Implementing a Quality Intervention to Improve Confidence in Outpatient Venous Thromboembolism Management.

INTRODUCTION: Guidelines recommend that patients with acute venous thromboembolism (VTE) represented by low-risk deep vein thrombosis (DVT) and pulmonary embolism (PE) receive initial treatment at home versus at the hospital, but a large percentage of these patients are not managed at home. This study assessed the effectiveness of a quality intervention on provider knowledge and confidence in evaluating outpatient treatment for patients with VTE in the emergency department (ED). METHODS: A pilot program to overcome obstacles to outpatient VTE treatment in appropriate patients was initiated at Baylor Scott & White Health Temple ED. Subsequently, a formalized quality intervention with a targeted educational program was developed and delivered to ED providers. Provider surveys were administered pre- and post-quality intervention in order to assess clinical knowledge, confidence levels, and perceived barriers. Patient discharge information was extracted from electronic health records. RESULTS: Twenty-five ED providers completed the pre- and post-surveys; 690 and 356 patients with VTE were included in the pre- and post-pilot and pre- and post-quality intervention periods, respectively. Many ED providers reported that a major barrier to discharging patients to outpatient care was the lack of available and adequate patient follow-up appointments. Notably, after the quality intervention, an increase in provider clinical knowledge and confidence scores was observed. Discharge rates for patients with VTE increased from 25.6% to 27.5% after the pilot intervention and increased from 28.5% to 29.9% after the quality intervention, but these differences were not statistically significant. Despite instantaneous uptick in discharge rates after the interventions, there was not a long-lasting effect. CONCLUSION: Although the quality intervention led to improvements in provider clinical knowledge and confidence and identified barriers to discharging patients with VTE, discharge rates remained stable, underscoring the need for additional endeavors.

When patients develop blood clots in their veins or have blood clots travel to their lungs, they may seek treatment at the hospital emergency department. As a best practice, most people can treat blood clots with medicines at home; however, many patients are treated at the hospital. This study looked at how an education program for doctors in the hospital could help more patients be treated at home. The education program improved doctors' knowledge and confidence when evaluating patients with blood clots who could be treated at home. However, this study found that the number of patients treated at home was the same before and after the doctors participated in the education program. Two major problems that prevented patients from being treated at home were not having follow-up appointments readily available and patients taking their medicine as needed. More and different types of programs may help doctors understand the best ways to treat patients with blood clots in the emergency department.

Associations between clinical and social factors and anticoagulant prescription among patients with atrial fibrillation: A retrospective cohort study from a large healthcare system.

BACKGROUND: Patient clinical factors and social determinants of health (SDOH) are associated with an increased risk of stroke for patients with atrial fibrillation (AF); however, the association between these factors and the management of AF is not well characterized, particularly among those factors commonly collected in electronic health records (EHRs). This study used EHR data to evaluate the associations between patient clinical factors and SDOH and prescribing of an oral anticoagulant (OAC) for stroke prevention in AF. METHODS: This analysis included adult patients with newly diagnosed AF who had ≥2 encounters in the Advocate Aurora Health system in Wisconsin between May 2016 and May 2021. Patient-level demographics, comorbidities, medications, and SDOH were retrospectively extracted from EHRs. Area deprivation index (ADI) was linked to patient records as a measure of socioeconomic status. RESULTS: Of 16,656 patients with AF, 10,898 (65.4%) were prescribed an OAC within the first year of diagnosis. Patients were less likely to be prescribed an OAC (relative risk [95% CI]) if they were widowed (0.98 [0.96-0.99] vs single) or had a history of alcoholism (0.86 [0.79-0.95] vs no history). Most patients (53.3%) received prescriptions from a primary care provider. A linear relationship was found between worsening ADI and increased prescriptions for warfarin vs those for direct-acting OACs. CONCLUSIONS: Although guideline-concordant anticoagulant use remained suboptimal, clinical characteristics were strongly associated for whether a patient with AF would be prescribed an OAC. Disparities in patient care regarding the prescribing of OACs due to SDOH and associated behaviors were small but present, particularly for national ADI.

