Contributors to Organ Damage in Childhood Lupus: Corticosteroid Use and Disease Activity.

BACKGROUND: Awareness of paediatric-specific predictors of damage in Childhood-lupus is needed to inform mitigation measures. OBJECTIVES: To ascertain how clinical and demographic variables correlate with damage accrual and identify predictors of damage. METHODS: Analysis included UK JSLE Cohort Study participants. Univariable and multivariable Prentice-Williams-Peterson models investigated how demographic and clinical factors influenced hazards of new damage. Analyses were performed across the entire cohort, in patients with minimal disease activity marked by a time-adjusted average SLEDAI-2K score (AMS)≤2, low activity (AMS ≤ 4), moderate-high activity (AMS > 4) and those with no corticosteroids. RESULTS: Within the entire cohort (n = 430), factors associated with damage included: any methylprednisolone (Hazard Ratio, HR 2.20, [CI 1.33-3.62]), time-adjusted mean Physicians Global Assessment (PGA) (HR 2.87, [CI 1.48-5.56]) and AMS score (HR 1.13, [CI 1.03-1.24], all p< 0.05). Within the low activity subgroup, any methylprednisolone (HR 2.61, [CI 1.04-6.53]) and time-adjusted mean PGA (HR 3.41, [CI 1.52-7.76]) were associated with damage (both p< 0.05). Within the moderate-high activity subgroup, any methylprednisolone (HR 2.29, [CI 1.31-4.00]), time-adjusted mean PGA (HR 2.66, [CI 1.20-5.87]) and AMS score (HR 1.15, [CI 1.03-1.29]), were predictive of damage (all p< 0.05). Baseline organ damage was predictive of subsequent damage accrual in the minimal activity (HR 1.33, CI [1.78-8.08]) and no corticosteroids subgroups (HR 3.64, CI [1.83-7.24], both p< 0.005). CONCLUSION: Disease activity levels (AMS/PGA) and proxy indicators (methylprednisolone exposure, baseline damage) were found to be key predictors of damage accrual. This highlights the importance of practical strategies, to reduce disease activity and long-term treatment toxicity, such as treat-to-target.

Two-year mortality and seizure recurrence following status epilepticus in Auckland, New Zealand: A prospective cohort study.

PURPOSE: To document the 2-year mortality and seizure recurrence rate of a prospective cohort of patients identified with status epilepticus (SE). METHODS: Patients presenting to any hospital in the Auckland region between April 6 2015, and April 5 2016, with a seizure lasting 10 min or longer were identified. Follow up was at 2 years post index SE episode via telephone calls and detailed review of clinical notes. RESULTS: We identified 367 patients with SE over the course of one year. 335/367 (91.3 %) were successfully followed up at the 2-year mark. Two-year all-cause mortality was 50/335 (14.9 %), and 49/267 (18.4 %) when febrile SE was excluded. Two-year seizure recurrence was 197/335 (58.8 %). On univariate analyses, children (preschoolers 2 to < 5 years and children 5 to < 15 years), Asian ethnicity, SE duration <30 mins and acute (febrile) aetiology were associated with lower mortality, while older age >60 and progressive causes were associated with higher mortality on both univariate and multivariate analyses. Age < 2 years and acute aetiology were associated with lower seizure recurrence, while non convulsive status epilepticus (NCSE) with coma and a history of epilepsy were associated with higher seizure recurrence. On multivariate analyses, a history of epilepsy, as well as having both acute and remote causes were associated with higher seizure recurrence. CONCLUSIONS: All-cause mortality in both the paediatric and adult populations at 2 years was lower than most previous reports. Older age, SE duration ≥30 mins and progressive aetiologies were associated with the highest 2-year mortality, while febrile SE had the lowest mortality. A history of epilepsy, NCSE with coma, and having both acute and remote causes were associated with higher seizure recurrence at 2 years. Future studies should focus on functional measures of outcome and long-term quality of life.

Defining wound bed conformability: a new testing methodology to assess the relative swelling rise of foam dressings.

