Defining conditions for effective interdisciplinary care team communication in an open surgical intensive care unit: a qualitative study.

OBJECTIVE: Poor interdisciplinary care team communication has been associated with increased mortality. The study aimed to define conditions for effective interdisciplinary care team communication. DESIGN: An observational cross-sectional qualitative study. SETTING: A surgical intensive care unit in a large, urban, academic referral medical centre. PARTICIPANTS: A total 6 interviews and 10 focus groups from February to June 2021 (N=33) were performed. Interdisciplinary clinicians who cared for critically ill patients were interviewed. Participants included intensivist, transplant, colorectal, vascular, surgical oncology, trauma faculty surgeons (n=10); emergency medicine, surgery, gynaecology, radiology physicians-in-training (n=6), advanced practice providers (n=5), nurses (n=7), fellows (n=1) and subspecialist clinicians such as respiratory therapists, pharmacists and dieticians (n=4). Audiorecorded content of interviews and focus groups were deidentified and transcribed verbatim. The study team iteratively generated the codebook. All transcripts were independently coded by two team members. PRIMARY OUTCOME: Conditions for effective interdisciplinary care team communication. RESULTS: We identified five themes relating to conditions for effective interdisciplinary care team communication in our surgical intensive care unit setting: role definition, formal processes, informal communication pathways, hierarchical influences and psychological safety. Participants reported that clear role definition and standardised formal communication processes empowered clinicians to engage in discussions that mitigated hierarchy and facilitated psychological safety. CONCLUSIONS: Standardising communication and creating defined roles in formal processes can promote effective interdisciplinary care team communication by fostering psychological safety.

Slow Release of GA3 Hormone from Polymer Coating Overcomes Seed Dormancy and Improves Germination.

Seed dormancy often hinders direct seeding efforts that are attempting to restore degraded landscapes. Gibberellic acid (GA3) can be applied to physiologically dormant seeds to induce germination, but this hormone is rarely effective, as it can degrade or be leached from the seed. We tested different polymer matrixes (polylactic acid, polyvinylpyrrolidone, and ethylcellulose) to apply and slowly release GA3 to the seed. These polymers were tested as seed coatings in either a powder, liquid, or a combination of powder and liquid forms. We found that a liquid ethylcellulose/GA3 coating generally outperformed the other polymers and applications methods using our test species Penstemon palmeri. With this top-performing treatment, seed germination was 3.0- and 3.9-fold higher at 15 °C and 25 °C, respectively. We also evaluated the liquid ethylcellulose/GA3 coating on P. comharrenus, P. strictus, P. pachyphyllus, and P. eatonii. Again, the coating had a strong treatment response, with the degree of difference related to the relative level of dormancy of the species. Growth studies were also performed in pots to ensure that the side effects of GA3 overdosing were not present. Here, we found minimal differences in root length, shoot length, or biomass between plants grown from untreated and GA3-coated seeds.

Using Methicillin-Resistant Staphylococcus aureus Nasal Screens to Rule Out Methicillin-Resistant S aureus Pneumonia in Surgical Intensive Care Units.

INTRODUCTION: The methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) has a high negative predictive value (NPV). We aimed to understand if there was a difference in the NPV of the MRSA screen in surgical intensive care units (ICUs) and to determine its role in antibiotic de-escalation. METHODS: We performed a single-center, retrospective cohort study of adults with a positive respiratory culture and MRSA nasal PCR admitted to a surgical ICU from 2016 to 2019. Patients were stratified by surgical ICU: cardiothoracic/cardiovascular intensive care unit (CVICU) or transplant/acute care surgery intensive care unit (ACS-ICU). Our primary outcome was the NPV of MRSA screen. Secondary outcome was the duration of empiric MRSA-targeted therapy. RESULTS: We analyzed 61 patients: 42.6% (n = 26) ACS-ICU and 57.4% (n = 35) CVICU. There were no differences in age, comorbidities, prior MRSA infection, recent antibiotic use, immunocompromised status, or renal replacement therapy. At pneumonia diagnosis, more patients in the ACS-ICU were hospitalized ≥5 d (65.4% versus 8.6%, P < 0.0001) and more patients in the CVICU were in septic shock (88.6% versus 34.5%, P < 0.0001) and thrombocytopenic (40% versus 11.5%, P = 0.02). NPV of the PCR was similar (ACS-ICU: 0.92 [0.75-0.98], CV-ICU 0.89 [0.73-0.96]). On multivariable linear regression, the CVICU was associated with longer empiric therapy (ß 1.5, 95% CI 0.8-2.3, P < 0.0001), as was hospitalization for ≥5 d (ß 0.73, 95% CI 0.06-1.39, P = 0.03). CONCLUSIONS: The MRSA nasal PCR screen has a high NPV for ruling out MRSA pneumonia in critically ill surgical patients. However, patients in the CVICU and patients hospitalized ≥5 d had a longer time to de-escalation of MRSA-targeted therapy, potentially due to higher clinical risk profile.

