Shorter versus longer duration antibiotic regimens for treatment of suspected neonatal sepsis.

OBJECTIVES: This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the safety and effectiveness of shorter versus longer duration antibiotic regimens for the treatment of suspected neonatal sepsis.

Patagonian dust, Agulhas Current, and Antarctic ice-rafted debris contributions to the South Atlantic Ocean over the past 150,000 years.

Disentangling inputs of aeolian dust, ice-rafted debris (IRD), and eroded continental detritus delivered by ocean currents to marine sediments provide important insights into Earth System processes and climate. This study uses Sr-Nd-Pb isotope ratios of the continent-derived (lithogenic) fraction in deep-sea core TN057-6 from the subantarctic Southern Ocean southwest of Africa over the past 150,000 y to identify source regions and quantify their relative contributions and fluxes utilizing a mixing model set in a Bayesian framework. The data are compared with proxies from parallel core Ocean Drilling Program Site 1090 and newly presented data from potential South America aeolian dust source areas (PSAs), allowing for an integrated investigation into atmospheric, oceanic, and cryospheric dynamics. PSA inputs varied on glacial/interglacial timescales, with southern South American sources dominating up to 88% of the lithogenic fraction (mainly Patagonia, which provided up to 68%) during cold periods, while southern African sources were more important during interglacials. During the warmer Marine Isotope Stage (MIS) 3 of the last glacial period, lithogenic fluxes were twice that of colder MIS2 and MIS4 at times, and showed unique isotope ratios best explained by Antarctic-derived IRD, likely from the Weddell Sea. The IRD intrusions contributed up to 41% at times and followed Antarctic millennial warming events that raised temperatures, causing instability of icesheet margins. High IRD was synchronous with increased bioavailable iron, nutrient utilization, high biological productivity, and decreased atmospheric CO2. Overall, TN057-6 sediments record systematic Southern Hemisphere climate shifts and cryospheric changes that impacted biogeochemical cycling on both glacial/interglacial and subglacial timescales.

Shorter versus longer duration antibiotic regimens for treatment of culture-positive neonatal sepsis.

OBJECTIVES: This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the safety and effectiveness of shorter versus longer duration antibiotic regimens for the treatment of culture-positive neonatal sepsis with or without meningitis.

Five million years of Antarctic Circumpolar Current strength variability.

The Antarctic Circumpolar Current (ACC) represents the world's largest ocean-current system and affects global ocean circulation, climate and Antarctic ice-sheet stability1-3. Today, ACC dynamics are controlled by atmospheric forcing, oceanic density gradients and eddy activity4. Whereas palaeoceanographic reconstructions exhibit regional heterogeneity in ACC position and strength over Pleistocene glacial-interglacial cycles5-8, the long-term evolution of the ACC is poorly known. Here we document changes in ACC strength from sediment cores in the Pacific Southern Ocean. We find no linear long-term trend in ACC flow since 5.3 million years ago (Ma), in contrast to global cooling9 and increasing global ice volume10. Instead, we observe a reversal on a million-year timescale, from increasing ACC strength during Pliocene global cooling to a subsequent decrease with further Early Pleistocene cooling. This shift in the ACC regime coincided with a Southern Ocean reconfiguration that altered the sensitivity of the ACC to atmospheric and oceanic forcings11-13. We find ACC strength changes to be closely linked to 400,000-year eccentricity cycles, probably originating from modulation of precessional changes in the South Pacific jet stream linked to tropical Pacific temperature variability14. A persistent link between weaker ACC flow, equatorward-shifted opal deposition and reduced atmospheric CO2 during glacial periods first emerged during the Mid-Pleistocene Transition (MPT). The strongest ACC flow occurred during warmer-than-present intervals of the Plio-Pleistocene, providing evidence of potentially increasing ACC flow with future climate warming.

Implementation of a Web Camera System in an Australian Neonatal Intensive Care Unit: Pre- and Postevaluation of the Parent and Staff Experience.