OBJECTIVE: Using a dressing that expands and conforms to the wound bed upon exudate absorption is one of the best ways to promote wound healing. While many products claim wound bed conformability, no externally replicated or verified test methodology had been developed to quantify a wound dressing's ability to conform to the wound bed. The Relative Swelling Rise (RSR) test methodology was developed to measure the relative swelling rise of foam dressings upon fluid absorption, and offers a quantifiable and easily replicated method to measure wound bed conformability. METHOD: The RSR test method was developed, validated and reliability tested by Coloplast A/S, Denmark. External replication was provided by ALS Odense, Denmark (previously DB Lab). Circular fences provide a fixed diameter to apply and contain the fluid and prevent horizontal spreading in the test set-up. The swelling height is quantified relative to the fence's inner diameter, i.e., the ratio alpha (α), and allows evaluation of a material's ability to conform to the wound bed. RESULTS: Biatain Silicone foam products (n=3, Coloplast A/S, Denmark) were tested, all afforded an average α-ratio from 0.30 to 0.60. The relative standard deviations were between 1-3%, demonstrating the strength of the test. Robustness of the methodology was demonstrated through the internal validation study, the reliability study, and both an internal and external replication study, as well as a systematic literature review and expert review of the construct, content, criterion and generalisability of the method. CONCLUSION: Having a validated, effective and easily replicable testing method to quantify wound bed conformability of foam dressings is an important step towards achieving better healing outcomes.

Nutritional, environmental and economic implications of children plate waste at school: a comparison between two Italian case studies.

OBJECTIVE: This study aims at comparing two Italian case studies in relation to schoolchildren's plate waste and its implications, in terms of nutritional loss, economic cost and carbon footprint. DESIGN: Plate waste was collected through an aggregate selective weighting method for 39 d. SETTING: Children from the first to the fifth grade from four primary schools, two in each case study (Parma and Lucca), were involved. RESULTS: With respect to the served food, in Parma, the plate waste percentage was lower than in Lucca (P < 0·001). Fruit and side dishes were highly wasted, mostly in Lucca (>50 %). The energy loss of the lunch meals accounted for 26 % (Parma) and 36 % (Lucca). Among nutrients, dietary fibre, folate and vitamin C, Ca and K were lost at most (26-45 %). Overall, after adjusting for plate waste data, most of the lunch menus fell below the national recommendations for energy (50 %, Parma; 79 %, Lucca) and nutrients, particularly for fat (85 %, Parma; 89 %, Lucca). Plate waste was responsible for 19 % (Parma) and 28 % (Lucca) of the carbon footprint associated with the food supplied by the catering service, with starchy food being the most important contributor (52 %, Parma; 47 %, Lucca). Overall, the average cost of plate waste was 1·8 €/kg (Parma) and 2·7 €/kg (Lucca), accounting respectively for 4 % and 10 % of the meal full price. CONCLUSION: A re-planning of the school meals service organisation and priorities is needed to decrease the inefficiency of the current system and reduce food waste and its negative consequences.

Movement is muscle in hospitalized adults.

Physical inactivity is a major public health concern, but for hospitalized adults, the results of immobility are even more alarming. The "trauma of hospitalization" is a syndrome that refers to the collective impact of immobility, sleep deficits, and malnutrition associated with hospitalization and contributes to functional deficits. Functional decline is a modifiable and preventable risk factor. Nursing, at the center of patient care, is poised to coordinate the patient's mobility activities. Multiple steps to stave off functional decline to improve health outcomes for older adults are in the control of nurses and nursing practice and reflect the goals of the NICHE practice model.

Procedural Unit Nurses' Perception of Confidence in Performing Critical Care Skills During COVID-19 Crisis.

Nursing professional development practitioners at an academic medical center conducted a quality improvement project to address the educational needs of procedural unit nurses during the COVID-19 pandemic. Procedural nurses completed a 1-day critical care nursing skills education and pre- and postsurveys. Survey results indicated an improved nurses' skills confidence in caring for COVID-19 patients, which was statistically significant, t (34.9) = 4.8, p < .001.

Reducing lower extremity hospital-acquired pressure injuries: a multidisciplinary clinical team approach.

OBJECTIVE: Optimal methods of reducing incidence of hospital-acquired pressure injuries (HAPIs) remain to be determined. We assessed changes in yearly incidence of lower extremity HAPIs before and after an intervention aimed at reducing these wounds. METHOD: In 2012, we implemented a three-pronged intervention to reduce the incidence of HAPIs. The intervention included: a multidisciplinary surgical team; enhanced nursing education; and improved quality data reporting. Yearly incidence of lower extremity HAPIs was tracked. RESULTS: Pre-intervention, incidence of HAPIs was 0.746%, 0.751% and 0.742% in 2009, 2010 and 2011, respectively. Post-intervention, incidence of HAPIs was 0.002%, 0.051%, 0.038%, 0.000% and 0.006% in 2013, 2014, 2015, 2016 and 2017, respectively. Mean incidence of HAPIs was reduced from 0.746% before the intervention to 0.022% after the intervention (p<0.001). CONCLUSION: An intervention by a multidisciplinary surgical team enhanced nursing education, and improved quality data reporting reduced the incidence of lower extremity HAPIs.