Reducing Inappropriate Testing for the Evaluation of Diarrhea Among Hospitalized Patients.

BACKGROUND: Diarrhea is one of the most common illnesses in the United States. Evaluation frequently does not follow established guidelines. The objective of this study was to evaluate the effectiveness of a computerized physician order entry-based test guidance algorithm with regard to the clinical, financial, and operational impacts. METHODS: Our population was patients with diarrheal illness at a tertiary academic medical center. The intervention was a computerized physician order entry-based test guidance algorithm that restricted the use of stool cultures and ova and parasites testing of diarrhea in the adult inpatient location vs nonintervention sites, which were the emergency department, pediatric inpatient and adult and pediatric outpatient locations. We measured stool culture, ova and parasites, and Clostridium difficile testing rates from July 1, 2012 to January 31, 2016. Additionally, we calculated advisor usage, consults generated, accuracy of information, and cost savings. RESULTS: There was a significant decrease in stool culture and ova and parasites testing rates at the adult inpatient (P = .001 for both), pediatric (P < .001 for both), and adult emergency department (P < .001; P = .009) locations. The decrease at the intervention site was immediate, whereas the other locations showed a delayed but sustained decrease that suggests a collateral impact. A significant increase in the rate of stool culture and ova and parasites testing was observed in the outpatient setting (P = .02 and P = .001). We estimate that $21,931 was saved annually. CONCLUSIONS: A point-of-order test restriction algorithm for hospitalized adults with diarrhea reduced stool testing. Similar programs should be considered at other institutions and for the evaluation of other conditions.

Does Intrawound Vancomycin Application During Spine Surgery Create Vancomycin-Resistant Organism?

BACKGROUND: Surgical site infection (SSI) following spine surgery is a morbid and expensive complication. The use of intrawound vancomycin is emerging as a solution to reduce SSI. The development of vancomycin-resistant pathogens is an understandable concern. OBJECTIVE: To determine the occurrence of vancomycin-resistant SSI in patients with and without use of intrawound vancomycin. METHODS: Patients undergoing elective spine surgery were dichotomized based on whether intrawound vancomycin was applied. Outcome was occurrence of SSI requiring return to the operating room within postoperative 90 days. The intrawound culture and vancomycin minimal inhibitory concentrations (MIC) were reviewed. Analyses were conducted to compare the pathogen profile and MIC for vancomycin in patients who received vancomycin and those who did not. RESULTS: Of the total 2802 patients, 43% (n = 1215) had intrawound vancomycin application during the index surgery. The use of vancomycin was associated with significantly lower deep SSI rates (1.6% [n = 20] vs 2.5% [n = 40], P = .02). The occurrence of Staphylococcus aureus SSI was significantly lower in the patients who had application of intrawound vancomycin (32% vs 65%, P = .003). None of the patients who had application of intrawound vancomycin powder, and subsequently developed an S aureus SSI, demonstrated pathogens with resistance to vancomycin. All patients had MIC < 2 µg/mL, the vancomycin susceptibility threshold. The occurrence of gram-negative SSI (28% vs 7%) and culture negative fluid collection (16% vs 5%) was higher in the vancomycin cohort. CONCLUSIONS: The use of intrawound vancomycin during the index spine surgery was protective against SSI following spine surgery. The application of intrawound vancomycin during index surgery does not appear to create vancomycin-resistant organisms in the event of an SSI.

Cost Analysis of Free Colonoscopies in an Uninsured Population at Increased Risk for Colorectal Cancer.

