Applying RE-AIM to examine the impact of an implementation facilitation package to scale up a program for Veterans with chronic obstructive pulmonary disease.

BACKGROUND: US Veterans are four times more likely to be diagnosed with chronic obstructive pulmonary disease (COPD) compared to the civilian population with no care model that consistently improves Veteran outcomes when scaled. COPD Coordinated Access to Reduce Exacerbations (CARE) is a care bundle intended to improve the delivery of evidence-based practices to Veterans. To address challenges to scaling this program in the Veterans' Health Administration (VA), the COPD CARE Academy (Academy), an implementation facilitation package comprised of five implementation strategies was designed and implemented. METHODS: This evaluation utilized a mixed-methods approach to assess the impact of the Academy's implementation strategies on the RE-AIM framework implementation outcomes and the extent to which they were effective at increasing clinicians' perceived capability to implement COPD CARE. A survey was administered one week after Academy participation and a semi-structured interview conducted 8 to 12 months later. Descriptive statistics were calculated for quantitative items and thematic analysis was used to analyze open-ended items. RESULTS: Thirty-six clinicians from 13 VA medical centers (VAMCs) participated in the Academy in 2020 and 2021 and 264 front-line clinicians completed COPD CARE training. Adoption of the Academy was indicated by high rates of Academy session attendance (90%) and high utilization of Academy resources. Clinicians reported the Academy to be acceptable and appropriate as an implementation package and clinicians from 92% of VAMCs reported long-term utilization of Academy resources. Effectiveness of the Academy was represented by clinicians' significant increases (p < 0.05) in their capability to complete ten implementation tasks after Academy participation. CONCLUSIONS: This evaluation found that the use of implementation facilitation paired with additional strategies enhanced the capacity of clinicians to implement COPD CARE. Future assessments are needed to explore post-academy resources that would help VAMCs to strategize localized approaches to overcome barriers.

Applying RE-AIM to examine the impact of an implementation facilitation package to scale up a program for Veterans with Chronic Obstructive Pulmonary Disease.

Background: U.S. Veterans are four-times more likely to be diagnosed with Chronic Obstructive Pulmonary Disease (COPD) compared to the civilian population with no care model that consistently improves Veteran outcomes when scaled. COPD Coordinated Access to Reduce Exacerbations (CARE) is a care bundle intended to improve the delivery of evidence-based practices to Veterans. To address challenges to scaling this program in the Veterans' Health Administration (VA), the COPD CARE Academy (Academy), an implementation facilitation package comprised of four implementation strategies was designed and implemented. Methods: This evaluation utilized a mixed-methods approach to assess the impact of the Academy's implementation strategies on the RE-AIM framework implementation outcomes and the extent to which they were effective at increasing clinicians' perceived capability to implement COPD CARE. A survey was administered one week after Academy participation and a semi-structured interview conducted eight to 12 months later. Descriptive statistics were calculated for quantitative items and thematic analysis was used to analyze open-ended items. Results: Thirty-six clinicians from 13 VA medical centers (VAMCs) participated in the Academy in 2020 and 2021 and 264 front-line clinicians completed COPD CARE training. Adoption of the Academy was indicated by high rates of Academy completion (97%), session attendance (90%), and high utilization of Academy resources. Clinicians reported the Academy to be acceptable and appropriate as an implementation package and clinicians from 92% of VAMCs reported long-term utilization of Academy resources. Effectiveness of the Academy was represented by clinicians' significant increases (p < 0.05) in their capability to complete ten implementation tasks after Academy participation. Conclusions: This evaluation found that the use of implementation facilitation paired with additional strategies seemed to demonstrate positive implementation outcomes across all RE-AIM domains and identified areas for potential improvement. Future assessments are needed to explore post-academy resources that would help VAMCs to strategize localized approaches to overcome barriers.