Curricular Quality Improvement in Midwifery: Simulating Unexpected Perinatal Loss.

INTRODUCTION: Caring for families experiencing perinatal loss is a fundamental component of midwifery practice, but little attention is paid to perinatal palliative care in midwifery curricula. Lack of educational preparation and self-care resources negatively impacts midwifery students and health care teams caring for families experiencing stillbirth. PROCESS: A private, urban university conducted a curricular quality improvement project to integrate perinatal palliative care into the midwifery curriculum using a high-fidelity, branching simulation pedagogy. Simulation objectives were developed from curricular gap analyses and the Core Competencies for Basic Midwifery Practice. Development of the Unexpected Perinatal Loss Simulation was guided by the International Nursing Association for Clinical Simulation and Learning Outcomes and Objectives and Design Standards. The Unexpected Perinatal Loss Simulation was revised based on qualitative data from student focus groups and expert content validation. OUTCOMES: Qualitative data yielded 4 key domains: presimulation, simulation skills, prior experience/personal reflections, and recommendations. Simulation procedures and scenario content were revised, after which 8 expert clinicians in the fields of midwifery, palliative care, and psychiatry validated the scenario content using the Lynn method. Two items did not meet the content validity index (CVI) threshold of 0.78, necessitating review by stakeholders; however, the overall scenario CVI threshold was met (0.82). DISCUSSION: Through this project, faculty integrated perinatal palliative care into the midwifery program using a novel approach of high-fidelity, branching simulation, structured debriefing, and an introductory self-care skills workshop. Potential clinical impact includes skillful perinatal palliative care with effective communication skills to mitigate how families experience and remember a traumatic loss and facilitate the grieving process. Students voiced insights into how they would process loss and seek support to mitigate their own grief as future midwives.

Quality Improvement to Promote Sepsis Reassessment: The Sepsis Reassessment Protocol Improvement Project (SRPIP).

BACKGROUND: Implementation of the Surviving Sepsis Campaign (SSC) guidelines into practice has demonstrated improved outcomes. LOCAL PROBLEM: Compliance with a sepsis protocol, based on the SSC guidelines, in an urban teaching hospital was below the national average. METHODS: A pre- and posttest intervention design was used to improve clinician knowledge, confidence, and compliance with the protocol. INTERVENTIONS: Educational modules were developed on the SSC guidelines and reminder system alerts (RSA) for timely revaluation of patients with sepsis and lactate monitoring were implemented. RESULTS: A total of 33 (48%) clinicians participated. There was an increase in knowledge, documentation of sepsis reassessment, and serum lactate monitoring. There was an improvement in clinician perceptions following the initiative. CONCLUSIONS: The results demonstrate that education, combined with RSAs, can improve protocol knowledge and compliance.

Virtual Events in the Era of COVID-19: Perspectives From a Virtual Interdisciplinary Wound Care Symposium.

BACKGROUND: The coronavirus disease-19 pandemic has created changes in the way medicine is practiced. The move to virtual conferencing to avoid mass gatherings is a significant change to how health care professionals meet, discuss current trends, and share research. METHODS: Data from exit polls conducted after annual wound care symposiums were reviewed. Physicians, nurses, podiatrists, and other health care professionals attended. Respondents were asked to comment and reflect on their experiences of attending a virtual conference. RESULTS: Over 60% of all (N = 283) respondents stated the virtual conference was better than or on par with a live event. Many respondents had attended this live event in person in previous years. Of all respondents, 83% stated that they planned to access conference materials for the 30 days they remained posted after the event. More than 50% of respondents stated they favored the ability to communicate effectively with colleagues via the instant messaging feature offered by the conference. Approximately 80% of respondents stated that they would like to attend this and other conferences virtually in the future. CONCLUSIONS: The shift from in-person to virtual conferences has the potential to remain a significant method of attending health care conferences. Conference organizers are encouraged to consider how they can implement virtual components, including postconference access to materials, to enhance the conference experience. Additional work needs to be done to understand the impact of the virtual format on knowledge retention.