BACKGROUND: Uninsured patients have poor access to screening colonoscopy and subsequently present with advanced stages of colorectal cancer (CRC) that beget worse outcomes and higher total costs. Providing pro bono colonoscopies to uninsured patients at high risk for CRC can detect early stage disease and be cost-effective. STUDY DESIGN: Patients considered at increased risk for CRC were offered free screening colonoscopies. Patient data from these colonoscopies were collected during a 12-month period, and the incidence of CRC was compared with a control group of uninsured patients from the Surveillance, Epidemiology, and End Results (SEER) registry. Published estimates derived from SEER Medicare data of health expenditures by CRC stage were used to develop a cost model. To compare overall costs between our cohort and the SEER control, the mean initial cost of care (up to 1 year) was weighted by the stage-specific CRC incidence in each group. RESULTS: There were 682 uninsured patients screened, with 9 cancers identified (stage 0, n = 1; stage I, n = 3; stage II, n = 2; and stage III, n = 3) for an incidence of 1.3%. A total cost of $388,137 was estimated to be incurred during the initial phase of care. Compared with the SEER control, our cohort included more early stage cancers and subsequently had a marginally lower per-patient initial cost ($43,126 vs $43,736). CONCLUSIONS: Our screening criteria successfully identified a high-risk population with an overall 1.3% incidence of CRC. For these patients, the provision of free screening colonoscopies identified earlier-stage tumors and appears to be cost-neutral.

Intervening to Improve Compassion Fatigue Resiliency in Forensic Nurses.

Evidence suggests that forensic nurses (FNs) may be predisposed to compassion fatigue (CF) as a result of the challenges of the profession including high caseloads, role ambiguity, prosecution goals, vicarious traumatization, attending to survivors' emotional needs, and empowering victims. The purpose of this exploratory study was to determine the prevalence of CF in a convenience sample of 55 FNs and examine the treatment effectiveness of a multifaceted education program in an intervention subset. The intervention was intended to increase compassion satisfaction (CS) and decrease CF symptoms in FNs in one organization who participated in the training. The hypothesis was that the FNs will have moderate to high CF and moderate to high CS and the CF intervention will add in CF prevention and resiliency as measured with an improvement in the Professional Quality of Life test scores (B. H. ). In the prevalence sample, 69% of the FNs had moderate to low CS, 73% had moderate to high burnout, and 73% had moderate to high levels of secondary traumatic stress (STS). In the intervention group, the education program resulted in a statistically significant increase in CS and decreases in STS symptoms.

Understanding distress in posttreatment adult leukemia and lymphoma survivors: a lifespan perspective.

Using in-depth interviews, this paper explores the nature and sources of cancer-specific distress among 51 posttreatment adult leukemia and lymphoma survivors (LLS), focusing on the role of lifespan stage in shaping reported stressors. LLS (all ages) reported physical aftereffects of cancer treatment, with reported sources of emotional and financial distress varying by lifespan stage. Young adult survivors (18-39) reported a greater number of distress sources. Distress may persist up to 4 years posttreatment, particularly among younger LLS, who appear to be at greater risk of distress in multiple domains.

Prevalence and predictors of distress in posttreatment adult leukemia and lymphoma survivors.

This paper examines predictors of cancer-specific distress among posttreatment adult leukemia and lymphoma survivors (LLS). Using a survey mailed to LLS in the Colorado Central Cancer Registry (N = 477), the authors developed a multivariable risk profile for distress. Thirty one percent of LLS reported indicators of distress. Significantly higher distress was associated with younger age (p < 0.001) in bivariate analyses. The risk profile included fear of recurrence, financial burden, and younger age. Distress did not attenuate based on time since treatment completion and may persist up to 4 years posttreatment, suggesting a need for intervention, particularly among high-risk LLS.

Psychosocial telephone interventions for patients with cancer and survivors: a systematic review.