The fast camera (Fastcam) imaging diagnostic systems on the DIII-D tokamak.

Two camera systems are installed on the DIII-D tokamak at the toroidal positions of 90° (90° system) and 225° (225° system), respectively. The cameras have two types of relay optics, namely, a coherent optical fiber bundle and a periscope system. The periscope system provides absolute intensity calibration stability while sacrificing resolution (10 lp/mm), while the fiber system provides high resolution (16 lp/mm) while sacrificing calibration stability. The periscope is available only for the 90° system. The optics of the 225° system were designed for view stability, repeatability, and easy maintenance. The cameras are located inside optimized neutron, x ray and magnetic shielding in order to reduce electronics damage, reboots, and magnetic and neutron interference, increasing the overall system reliability. An automated filter wheel, providing remote filter change, allows for remote wavelength selection. A software suite automates camera acquisition and data storage, allowing for remote operation and reduced operator involvement. System metadata is used to streamline the data analysis workflow, particularly for intensity calibration. The spatial calibration uses multiple observable wall features, resulting in a reconstruction accuracy ≤2 cm.

Exploring current undergraduate student perspectives on the introduction of the degree apprenticeship scheme in diagnostic radiography - a single institution study.

INTRODUCTION: The first degree apprenticeship programme in diagnostic radiography was launched in March 2020. This route into radiography runs in parallel with 'conventional' pre-registration programmes where students apply to a higher education institution (HEI) and undertake discrete clinical placements. The aim of this study was to explore the perspectives of pre-registration students on the diagnostic radiographer degree apprenticeship route. METHODS: A qualitative approach (online questionnaire) gathered attitudes and opinions of pre-registration students from a single HEI, regarding the degree apprenticeship programme. Participants were pre-registration medical imaging students from all stages of the programme (n = 204). Braun and Clarks's thematic analysis was employed for data analysis. RESULTS: A response rate of 21% (n = 44) was recorded. Four themes emerged from data analysis: (1) misunderstandings surrounding the degree apprenticeship, (2) financial implications and (3) practical experience associated with both degree courses and (4) the experience the pre-registration degree has to offer. CONCLUSION: There was an apparent lack of understanding regarding the degree apprenticeship leading students to misinterpret aspects of the course. Additionally, students highlighted the earning aspect of the apprenticeship to be an advantage in comparison to student debts associated with the traditional pre-registration programmes. Furthermore, students emphasised the advantage of the clinical focus practice associated with the degree apprenticeship. Nevertheless, students who have selected the HEI route still value what the traditional pre-registration degree offers. IMPLICATIONS FOR PRACTICE: As degree apprenticeship programmes become widely available, a greater awareness should, therefore, follow. In the interim, there is scope for HEIs to seek to raise awareness of degree apprenticeship provision. HEIs should seek to allay any concerns and highlight the benefits of having this alternative route into the profession.

Placental characteristics and risks of maternal mortality 50 years after delivery.

INTRODUCTION: Adverse pregnancy outcomes such as preterm delivery and preeclampsia are associated with a higher maternal risk for subsequent cardiovascular disease (CVD) and all-cause mortality. While such pregnancy conditions are related to abnormal placentation, little research has investigated whether pathologic placental measures could serve as a risk factor for future CVD mortality in mothers. METHODS: Longitudinal study of 33,336 women from the Collaborative Perinatal Project (CPP; 1959-1966) linked to mortality information through December 2016. Pathologists took extensive morphological and histopathological measures. Apart from assessing associations with morphological features, we derived an overall composite score and specific inflammation-related, hemorrhage-related, and hypoxia-related pathologic placenta index scores. Cox regression estimated hazard ratios (HR) and 95% confidence intervals (CI) for mortality adjusting for covariates. RESULTS: Thirty-nine percent of women died with mean (standard deviation, SD) time to death of 39 (12) years. Mean (SD) placental weight and birthweight were 436 g (98) and 3156 g (566), respectively. Placenta-to-birthweight ratio was associated with all-cause mortality (adjusted HR 1.03: 1.01, 1.05 per SD in ratio). In cause-specific analyses, it was significantly associated with respiratory (HR 1.06), dementia (HR: 1.10) and liver (HR 1.04) related deaths. CVD, cancer, diabetes and kidney related deaths also tended to increase, whereas infection related deaths did not (HR 0.94; 0.83, 1.06). Placental measures of thickness, diameters, and histopathological measures grouped by inflammatory, hemorrhagic, or hypoxic etiology were not associated with mortality. DISCUSSION: Placental weight in relation to birthweight was associated with long-term maternal mortality but other histopathologic or morphologic features were not.

