isolates harbored plasmids encoding mupirocin resistance (
), suggesting an association between the proliferation of this clone and decolonization efforts with mupirocin. Comparative genomics indicated genotype-specific pathways of introduction and spread of MSSA via community-associated (ST398) or health care-associated (ST1898) sources and the potential role of mupirocin resistance in dissemination of ST1898. Future surveillance efforts could benefit from routine genotyping to inform clone-specific infection prevention strategies.
Methicillin-susceptible Staphylococcus aureus (MSSA) is a significant pathogen in neonates. However, surveillance efforts in neonatal intensive care units (NICUs) have focused primarily on methicillin-resistant S. aureus (MRSA), limiting our understanding of colonizing and infectious MSSA clones which are prevalent in the NICU. Here, we identify two dominant colonizing MSSA clones during an 18-month surveillance effort in a level III to IV NICU, ST398 and ST1898. Using genomic surveillance and phylogenetic analysis, coupled with epidemiological investigation, we found that these two sequence types had distinct modes of spread, namely the suggested exchange with community reservoirs for ST398 and the contribution of antibiotic resistance to dissemination of ST1898 in the health care setting. This study highlights the additional benefits of whole-genome surveillance for colonizing pathogens, beyond routine species identification and genotyping, to inform targeted infection prevention strategies.
Premise of the study: The Million Orchid Project at Fairchild Tropical Botanic Garden is an initiative to propagate native orchids for reintroduction into Miami's urban landscapes. The aim of this ...study was to develop microsatellites for Encyclia tampensis and Cyrtopodium punctatum (Orchidaceae). Methods and Results: Ten microsatellites were developed for each species. For E. tampensis sampled from the natural population, allele numbers ranged from one to four, with an average observed heterozygosity (Ho) of 0.314 and average expected heterozygosity (He) of 0.281. For the individuals from cultivation, allele numbers ranged from one to six, with an average Ho of 0.35 and an average He of 0.224. For C. punctatum, allele numbers ranged from one to three, with an average Ho of 0.257 and an average He of 0.272. Conclusions: These microsatellites will be used to assess the genetic diversity of natural and cultivated populations with the intention of guiding genetic breeding under the Million Orchid Project.
•The CBT-based intervention has a positive effect on health outcomes in diabetic patients.•CBT-based interventions might be significantly effective for blood glucose management in diabetic patients ...when it is delivered as the group-based and face-to-face treatment method.•CBT-based intervention might be significantly effective when the psycho-education, behavioral strategies, cognitive strategies, goal-setting, and homework assignment strategies are applied as central strategies.
This meta-analysis aims to update former meta-analyses from randomized controlled trials (RCT) focused on the efficacy of CBT for diabetes.
Five databases were searched for RCTs. Primary outcomes were glycated hemoglobin (HbA1c), fasting blood glucose (FBS), systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI). Secondary outcomes were depression, anxiety and distress symptoms, quality of life, sleep quality.
32 RCTs were included. Results revealed that CBT could reduce HbA1c: −0.14% (95% CI: −0.25 to −0.02%, P = 0.020); FBS: −15.48 mg/dl (95% CI: −30.16 to −0.81 mg/dl, P = 0.040); DBP: −2.88 mmHg (95% CI: −4.08 to −1.69 mmHg, P < 0.001); depression symptoms: −0.90 (95% CI: −1.22 to −0.57, P < 0.001); anxiety symptoms: −0.28 (95% CI: −0.50 to −0.07, P = 0.009); improve sleep quality: −0.92 (95% CI: −1.77 to −0.07, P = 0.030). Subgroup analysis indicated that CBT has siginificantly reduced HbA1c when delivered as a group-based and face-to-face method, and psycho-education, behavioral, cognitive, goal-setting, homework assignment strategies were applied as central strategies.
CBT was an effective treatment for diabetes patients, significantly reduced their HbA1c, FBS, DBP, depression and anxiety symptoms, and improved sleep quality.