Evaluation of an implementation package to deliver the COPD CARE service.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is estimated to be the leading cause of death in the next 15 years. Patients with COPD suffer from persistent chronic cough, sputum production and exacerbations leading to deteriorating lung function, worsening quality of life and loss of independence. While evidence-based interventions exist to improve the well-being of patients with COPD, incorporation of these interventions into routine clinical care is challenging. Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE) is a team-based, coordinated care transitions service integrating evidence-based interventions for COPD management within the patient care delivery model to reduce readmissions. This evaluation considers the process of scaling the COPD CARE service across medical facilities using an implementation package designed for service expansion. The implementation package was developed at the United States Veterans Health Administration and implemented at two medical centres. Core dissemination and implementation science methods were applied to guide design and delivery of the implementation package.The aims of this evaluation were to (1) evaluate the impact of the implementation package on use of evidence-based interventions for COPD management and (2) explore clinician perceptions of the implementation package. This prospective mixed-methods quality improvement project included two Plan Do Check Act (PDCA) cycles conducted over a 24-month period. Electronic health record data demonstrated significant improvements in the count of evidence-based interventions incorporated into routine clinical care after training completion (p<0.001), offering preliminary effectiveness of the package to improve uptake of best practices for COPD management. Clinician perceptions of the implementation package, measured by questionnaire at multiple time points, demonstrated significant improvements for all scales at the end of the final PDCA cycle. Clinicians described the implementation package as positively impacting clinician confidence, interprofessional collaboration and patient care delivery.

Acquisition of potential reservoirs of nosocomial infection on gadgets and clothing in the dental hospital setting: An epidemiological study.

Introduction: During dental procedures, dental professionals as well as patients are exposed to pathogens and toxic substances, which may be transmitted through direct or indirect contact. Their clothing is visibly soiled during the procedures. Their hands can serve as vectors for the transmission of pathogens. Use of mobiles, laptop, and other gadgets tend to increase the chances of microbial colonization on these surfaces. The objective of the study is to screen for the presence of microorganism the most common items pertaining to our daily personal utility which are being used in the hospital settings, to access the microbial load and their potential hazards. Materials and Methods: In this study, 80 samples were collected from different personal utility items such as white coats, mobiles, hand towels, and laptops. These samples were evaluated for the presence of any microbial colonization on them. Results: All the sampled surfaces showed the presence of microorganisms and all showed polymicrobial growth. Conclusion: These identified surfaces should be cleaned and decontaminated on regular basis to prevent the transmission of pathogens in the dental hospital environment.

Incorporation of Student Pharmacists into a Proton Pump Inhibitor Deprescribing Telehealth Program for Rural Veterans.

Background: Proton pump inhibitors (PPIs) are among the most widely prescribed class of medications in the United States. Although effective in the treatment of acid related disease, inappropriate PPI use is prevalent, and long-term PPI use has been associated with adverse effects. Objectives: This evaluation explores the novelty of a student-pharmacist directed PPI deprescribing telehealth program with the goals of (1) determining whether PPIs are appropriately prescribed in Veterans via remote student-led chart reviews, (2) identifying if a gap exists between urban and rural Veterans prescribed a PPI, and (3) assessing the feasibility of integrating student pharmacists into the PPI deprescribing process utilizing telehealth visits through a pilot study. Methods: Student pharmacists evaluated PPI appropriateness in Veterans at the William S. Middleton Veterans Hospital. Students collected data via remote chart reviews, compared appropriateness of PPI therapy in rural versus urban Veterans, and conducted a deprescribing pilot call study in rural Veterans with inappropriate PPI indications. Clinical decision-making was agreed upon in collaboration with pharmacist preceptors, however all means of communication with Veterans was performed by student pharmacists. Results: 51% of Veterans were found to have an inappropriate indication for their PPI, though comparison of inappropriate PPI use in rural versus urban Veterans was not statistically significant (n=170, p-value 0.34). 83% of Veterans agreed to proceed with PPI deprescribing and 71% of Veterans ended the pilot study with at least some degree of PPI dose reduction (n=33). Conclusion: Inappropriate PPI use among rural and urban Veterans is prevalent, however a significant difference was not observed between the two cohorts. Student pharmacists are capable of successful telehealth deprescribing interventions in collaboration with pharmacists.