Hemispheric asymmetry in ocean change and the productivity of ecosystem sentinels.

Climate change and other human activities are causing profound effects on marine ecosystem productivity. We show that the breeding success of seabirds is tracking hemispheric differences in ocean warming and human impacts, with the strongest effects on fish-eating, surface-foraging species in the north. Hemispheric asymmetry suggests the need for ocean management at hemispheric scales. For the north, tactical, climate-based recovery plans for forage fish resources are needed to recover seabird breeding productivity. In the south, lower-magnitude change in seabird productivity presents opportunities for strategic management approaches such as large marine protected areas to sustain food webs and maintain predator productivity. Global monitoring of seabird productivity enables the detection of ecosystem change in remote regions and contributes to our understanding of marine climate impacts on ecosystems.

Meeting Report: WHO Workshop on modelling global mortality and aetiology estimates of enteric pathogens in children under five. Cape Town, 28-29th November 2018.

Investment in vaccine product development should be guided by up-to-date and transparent global burden of disease estimates, which are also fundamental to policy recommendation and vaccine introduction decisions. For low- and middle-income countries (LMICs), vaccine prioritization is primarily driven by the number of deaths caused by different pathogens. Enteric diseases are known to be a major cause of death in LMICs. The two main modelling groups providing mortality estimates for enteric diseases are the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, Seattle and the Maternal Child Epidemiology Estimation (MCEE) group, led by Johns Hopkins Bloomberg School of Public Health. Whilst previous global diarrhoea mortality estimates for under five-year-olds from these two groups were closely aligned, more recent estimates for 2016 have diverged, particularly with respect to numbers of deaths attributable to different enteric pathogens. This has impacted prioritization and investment decisions for vaccines in the development pipeline. The mission of the Product Development for Vaccines Advisory Committee (PDVAC) at the World Health Organisation (WHO) is to accelerate product development of vaccines and technologies that are urgently needed and ensure they are appropriately targeted for use in LMICs. At their 2018 meeting, PDVAC recommended the formation of an independent working group of subject matter experts to explore the reasons for the difference between the IHME and MCEE estimates, and to assess the respective strengths and limitations of the estimation approaches adopted, including a review of the data on which the estimates are based. Here, we report on the proceedings and recommendations from a consultation with the working group of experts, the IHME and MCEE modelling groups, and other key stakeholders. We briefly review the methodological approaches of both groups and provide a series of proposals for investigating the drivers for the differences in enteric disease burden estimates.

Treatment of feline patellar luxation with polyethylene sulcal ridge prostheses.

Patellar luxation and associated pelvic limb lameness were treated with polyethylene sulcal ridge augmentation prostheses in four cats. In all cases, the lameness resolved within weeks of a single surgery. No important complications were encountered. On radiographs obtained at least 2 years postoperatively, three cases showed radiographic progression of degenerative joint disease, and one showed evidence of screw loosening, but these were not reflected in apparent lameness and no case required revision.

Chronic activation of anti-oxidant pathways and iron accumulation in epileptogenic malformations.