OBJECTIVE: Over one third of patients with cancer experience elevated psychosocial distress. As screening for distress becomes more common, the number of patients referred for psychosocial care will increase. Psychosocial telephone interventions are recommended as a convenient and exportable alternative to in-person interventions addressing psychosocial distress. This study reviews the efficacy of randomized controlled trials (RCTs) of psychosocial telephone interventions for patients with cancer. METHODS: We conducted a systematic review of peer-reviewed RCTs evaluating telephone interventions in adult patients with cancer across the survivorship continuum. RESULTS: Through a database search, 480 articles were identified. After manual review, 13 were included, with 7 additional studies identified by back citation, totaling 20 studies. Participants were largely Caucasian, highly educated, with mean age ranging from 49 to 75 years. Most participants were patients with breast cancer (n = 13 studies). Sample sizes were generally small, with most patients recruited from large medical centers. Only one screened for psychosocial need. Interventions varied greatly in length and intensity. Eight studies reported significant effects post-intervention in the hypothesized direction on at least one psychosocial outcome measure. Of these eight studies, four included more than one follow-up assessment; of these, only one reported significant effects at last follow-up. No clear commonalities were found among studies reporting significant effects. CONCLUSIONS: Methodological concerns and lack of consistency in adherence to CONSORT reporting guidelines were identified. This body of research would benefit from well-designed, theory-based RCTs adequately powered to provide more definitive evidence for intervention efficacy. This will probably require multi-institutional collaborations, guided by intervention and research methodology best practices.

Iatrogenic cushing syndrome secondary to a probable interaction between voriconazole and budesonide.

Oral budesonide is commonly used for the management of Crohn's disease given its high affinity for glucocorticoid receptors and low systemic activity due to extensive first-pass metabolism through hepatic cytochrome P450 (CYP) 3A4. Voriconazole, a second-generation triazole antifungal agent, is both a substrate and potent inhibitor of CYP isoenzymes, specifically CYP2C19, CYP2C9, and CYP3A4; thus, the potential for drug-drug interactions with voriconazole is high. To our knowledge, drug-drug interactions between voriconazole and corticosteroids have not been specifically reported in the literature. We describe a 48-year-old woman who was receiving oral budesonide 9 mg/day for the management of Crohn's disease and was diagnosed with fluconazole-resistant Candida albicans esophagitis; oral voriconazole 200 mg every 12 hours for 3 weeks was prescribed for treatment. Because the patient experienced recurrent symptoms of dysphagia, a second 3-week course of voriconazole therapy was taken. Seven weeks after originally being prescribed voriconazole, she came to her primary care clinic with elevated blood pressure, lower extremity edema, and weight gain; she was prescribed a diuretic and evaluated for renal dysfunction. At a follow-up visit 6 weeks later with her specialty clinic, the patient's blood pressure was elevated, and her physical examination was notable for moon facies, posterior cervical fat pad prominence, and lower extremity pitting edema. Iatrogenic Cushing syndrome due to a drug-drug interaction between voriconazole and budesonide was suspected, and voriconazole was discontinued. Budesonide was continued as previously prescribed for her Crohn's disease. On reevaluation 2 months later, the patient's Cushingoid features had markedly regressed. To our knowledge, this is the first published case report of iatrogenic Cushing syndrome due to a probable interaction between voriconazole and oral budesonide. In patients presenting with Cushingoid features who have received these drugs concomitantly, clinicians should consider the potential drug interaction between these agents, and the risks and benefits of continued therapy must be considered.

The increasing incidence of young-onset colorectal cancer: a call to action.

In the United States, colorectal cancer (CRC) is the third most common and second most lethal cancer. More than one-tenth of CRC cases (11% of colon cancers and 18% of rectal cancers) have a young onset (ie, occurring in individuals younger than 50 years). The CRC incidence and mortality rates are decreasing among all age groups older than 50 years, yet increasing in younger individuals for whom screening use is limited and key symptoms may go unrecognized. Familial syndromes account for approximately 20% of young-onset CRCs, and the remainder are typically microsatellite stable cancers, which are more commonly diploid than similar tumors in older individuals. Young-onset CRCs are more likely to occur in the distal colon or rectum, be poorly differentiated, have mucinous and signet ring features, and present at advanced stages. Yet, stage-specific survival in patients with young-onset CRC is comparable to that of patients with later-onset cancer. Primary care physicians have an important opportunity to identify high-risk young individuals for screening and to promptly evaluate CRC symptoms. Risk modification, targeted screening, and prophylactic surgery may benefit individuals with a predisposing hereditary syndrome or condition (eg, inflammatory bowel disease) or a family history of CRC or advanced adenomatous polyps. When apparently average-risk young adults present with CRC-like symptoms (eg, unexplained persistent rectal bleeding, anemia, and abdominal pain), endoscopic work-ups can expedite diagnosis. Early screening in high-risk individuals and thorough diagnostic work-ups in symptomatic young adults may improve young-onset CRC trends.