Effect of nano-crystalline silver membrane on early wound healing after periodontal surgery: A comparative randomized study.

BACKGROUND: Periodontal dressings are used for wound protection and patient comfort. Nano-silver particles have the ability to promote wound healing through anti-inflammatory properties. Hence, the present study aims to evaluate early wound healing parameters following periodontal surgery using nano-crystalline silver membrane as periodontal dressing. MATERIALS AND METHODS: Forty-two systemically healthy patients diagnosed with chronic periodontitis indicated for periodontal flap surgery were enrolled for the present study. Post surgery, the patients were randomly allocated to either a nano-crystalline silver dressing (Acticoat™) group (test group) or only the noneugenol dressing group (control group). Plaque index (PI) and wound healing index were recorded at the 7th- and 14th-day postsurgery. The microbiological analysis and vascular endothelial growth factor (VEGF) levels were evaluated at baseline and 7th-day postsurgery. RESULTS: The healing index was significantly higher in the test group as compared to the control group at days 7 and 14 (P < 0.001; P < 0.001). The colony-forming units/ml count of bacteria were significantly reduced postsurgery in the test group (P = 0.019). VEGF levels increased significantly 7th-day postsurgery in the test group (P = 0.001). There was no statistically significant difference in the PI on the 7th-day postsurgery between the two groups (P = 0.173). CONCLUSION: The results of the study revealed that silver can be used as a potent periodontal dressing ingredient that can decrease the microbial colonization beneath the pack and promote faster healing postsurgery due to its antimicrobial activity.

Proximal subungual onychomycosis of digitus minimus due to Aspergillus brasiliensis.

Onychomycosis is a common nail infection caused by dermatophytes, non-dermatophytic molds (NDMs) and yeast. Aspergillus spp. are emerging etiological agents of non-dermatophyte mold onychomycosis (NDMO). Though this is usually of cosmetic concern, it may also cause pain and discomfort to the patient. The toenail is more commonly involved as compared to fingernail. The nails are discoloured and disfigured. Onychomycosis may expose the patient to cellulitis of lower extremities. The clinical presentation of dermatophytic and NDM onychomycosis is more or less similar, which creates problem in the diagnosis. Fingernail infection may cause social and psychological problem to the patient if fingernail is involved. Incidence of onychomycosis has been seen more in immunosuppressed individuals, where it is of more serious medical concern. In the present study we are reporting a case of proximal subungual onychomycosis (PSO) due to Aspergillus brasiliensis.

Enterococci in the oral cavity of periodontitis patients from different urban socioeconomic groups.

BACKGROUND: Enterococci are the transient constituents of the oral microbiome and have been now increasingly related to oral and systemic diseases. They have now become the most notable nosocomial pathogens and also been linked to etiology of periodontitis. This study evaluates the prevalence of Enterococci in the chronic periodontitis and healthy Indian cohort in different urban socioeconomic groups. MATERIALS AND METHODS: In this retrospective study, individuals in the age range of 18.75 years were included. Seventy individuals had mild-to-moderate periodontitis and 30 healthy persons were taken as controls. A questionnaire was administered. Paper point samples of gingival crevicular fluid were obtained, pooled, and sent to microbiology laboratory in a transport media. Forty-six isolates were identified as enterococci for statical analyzes Pearson's Chi-square test used and. P < 0.001 was considered to be significant. RESULTS: The prevalence of enterococci was seen mostly in the individuals from lower socioeconomic class, having poor oral hygiene, and smokers. This was significantly different from those of upper class (P < 0.001). The predominant species isolated was Enterococcus faecalis. CONCLUSION: Enterococci particularly E. faecalis followed by Enterococcus faecium could play a crucial role in the severity or progression of periodontitis particularly in a favorable oral environment.