Abstract Many adolescents feel they are subjected to acts of discrimination. Research shows that discrimination is associated with adverse outcomes including poor psychological adjustment, school ...adjustment, and academic achievement. This study investigated alternative pathways through which discrimination affects adolescents' academic achievement. A sample of 244 Year 7–10 Australian secondary school students (65% male; Mage = 13.6 years; SD = 1.24) completed questionnaires measuring discrimination, psychological adjustment, and sense of school membership. Both at the time of questionnaire completion and one semester later, absenteeism data, teacher ratings of classroom behavior, and academic grades were retrieved from school records. The fit of four competing structural models were compared. In the best fitting model, the effects of prior discrimination on academic achievement one semester later were serially mediated, first through psychological adjustment, and then through school adjustment. By elucidating these mechanisms, the study informs theory and practice regarding the effects of discrimination on adolescents.
Purpose
In occupational rehabilitation, the biopsychosocial model endorses the role of social factors in worker recovery. We conducted a systematic review to explore three questions examining the ...role of social support for the return-to-work (RTW) of individuals with work-related injury: (1) What are the worker-identified social barriers and facilitators in RTW; (2) What is the relationship between social factors and RTW; and (3) What is the effectiveness of social interventions for RTW.
Methods
Systematic searches of six databases were conducted for each research question. These identified 11 studies meeting inclusion criteria for Research Question 1, and 12 studies for Research Question 2. No studies were identified that met inclusion criteria for Research Question 3. A narrative synthesis approach was used to analyse the included studies.
Results
Research Question 1 identified five themes in social barriers and facilitators to RTW, including
contact
/
communication, person-centred approaches, mutual trust, reaction to injury
, and
social relationships
. Research Question 2 identified moderate support for
reaction to injury
and
social integration
/
functioning
as predictors of RTW and weak evidence for
co-worker support
. Four studies reported significant associations between social factors and RTW, six reported mixed findings with at least one significant social predictor, and two found no significant relationships. However, conclusions were limited by the inconsistency in measurement of social factors.
Conclusions
Our findings indicate that social support and integration may influence RTW following work-related injury, and highlights the need for further systematic examination of social factors in the field of occupational rehabilitation.
Passenger hostility is commonplace in the transit industry. However, research investigating this job stressor is limited in both scope and quality. This systematic review examines three questions ...regarding passenger hostility: (a) what is its occurrence (incidence and prevalence); (b) what are its consequences; and (c) what factors are related to its occurrence, intensity, or consequences? Six databases were searched for studies published between 2010 and 2020 reporting the occurrence, consequences, or correlates of passenger hostility directed toward transit workers. Risk of bias was categorized using the Critical Appraisal Skills Programme. Results were summarized in tables and narratively synthesized. Nineteen eligible studies (10 quantitative and nine qualitative or mixed methods) were identified. Evidence from 14 studies indicated that passenger hostility occurs frequently, and is often underreported, especially in its less severe forms. Sixteen studies reported correlates of the occurrence, intensity, or consequences of hostility, with these grouped into worker, passenger, organizational, environmental, and event categories. Immediate and long-term impacts were identified in ten studies. This review contributes to understanding the likely antecedents, correlates and consequences of passenger hostility directed at transit industry workers. It also highlights some common methodological limitations in past research and proposes solutions to them. As such, the paper provides suggestions for future explorations and intervention targets aimed at reducing this common workplace stressor.
Previous open-label studies showed that chronic post-stroke pain could be abated by treatment with perispinal etanercept, although these benefits were questioned. A randomized double-blind placebo ...controlled clinical trial was conducted to test perispinal etanercept for chronic post-stroke pain.
Participants received two treatments, either perispinal etanercept (active) or saline (control). Primary outcomes were the differences in daily pain levels between groups analyzed by SPSS.
On the 0-100 points visual analog scale, perispinal etanercept reduced mean levels for worst and average daily pain from baseline after two treatments by 19.5 - 24 points (p < 0.05), and pain alleviation was maintained in the etanercept group, with no significant change in the control group. Thirty percent of etanercept participants had near complete pain abatement after first treatment. Goniometry of the paretic arm showed improved mean shoulder rotation by 55 degrees in active forward flexion for the etanercept group (p = 0.003) only.
Perispinal etanercept can provide significant and ongoing benefits for the chronic post-stroke management of pain and greater shoulder flexion by the paretic arm. Effects are rapid and highly significant, supporting direct action on brain function.
ACTRN12615001377527 and Universal Trial Number U1111-1174-3242.
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