Background: Admission to a neonatal intensive care unit (NICU) for prematurity or illness is necessary for approximately 20% of newborns in Australia, resulting in parent-infant separation. Web cameras in the NICU provide a virtual link for parents to remain remotely connected to their infant during admission. Web camera use is increasing; however, there is limited evidence on the impact of web cameras on parents, infants, and neonatal staff. Objective: There were two objectives: (1) to determine the attitudes of parents and staff toward web cameras in the NICU and (2) to compare parental depression, anxiety, and stress levels using validated scales before and after web camera implementation in the NICU. Methods: A pre- and postevaluation survey was administered before and after implementation of the NICVIEW camera system in a tertiary NICU in Sydney, Australia. The NICVIEW camera system provides secure real-time viewing of infants and can be accessed from any device with an internet connection. Surveys were administered to parents of inpatients and staff, and included open- and closed-ended questions and Likert scales. Survey questions aimed to determine parent and staff attitudes and use of web cameras before and after implementation. In addition, pre- and postimplementation parental levels of depression, anxiety, and stress, as measured by the 21-item version of the Depression Anxiety Stress Scale (DASS-21) and Parental Stressor Scale: Neonatal Intensive Care Unit, were recorded. Results: In total, 94 parents and 109 staff members completed the pre- and postimplementation surveys. Post implementation, 43 of 44 (98%) parents supported web cameras, and 40 of 42 (95%) parents stated that they used web cameras. The most common reasons for support from parents included web cameras making parents feel more at ease, facilitating parent-infant bonding, increasing parental confidence in staff, and allowing others to see infants. There was no significant difference between the parental groups for the depression, anxiety, or stress scales measured by DASS-21. Staff support for web cameras increased significantly from 34 of 42 (81%) participants before to 64 of 67 (96%) participants after implementation (P=.01). Following implementation, there was a resolution in staff concerns about web cameras having an adverse impact on staff roles and privacy and security concerns. Conclusions: Web camera use in a tertiary Australian NICU was strongly supported by parents and staff and may reduce parental stress, facilitate parent-infant bonding, and encourage positive parent-staff engagement. Web cameras are a feasible method of providing continuity of care for families and should be considered as a standard of care in similarly resourced settings.

Re-thinking How We Teach Quality Improvement: Adding Meaning to an ACGME Requirement.

BACKGROUND: Many residency programs have struggled to meaningfully meet the ACGME quality improvement (QI) requirements. Similarly, our residents were receiving limited QI education, and their longitudinal projects were ineffective. AIM: Create an integrated didactic and experiential learning environment that equips residents to become leaders of QI. SETTING AND PARTICIPANTS: Internal medicine (IM) residency program of 45 residents in a large community hospital. PROGRAM DESCRIPTION: This curriculum included eight content areas. Games, real-life application, and project celebrations cultivated engagement. Sessions occurred during residents' 2-week outpatient rotations. Project development was standardized. PROGRAM EVALUATION: The QI Knowledge Application Tool-Revised (QIKAT-R) and separate surveys were used before and after the curriculum's implementation to evaluate resident QI knowledge and confidence, respectively. We also tracked QI scholarship and faculty engagement. Mean QIKAT-R scores improved significantly from 7.0 (SD 2.9) at baseline to 16.6 (SD 4.7) post-curriculum (n = 37 pairs, p = 0.043). Residents' adverse event reporting increased from 44% (19/43) at baseline to 90% (28/31) post-curriculum. Seven presentations were accepted for local, regional, and national conferences, compared with one presentation the preceding year. DISCUSSION: A QI curriculum can be successfully integrated in a "4 + 2" program.

Overuse of Acid-Suppression Therapy at an Urban Tertiary Hospital.