Isolation of a Novel Phage and Targeting Biofilms of Drug-Resistant Oral Enterococci.

INTRODUCTION: Enterococci are now recognized as the second most cause of nosocomial infections worldwide. The emergence of multidrug-resistant strains in the organism has given rise to alternative strategies such as phage therapy. In this study, an Enterococcus faecalis infecting phage was isolated and its efficiency against biofilms formed by drug-resistant enterococci obtained from chronic periodontitis was evaluated. MATERIALS AND METHODS: Bacteriophage against E. faecalis was isolated from sewage sample. The phage was propagated and identified using transmission electron microscope (TEM). In vitro biofilm formation was assessed. RESULTS: TEM microscopy showed that the phage belonged to Siphoviridae family. In the presence of the novel phage, the metabolic activity of enterococci biofilm was reduced at 48 h of contact. A difference of at least 5 log CFU/ml was seen in the live cells of the control biofilm, and the phage treated biofilm of enterococci isolates. CONCLUSION: The study shows that the novel phage inhibits biofilm production in oral enterococci isolates from periodontitis patients but has a narrow host range. The role of bacteriophages as strong biotechnological and natural therapeutic agents for E. faecalis in chronic periodontitis can be considered.

Biofilm Formation by Drug Resistant Enterococci Isolates Obtained from Chronic Periodontitis Patients.

INTRODUCTION: Enterococci are an important cause of opportunistic nosocomial infections and several multidrug resistant strains have emerged. The severity of periodontal diseases is managed by reduction in the pathogenic bacteria. There is a need to assess the prevalence and antibiotic susceptibility of enterococci colonizing the periodontal pocket and correlate its biofilm formation ability because oral biofilms provide a protective environment and are a reservoir of bacterial colonization of the gingival crevice. AIM: To investigate possible association between antibiotic susceptibility and biofilm formation in enterococci isolates from chronic periodontitis patients. MATERIALS AND METHODS: This retrospective study was conducted at Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Punjab University, Chandigarh from January 2015 to October 2015. Sterile paper points were inserted in the periodontal pocket of 100 subjects and put in a transport media. Forty -six isolates were identified as enterococci. The isolates were further examined for their ability to form biofilm by microtitre plate assay and antimicrobial susceptibility testing was done by disc diffusion method for clinically relevant antibiotics. RESULTS: Significant relationship (p<0.001) was found between biofilm production with antibiotic resistance to Vancomycin, Erythromycin, Ciprofloxacin, Tiecoplanin, Amoxycillin and Gentamycin. CONCLUSION: The study demonstrates a high propensity among the isolates of Enterococci to form biofilm and a significant association of biofilm with multiple drug resistance.

Susceptibility of Urinary Tract Bacteria to Newer Antimicrobial Drugs.

Urinary tract infections (UTIs) are among the commonest types of bacterial infections. The antibiotic treatment for UTIs is associated with important medical and economic implications. Many different microorganisms can cause UTIs though the most common pathogens are E. coli and members of family Enterobacteriaceae. The knowledge of etiology and antibiotic resistance pattern of the organisms causing urinary tract infection is essential. The present study was undertaken to evaluate trends of antibiotic susceptibility of commonly isolated uropathogens using newer antimicrobial agents, prulifloxacin, fosfomycin (FOM) and doripenem. We conclude that maintaining a record of culture results and the antibiogram may help clinicians to determine the empirical and/or specific treatment based on the antibiogram of the isolate for better therapeutic outcome.

Nanotechnology: role in dental biofilms.