Real world treatment of juvenile-onset systemic lupus erythematosus: Data from the UK JSLE cohort study.

BACKGROUND: In the absence of clinical trials evidence, Juvenile-onset Systemic Lupus Erythematosus (JSLE) treatment plans vary. AIM: To explore 'real world' treatment utilising longitudinal UK JSLE Cohort Study data. METHODS: Data collected between 07/2009-05/2020 was used to explore the choice/sequence of immunomodulating drugs from diagnosis. Multivariate logistic regression determined how organ-domain involvement (pBILAG-2004) impacted treatment choice. RESULT: 349 patients met inclusion criteria, median follow-up 4-years (IQR:2,6). Mycophenolate mofetil (MMF) was most commonly used for the majority of organ-domains, and significantly associated with renal involvement (OR:1.99, 95% CI:1.65-2.41, pc < 0.01). Analyses assessing the sequence of immunomodulators focused on 197/349 patients (meeting relevant inclusion/exclusion criteria). 10/197 (5%) solely recieved hydroxychloroquine/prednisolone, 62/197 (31%) received a single-immunomodulator, 69/197 (36%) received two, and 36/197 patients (28%) received ≥three immunomodulators. The most common first and second line immunomodulator was MMF. Rituximab was the most common third-line immunomodulator. CONCLUSIONS: Most UK JSLE patients required ≥two immunomodulators, with MMF used most commonly.

Phase 2 trial of T-cell activation using MVI-816 and pembrolizumab in patients with metastatic, castration-resistant prostate cancer (mCRPC).

BACKGROUND: We previously reported a trial using a DNA vaccine encoding prostatic acid phosphatase (MVI-816, pTVG-HP), given over 12 weeks concurrently or sequentially with pembrolizumab, in patients with mCRPC. We report the final analysis of this trial following two additional treatment arms in which patients with mCRPC continued concurrent treatment until progression. MATERIALS AND METHODS: Patients with mCRPC were treated with MVI-816 and pembrolizumab every 3 weeks (arm 3, n=20) or MVI-816 every 2 weeks and pembrolizumab every 4 weeks (arm 4, n=20). The primary objectives were safety, 6-month progression-free survival (PFS), median time to radiographic progression, and objective response rates. Secondary objectives included immunological evaluations. RESULTS: In 25 patients with measurable disease, there were no complete response and one confirmed partial response in a patient who subsequently found to have an MSIhi tumor. 4/40 patients (10%) had a prostate-specific antigen decline >50%. The estimated overall radiographic PFS rate at 6 months was 47.2% (44.4% arm 3, 61.5% arm 4). Accounting for all off-study events, overall median time on treatment was 5.6 months (95% CI: 5.4 to 10.8 months), 5.6 months for arm 3 and 8.1 months for arm 4 (p=0.64). Thirty-two per cent of patients remained on trial beyond 6 months without progression. Median overall survival was 22.9 (95% CI: 16.2 to 25.6) months. One grade 4 event (hyperglycemia) was observed. Immune-related adverse events (irAEs) >grade 1 were observed in 42% of patients overall. Interferon-γ and/or granzyme B immune response to prostatic acid phosphatase was detected in 2/20 patients in arm 3 and 6/20 patients in arm 4. Plasma cytokines associated with immune activation and CD8+ T-cell recruitment were augmented at weeks 6 and 12. The development of irAE was significantly associated with a prolonged time on treatment (HR=0.42, p=0.003). Baseline DNA homologous recombination repair mutations were not associated with longer time to progression. CONCLUSIONS: Findings here demonstrate that combining programmed cell death 1 blockade with MVI-816 is safe, can augment tumor-specific T cells, and can result in a favorable 6-month disease control rate. Correlative studies suggest T-cell activation by vaccination is critical to the mechanism of action of this combination. Future randomized clinical trials are needed to validate these findings. TRIAL REGISTRATION NUMBER: NCT02499835.

Attainment of low disease activity and remission targets reduces the risk of severe flare and new damage in childhood lupus.