AIMS: Oxidative stress is evident in resected epileptogenic brain tissue of patients with developmental brain malformations related to mammalian target of rapamycin activation: tuberous sclerosis complex (TSC) and focal cortical dysplasia type IIb (FCD IIb). Whether chronic activation of anti-oxidant pathways is beneficial or contributes to pathology is not clear. METHODS: We investigated oxidative stress markers, including haem oxygenase 1, ferritin and the inflammation associated microRNA-155 in surgically resected epileptogenic brain tissue of TSC (n = 10) and FCD IIb (n = 8) patients and in a TSC model (Tsc1GFAP-/- mice) using immunohistochemistry, in situ hybridization, real-time quantitative PCR and immunoblotting. Using human foetal astrocytes we performed an in vitro characterization of the anti-oxidant response to acute and chronic oxidative stress and evaluated overexpression of the disease-relevant pro-inflammatory microRNA-155. RESULTS: Resected TSC or FCD IIb tissue displayed higher expression of oxidative stress markers and microRNA-155. Tsc1GFAP-/- mice expressed more microRNA-155 and haem oxygenase 1 in the brain compared to wild-type, preceding the typical development of spontaneous seizures in these animals. In vitro, chronic microRNA-155 overexpression induced haem oxygenase 1, iron regulatory elements and increased susceptibility to oxidative stress. Overexpression of iron regulatory genes was also detected in patients with TSC, FCD IIb and Tsc1GFAP-/- mice. CONCLUSION: Our results demonstrate that early and sustained activation of anti-oxidant signalling and dysregulation of iron metabolism are a pathological hallmark of FCD IIb and TSC. Our findings suggest novel therapeutic strategies aimed at controlling the pathological link between both processes.

Barriers and opportunities experienced by staff when implementing infection prevention and control guidelines during labour and delivery in healthcare facilities in Nigeria.

BACKGROUND: Infections account for 15% of neonatal deaths and one-tenth of maternal mortality globally. Evidence-based practices to prevent and control infection are essential to reduce newborn and maternal mortality. AIM: To identify the barriers and opportunities experienced by staff when implementing infection prevention and control (IPC) guidelines in maternity wards and delivery units in six health centres in two states in Nigeria. METHODS: A structured survey was undertaken in the maternity ward and delivery unit of six healthcare facilities to assess critical infrastructure and equipment. A survey was completed with the matron to assess staff practices and quality assurance procedures. Data were triangulated with qualitative data from interviews with facility staff. FINDINGS: Usable handwashing facilities - with water, functioning taps and soap available - were present in the delivery units of all six facilities, but were present in only one postnatal ward. All facilities were visibly clean, and staff demonstrated a strong will to comply with protocol. Areas of concern included effectiveness of training, inadequate availability of personal protective equipment, inadequate hand hygiene practices, and outdated procedures to reprocess re-usable medical equipment. CONCLUSION: Safe childbirth and postnatal care require comprehensive adherence to hand hygiene protocols and the use of disposable personal protective equipment. Financial, equipment and human resource constraints are obstacles to effective implementation of IPC in labour and delivery wards in the centres included in this study. Recommended interim measures include the introduction of champions to systematize step-down training and to monitor and provide feedback at facility level.

Draft Opioid-Prescribing Guidelines for Uncomplicated Normal Spontaneous Vaginal Birth.

Women who experience an uncomplicated vaginal delivery have acute intrapartum pain and variable pain in the immediate postpartum period. Although the Centers for Disease Control and Prevention (CDC) has urged clinicians to improve opioid-prescribing behavior, there are no published clinical practice guidelines for prescribing opioids during labor and delivery and at discharge for patients with uncomplicated normal spontaneous vaginal delivery. To address the knowledge gap regarding guidelines for pain management in this population, we used the national Premiere Health Care Database for deliveries of uncomplicated vaginal births from January 1, 2014, to December 31, 2016, to determine the prevalence of opioid administration. Among the 49,133 women who met inclusion criteria, 78.2% were administered opioids during hospitalization and 29.8% were administered opioids on the day of discharge. Descriptive statistics were generated to document the characteristics of the patients receiving opioids as well as the characteristics of hospitals administering opioids during inpatient labor and delivery and on discharge. Patient-level variables included age group, marital status, race, ethnicity, payer type, and length of stay. Hospital-level variables included bed size, geographic region, teaching status, and urbanicity status. These data were then presented in an electronic Delphi survey to 14 participants. The survey participants were obstetrician-gynecologists identified by the American College of Obstetricians and Gynecologists as being thought leaders in the obstetrics field and who had also demonstrated an active interest in the opioid epidemic and its effect on women's health. After the panelists viewed the opioid administration data, they were presented with an adapted version of the CDC's guidelines for opioid prescribing for chronic pain management. The eight adapted guidelines were constructed to be more relevant and appropriate for the inpatient normal spontaneous vaginal delivery population. After three rounds of the surveying process, seven of the eight adapted guidelines were endorsed by the survey participants. These seven draft consensus guidelines could now be used as a starting point to develop more broadly endorsed and studied guidelines for appropriately managing pain control for women with uncomplicated spontaneous vaginal birth.