Bridging the transition from cancer patient to survivor: pilot study results of the Cancer Survivor Telephone Education and Personal Support (C-STEPS) program.

OBJECTIVE: To develop a feasibility study of a theory-driven telephone counseling program to enhance psychosocial and physical well-being for cancer survivors after treatment. METHODS: Participants (n=66) were recruited from two Colorado hospitals with self-administered questionnaires at baseline and two weeks post-intervention. The one group, intervention only design included up to six thematic telephone counseling sessions over three months. Topics included nutrition, physical activity, stress management, and medical follow-up. Primary outcomes were cancer-specific distress, self-reported fruit and vegetable consumption and physical activity. RESULTS: Of 66 subjects, 46 completed at least one counseling module and the follow-up assessment (70% retention rate). Mean satisfaction was 9 out of 10, and all participants would recommend C-STEPS to other survivors. Cancer-specific distress (Impact of Event Scale - Intrusion subscale) decreased for entire study population (p<0.001) and stress management session participants (p<0.001). Fruit and vegetable consumption increased for nutrition and exercise session participants (p=0.02) and the entire sample (p=NS). Physical activity increased in the entire group (p=0.006) and for nutrition and exercise session participants (p=0.01). CONCLUSION AND PRACTICE IMPLICATIONS: C-STEPS is a feasible telephone counseling program that transcends geographic barriers, demonstrating the potential to decrease distress and promote coping and healthy lifestyles among cancer survivors.

Bacterial production of organic acids enhances H2O2-dependent iodide oxidation.

To develop an understanding of the role that microorganisms play in the transport of (129)I in soil-water systems, bacteria isolated from subsurface sediments were assessed for iodide oxidizing activity. Spent liquid medium from 27/84 bacterial cultures enhanced iodide oxidation 2-10 fold in the presence of H(2)O(2). Organic acids secreted by the bacteria were found to enhance iodide oxidation by (1) lowering the pH of the spent medium, and (2) reacting with H(2)O(2) to form peroxy carboxylic acids, which are extremely strong oxidizing agents. H(2)O(2)-dependent iodide oxidation increased exponentially from 8.4 to 825.9 µM with decreasing pH from 9 to 4. Organic acids with ≥2 carboxy groups enhanced H(2)O(2)-dependent iodide oxidation (1.5-15-fold) as a function of increasing pH above pH 6.0, but had no effect at pH ≤ 5.0. The results indicate that as pH decreases (≤5.0), increasing H(2)O(2) hydrolysis is the driving force behind iodide oxidation. However, at pH ≥ 6.0, spontaneous decomposition of peroxy carboxylic acids, generated from H(2)O(2) and organic acids, contributes significantly to iodide oxidation. The results reveal an indirect microbial mechanism, organic acid secretion coupled to H(2)O(2) production, that could enhance iodide oxidation and organo-iodine formation in soils and sediments.

Effect of a dexmedetomidine substitution during a nationwide propofol shortage in patients undergoing coronary artery bypass graft surgery.