OBJECTIVES: To assess the achievability and effect of attaining low disease activity (LDA) or remission in childhood-onset SLE (cSLE). METHODS: Attainment of three adult-SLE derived definitions of LDA (LLDAS, LA, Toronto-LDA), and four definitions of remission (clinical-SLEDAI-defined remission on/off treatment, pBILAG-defined remission on/off treatment) was assessed in UK JSLE Cohort Study patients longitudinally. Prentice-Williams-Petersen gap recurrent event models assessed the impact of LDA/remission attainment on severe flare/new damage. RESULTS: LLDAS, LA and Toronto-LDA targets were reached in 67%, 73% and 32% of patients, after a median of 18, 15 or 17 months, respectively. Cumulatively, LLDAS, LA and Toronto-LDA was attained for a median of 23%, 31% and 19% of total follow-up-time, respectively. Remission on-treatment was more common (61% cSLEDAI-defined, 42% pBILAG-defined) than remission off-treatment (31% cSLEDAI-defined, 21% pBILAG-defined). Attainment of all target states, and disease duration (>1 year), significantly reduced the hazard of severe flare (P < 0.001). As cumulative time in each target increased, hazard of severe flare progressively reduced. LLDAS attainment reduced the hazard of severe flare more than LA or Toronto-LDA (P < 0.001). Attainment of LLDAS and all remission definitions led to a statistically comparable reduction in the hazards of severe flare (P > 0.05). Attainment of all targets reduced the hazards of new damage (P < 0.05). CONCLUSIONS: This is the first study demonstrating that adult-SLE-derived definitions of LDA/remission are achievable in cSLE, significantly reducing risk of severe flare/new damage. Of the LDA definitions, LLDAS performed best, leading to a statistically comparable reduction in the hazards of severe flare to attainment of clinical remission.

Weather, Workload and Money: Determining and Evaluating Sources of Stress for Farmers in Ireland.

The demands of modern farming can place substantial stress upon the farmer, adversely impacting their wellbeing. This study identifies both the prevalence of stress and assesses the demographic, farm, and social characteristics that impact the incidence of stress. We report the results of a survey of a nationally representative sample of farm enterprises in Ireland undertaken in association with the Teagasc National Farm Survey (NFS) in 2018, which saw 736 questionnaires completed by farm operators. Frequency analysis is used to report the primary sources and prevalence of stress. A probit model is developed identifying and quantifying the factors that impact the incidence of stress. There were 57% of farmers who reported experiencing stress resulting from their farm work. Key sources of stress included "poor weather", (47%), "workload" (32%) and "financial" concerns (28%). The results of the probit model establish that the effect of age on the incidence of stress is significant, positive, and non-linear, indicating as farmers get older they are more likely to experience stress but at a declining rate. Operating a sheep farm system, as opposed to any other type of farm system, reduces the probability of stress. Working off-farm also reduces the probability of stress by 0.097, other things being equal. The findings highlight variance in the levels of stress reported by farmers by age and farm system, and consequently, the need to develop targeted supports that take consideration of differences within the population of farmers and farm enterprises.

An Interdisciplinary Team Approach to Decrease Sacral Hospital-acquired Pressure Injuries: A Retrospective Cohort Study.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) of the sacrum are among the most common iatrogenic events in health care. Multi-intervention programs have been shown to decrease the prevalence of pressure injuries. PURPOSE: To assess changes in the yearly incidence of sacral HAPIs before and after implementation of a 3-pronged interdisciplinary intervention to reduce HAPI incidence. METHODS: A retrospective study of all patients admitted between 2010 and 2017 was conducted to evaluate the effect of a 2012 initiative on the incidence of sacral HAPIs. In 2012, an interdisciplinary team was created, and enhanced education programs for nursing staff and quality data reporting measures were implemented for all patients admitted to North Shore University Hospital, Manhasset, NY. Pre- and post-intervention patient variables and sacral HAPI outcomes were compared. RESULTS: Pre- intervention, the sacral HAPI incidence was 0.353% and 0.267% (mean 0.31%) in the years 2010 and 2011, respectively. Post-intervention the HAPI incidence was 0.033%, 0.043%, 0.008%, 0.007%, and 0.004% in the years 2013, 2014, 2015, 2016, and 2017, respectively (mean 0.019%) (2-sample unpaired t-statistic: 11.5937; P < .001). Significant variables and outcomes differences between pre-intervention (n = 245) and post-intervention (n = 49) patients with a sacral HAPI were seen for race (P < .0001), length of stay (P = .0096), and HAPI stage (P < .0001). CONCLUSION: A hospital-wide, multi-part, interdisciplinary intervention resulted in a significant and sustained reduction in the incidence of sacral HAPIs.