Multiplex immunohistochemistry accurately defines the immune context of metastatic melanoma.

A prospective study explored the heterogeneous nature of metastatic melanoma using Multiplex immunohistochemistry (IHC) and flow cytometry (FACS). Multiplex IHC data quantitated immune subset number present intra-tumoral (IT) vs the tumor stroma, plus distance of immune subsets from the tumor margin (TM). In addition, mIHC showed a close association between the presence of IT CD8+ T cells and PDL1 expression in melanoma, which was more prevalent on macrophages than on melanoma cells. In contrast, FACS provided more detailed information regarding the T cell subset differentiation, their activation status and expression of immune checkpoint molecules. Interestingly, mIHC detected significantly higher Treg numbers than FACS and showed preferential CD4+ T cell distribution in the tumor stroma. Based on the mIHC and FACS data, we provide a model which defines metastatic melanoma immune context into four categories using the presence or absence of PDL1+ melanoma cells and/or macrophages, and their location within the tumor or on the periphery, combined with the presence or absence of IT CD8+ T cells. This model interprets melanoma immune context as a spectrum of tumor escape from immune control, and provides a snapshot upon which interpretation of checkpoint blockade inhibitor (CBI) therapy responses can be built.

The effect of transportation and lairage on faecal shedding and carcass contamination with Escherichia coli O157 and O26 in very young calves in New Zealand.

The effect of transportation and lairage on the faecal shedding and post-slaughter contamination of carcasses with Escherichia coli O157 and O26 in young calves (4-7-day-old) was assessed in a cohort study at a regional calf-processing plant in the North Island of New Zealand, following 60 calves as cohorts from six dairy farms to slaughter. Multiple samples from each animal at pre-slaughter (recto-anal mucosal swab) and carcass at post-slaughter (sponge swab) were collected and screened using real-time PCR and culture isolation methods for the presence of E. coli O157 and O26 (Shiga toxin-producing E. coli (STEC) and non-STEC). Genotype analysis of E. coli O157 and O26 isolates provided little evidence of faecal-oral transmission of infection between calves during transportation and lairage. Increased cross-contamination of hides and carcasses with E. coli O157 and O26 between co-transported calves was confirmed at pre-hide removal and post-evisceration stages but not at pre-boning (at the end of dressing prior to chilling), indicating that good hygiene practices and application of an approved intervention effectively controlled carcass contamination. This study was the first of its kind to assess the impact of transportation and lairage on the faecal carriage and post-harvest contamination of carcasses with E. coli O157 and O26 in very young calves.

Women's Free-text Comments on their Quality of Life: An Exploratory Analysis from the UK Standardisation of Breast Radiotherapy (START) Trials for Early Breast Cancer.