STUDY OBJECTIVE: To assess the effect of substituting dexmedetomidine for propofol during a nationwide propofol shortage on postoperative time to extubation and opioid requirements in patients who underwent coronary artery bypass graft (CABG) surgery. DESIGN: Retrospective case-control study. SETTING: Single-center cardiothoracic intensive care unit (ICU) in a tertiary academic medical center. PATIENTS: Seventy adults undergoing isolated, primary, elective CABG who received dexmedetomidine between April 1 and June 30, 2010, during the propofol shortage (35 patients [cases]) or who received propofol between January 1 and March 31, 2010, or between July 1 and September 30, 2010 (35 patients [controls]) for postoperative sedation were included. Patients in the dexmedetomidine group were matched 1:1 to patients in the propofol group based on age, sex, weight, number of vessels bypassed, preoperative ejection fraction, cardiopulmonary bypass time, and aortic cross-clamp time. MEASUREMENTS AND MAIN RESULTS: The primary outcome consisted of opioid requirements in the first 12 hours after arrival to the ICU in the dexmedetomidine- and propofol-treated patients. Secondary outcomes included the time to extubation (from ICU admission until extubation) and opioid requirements in the first 24 hours. No significant demographic differences were noted between treatment groups. Median opioid requirements in the first 12 hours, as measured by morphine equivalents, were 8.0 mg in the propofol group and 7.0 mg in the dexmedetomidine group (p=0.1). Similarly, at 24 hours, opioid requirements were 16.7 and 17.3 mg in the propofol and dexmedetomidine groups, respectively (p=0.4). The time to extubation demonstrated that patients in the propofol group were extubated at a median of 300 minutes and patients in the dexmedetomidine group were extubated at a median of 318 minutes after ICU arrival (p=0.5). CONCLUSION: No statistically significant differences were noted between the propofol and dexmedetomidine groups when assessing the outcomes of opioid requirements and the time to extubation. A multicenter, prospective, randomized, blinded study is needed to determine the optimal sedative after CABG surgery.

Iodide accumulation by aerobic bacteria isolated from subsurface sediments of a 129I-contaminated aquifer at the Savannah River site, South Carolina.

(129)I is of major concern because of its mobility in the environment, excessive inventory, toxicity (it accumulates in the thyroid), and long half-life (∼16 million years). The aim of this study was to determine if bacteria from a (129)I-contaminated oxic aquifer at the F area of the U.S. Department of Energy's Savannah River Site, SC, could accumulate iodide at environmentally relevant concentrations (0.1 µM I(-)). Iodide accumulation capability was found in 3 out of 136 aerobic bacterial strains isolated from the F area that were closely related to Streptomyces/Kitasatospora spp., Bacillus mycoides, and Ralstonia/Cupriavidus spp. Two previously described iodide-accumulating marine strains, a Flexibacter aggregans strain and an Arenibacter troitsensis strain, accumulated 2 to 50% total iodide (0.1 µM), whereas the F-area strains accumulated just 0.2 to 2.0%. Iodide accumulation by FA-30 was stimulated by the addition of H(2)O(2), was not inhibited by chloride ions (27 mM), did not exhibit substrate saturation kinetics with regard to I(-) concentration (up to 10 µM I(-)), and increased at pH values of <6. Overall, the data indicate that I(-) accumulation likely results from electrophilic substitution of cellular organic molecules. This study demonstrates that readily culturable, aerobic bacteria of the F-area aquifer do not accumulate significant amounts of iodide; however, this mechanism may contribute to the long-term fate and transport of (129)I and to the biogeochemical cycling of iodine over geologic time.

Disparities in routine breast cancer screening for Medicaid managed care members with a work-limiting disability.

OBJECTIVE: Examine disparities in routine mammography for women who qualify for Medicaid, because of a work-limiting disability. METHODS: Individual-level data were obtained for women enrolled in Massachusetts Medicaid Managed Care plans who met the 2007 Healthcare Effectiveness Data and Information Set (HEDIS) criteria for the breast cancer screening measure (n=35,171). Disability status was determined from Medicaid eligibility records. Mammography screening was modeled using multivariate logistic regression. Separate models for women with and without a disability were also estimated. RESULTS: Although unadjusted breast cancer screening rates were roughly equal for women with and without disability, after adjusting for confounders disability status had a significant negative association with screening mammography (OR=0.74; p<0.0001). Living farther from a mammography facility or having a diagnosis of domestic violence reduced the odds of screening for women with disabilities, but not for other women. Having a higher illness burden was more detrimental to screening for women with a disability than for those without. Both groups benefited similarly from the first 26 ambulatory care visits, but the impact of additional visits on screening was much larger among women with disabilities. CONCLUSION: Nationwide, rates of routine mammography for Medicaid managed care plans averaged below 50% in 2006. Given that a majority of eligible women served by Medicaid have disabilities, and studies have shown that women with disabilities are more likely to be diagnosed with late stage disease, a focus on improving rates of screening for women with disabilities is overdue.