Biofilms are surface-adherent populations of microorganisms consisting of cells, water and extracellular matrix material Nanotechnology is promising field of science which can guide our understanding of the role of interspecies interaction in the development of biofilm. Streptococcus mutans with other species of bacteria has been known to form dental biofilm. The correlation between genetically modified bacteria Streptococcus mutans and nanoscale morphology has been assessed using AFMi.e atomic force microscopy. Nanotechnology application includes 16O/18O reverse proteolytic labeling,use of quantum dots for labeling of bacterial cells, selective removal of cariogenic bacteria while preserving the normal oral flora and silver antimicrobial nanotechnology against pathogens associated with biofilms. The future comprises a mouthwash full of smart nanomachines which can allow the harmless flora of mouth to flourish in a healthy ecosystem.

Putative structure and characteristics of a red water-soluble pigment secreted by Penicillium marneffei.

The dimorphic fungus, Penicillium marneffei, produces and secretes a brick red pigment, during growth at temperatures below 30 degrees C. It generally diffuses into commonly used media like Sabouraud dextrose agar and malt extract agar. The pigment was purified by reverse-phase liquid chromatography and subjected to structural determination by elemental and spectral analysis using atomic absorption (AAS), ultra violet and visible (UV-VIS), fluorescence, infra red (IR), nuclear magnetic resonance (NMR) and tandem mass spectrometry (MS-MS). The pigment showed a buffering ability in aqueous solutions, maintaining an alkaline pH of 8.0. It behaved as a colorimetric pH indicator over a wide acidic and alkaline pH range, with discoloration occurring ostensibly through hydrolysis of key chemical groups at extremely acidic pH ( approximately 2.0). The pigment was found to have some structural resemblance with the copper-colored pigment (herquinone) produced by Penicillium herquei as both pigments contain the phenalene carbon framework. The notable differences between herquinone and the pigment produced by P. marneffei are (i) the latter's apparent dimerization through a sulphur-sulphur (disulfide) bond and (ii) the presence of 1,1,3,3-tetramethyl-2,3-dihydropyrrole moiety in the latter instead of 2,3,3-trimethyl-2,3-dihydrofuran moiety found in the former. The delineation of the structure of the pigment produced by Penicillium marneffei may help in understanding certain aspects of the biology of this pathogenic fungus.

PCR-based identification and strain typing of Pichia anomala using the ribosomal intergenic spacer region IGS1.

Frequent outbreaks of Pichia anomala fungaemia in paediatric patients have warranted the development of a rapid identification system for this organism. This study describes a specific PCR-based method targeting the rRNA gene intergenic spacer region 1 (IGS1) for rapid identification of Pichia anomala isolates and characterization at the strain level. These methods of species identification and strain typing were used on 106 isolates of Pichia anomala (77 from a previously described outbreak and 29 isolated post-outbreak from the same hospital). Using conventional morphological and biochemical methods, 11 strains isolated during the outbreak were misidentified as P. anomala. blast analysis of sequences of internal transcribed spacer (ITS) regions of rRNA genes confirmed that they were Pichia guilliermondii (eight isolates) and Debaryomyces hansenii (three isolates). Strain typing of Pichia anomala isolates confirmed the previous finding of a point-source outbreak. The results suggest that IGS sequences and their polymorphisms could be exploited for similar typing methods in other organisms.

Protection in a mouse peritonitis model mediated by iron-regulated outer-membrane protein of Salmonella typhi coupled to its Vi antigen.

Vi polysaccharide and iron-regulated outer-membrane proteins (IROMPs) were extracted and purified from the standard strain of Salmonella typhi, Ty2. These were then conjugated by chemical coupling using the carbodimide method. Vi-IROMP conjugate was tested for its ability to protect against colonization by S. typhi in different organs. Mice immunized with 2.5 microg Vi-IROMP conjugate showed the most protection, as the least bacterial colonization of spleen, liver and Peyer's patches was observed. Peritoneal macrophages obtained from conjugate-treated mice phagocytosed bacteria efficiently. Circulating antibodies and the delayed type hypersensitivity response elucidated by mouse foot-pad swelling was significantly higher in conjugate-treated animals. These results clearly demonstrate that an IROMP and polysaccharide conjugate of S. typhi prepared from the same strain has the potential to protect animals against challenge.