AIMS: Exploratory analysis of patients' unsolicited written comments in the first 2 years of the Standardisation of Breast Radiotherapy (START) trial quality of life study highlighted a potential effect of non-treatment-related problems on the ratings and interpretation of patient self-reported questionnaires. At 5 years of follow-up all eligible subjects were invited to write comments to further explore these findings. MATERIALS AND METHODS: Using inductive qualitative methods informed by the exploratory analysis, comments were allocated to relevant themes. Key patient-reported outcome measures (PROMs), clinical and demographic factors were collated for patients who did and did not comment at 5 years and comparisons between the groups explored. RESULTS: Of 2208 women completing baseline PROMs, 482 proffered comments from 0 to 24 months, forming nine distinct themes, including chronic conditions, life events and psychosocial concerns. At 5 years, 1041/1727 (60.3%) women contributed comments, of whom 500 randomly selected participants formed the sample for analysis. Findings revealed comorbidity, impaired physical functioning and psychosocial problems as key themes, with prevalent adverse effects from local and systemic treatments. Eight new themes emerged at 5 years, including ageing, concerns about future cancer and positive aspects of care. Women commenting were better educated, slightly older and more likely to have had chemotherapy compared with non-commenters. They had significantly worse PROM scores for global health and key quality of life domains relevant to the difficulties they revealed. CONCLUSIONS: Difficult personal circumstances and other health concerns affected many women's PROM ratings at 5 years of follow-up, in addition to ongoing cancer treatment effects. Greater attention to multiple sources of distress and adversity could facilitate personalised care and aid interpretation of PROMs.

Farm and abattoir sources of Carnobacterium species and implications for lamb meat spoilage.

AIMS: To investigate the transmission route of Carnobacterium from the farm environment to the meat-manufacturing plant and potential risk for meat spoilage. METHODS AND RESULTS: A sheep farm-level survey of Carnobacterium, consisting of 150 environmental and animal (no 100) associated samples, was carried out on two farms. A further 20 lamb carcass samples were taken from an abattoir servicing one of the farms. The majority of Carnobacterium maltaromaticum isolates were associated with fleece followed by hard sheep contact surfaces, rectal-anal mucosal swabs and carcasses. Enterobacterial repetitive intergenic consenus PCR (ERIC-PCR) profiling revealed four distinct ERIC types. Each ERIC type was found on both farms, three of which were also found on lamb carcasses. CONCLUSIONS: Enterobacterial repetitive intergenic consenus PCR was effective at demonstrating within-species variability in C. maltaromaticum. This study provides initial information showing that farm sources maybe an important transmission route of Carnobacterium for contamination of lamb carcasses and subsequently the meat processing environment. SIGNIFICANCE AND IMPACT OF THE STUDY: Data on distribution, diversity, sources and transmission routes for meat product contamination is limited for spoilage bacteria. This study highlights the importance of good hygienic slaughter practices and cleaning routines to remove accumulated detritus from the handling of animals that may lead to cross-contamination.

The profile of diabetes healthcare professionals in Indonesia: a scoping review.

AIM: To explore and synthesize evidence of the literature about healthcare professionals involved in the provision of diabetes management within an Indonesian context. BACKGROUND: Indonesia is challenged to control the major burden of diabetes prevalence rate that requires a multidimensional approach with the aim to optimize existing health services by involving healthcare professionals who can promote access and provide diabetes management. METHODS: This literature review, which is integrated with a scoping study framework, used the electronic databases including CINAHL, PubMed, Scopus and Web of Science to locate papers particular to the Indonesian context. From the total of 568 papers found, 20 papers were selected. RESULTS: The literature review identified physicians, nurses, pharmacists, dieticians and diabetes educators as the providers of diabetes care and management in Indonesia. Collaborative management involving either interdisciplinary or intradisciplinary teams was mentioned in several papers. Internal challenges included limited skills and knowledge. External challenges included high patient volumes; a shortage of healthcare professionals and reduced funding. CONCLUSIONS: Overcoming the challenges cannot be undertaken with a workforce dominated by any one single healthcare professional. Coordinating with the government to improve the implementation of different roles in diabetes management will improve patient outcomes and thus reduce the burden of diabetes. IMPLICATION FOR NURSING AND HEALTH POLICY: Health policy reform should support nurses and other healthcare professionals in their professional development at all levels of health care. Policy makers can use the review findings to modify the current healthcare system to address key issues in workforce development; funding for services and medications; and fostering multidisciplinary care for diabetes management.