OBJECTIVES: Acid-suppressive therapy (AST) is widely used for gastrointestinal prophylaxis in hospitalized patients, particularly to prevent stress-related mucosal bleeding in critically ill individuals. Previous reports suggest gross overutilization and continuation of unnecessary therapy, which have been linked to several adverse effects. METHODS: Retrospective chart review at a large tertiary care hospital, evaluating the use of AST for ulcer prophylaxis in accordance with American Society of Health-System Pharmacists' guidelines and the less commonly studied nonsteroidal anti-inflammatory drug-related ulcer prophylaxis guidelines. RESULTS: A total of 119 (39.3%) patients who received AST met either American Society of Health-System Pharmacists guidelines or nonsteroidal anti-inflammatory drug-related prophylaxis guidelines. Subjects whose AST was appropriate were older, had a higher Charlson Comorbidity Index (P < 0.001), and were more often men (P = 0.005). The rate of discontinuation at discharge was 70.7%; subjects whose prescriptions were not discontinued were older, had a higher Charlson Comorbidity Index, and longer hospital and intensive care unit lengths of stay (P < 0.001). Family medicine physicians, hospitalists, and surgeons prescribed AST similarly; internal medicine physicians demonstrated higher adherence with guidelines than all others (P = 0.02). Adherence varied by etiology; cardiology patients were treated with the highest level of appropriateness (53.6%), whereas those admitted for gastrointestinal diagnoses demonstrated the lowest (17.6%, P = 0.03). CONCLUSIONS: Inappropriate prescribing of AST for ulcer prophylaxis remains problematic. There may be differences in prescribing habits of physicians of different specialties. Age and comorbidity scores were associated with inappropriate prescribing and continuation of medication at discharge. Interventions to raise prescribers' awareness of ulcer risk factors in hospitalized patients, both in the intensive care unit and those who are noncritically ill, are needed.

The use of electronic health records in the exam room and patient satisfaction: a systematic review.

BACKGROUND: Physicians may hesitate to implement electronic health record (EHR) systems because they fear a decrease in patient satisfaction. We conducted a systematic review to determine whether physician EHR use in the patient room affects patient satisfaction. METHODS: We searched the literature using MEDLINE (Ovid), EMBASE, CINAHL, Cochrane Library, PsycINFO, Proceedings First, and ProQuest Digital Dissertations. Our inclusion criteria were a description of physician EHR use in the examination room, EHR use in an outpatient setting, setting in the United States, publication year no earlier than 2000, and measurement of patient satisfaction. We included both qualitative and quantitative research. We included 7 articles in the final analysis: 3 cross-sectional, and 4 pre-design and post-design. RESULTS: Several studies had methodological concerns. Six studies found that physician EHR use had either a positive or neutral effect on patient satisfaction. One study found a negative effect on the physicians' perception of patient satisfaction. The reported statistical results from these studies were not homogenous enough for meta-analysis. CONCLUSION: Studies examining physician EHR use have found mostly neutral or positive effects on patient satisfaction, but primary care researchers need to conduct further research for a more definitive answer.

A proposed new model of hypertensive treatment behavior in African Americans.

African Americans have poorer levels of hypertensive control than their white counterparts in the US population. Multiple studies have examined the factors that contribute to this discrepancy, but no literature review has yet attempted to place these findings within the framework of health behavior theory. The Health Belief Model (HBM) and social cognitive theory (SCT) are 2 complementary models of health behavior theory that provide a unifying structure to interpret this broad body of literature. Inaccurate lay public understanding of hypertensive illness and its consequences contributes to decreased perceived severity and susceptibility to hypertension; lower rates of compliance with lifestyle recommendations reflect several common perceived barriers along with low self-efficacy and outcome efficacy regarding hypertensive treatments. Public health workers and health care providers must understand these factors within a socioecological perspective if they are to design effective interventions to assist African Americans in meeting antihypertensive treatment goals.

Today I'm grieving a physician suicide.

An estimated 250 physicians will commit suicide this year. In this essay, the author shares her grief and guilt over the suicide of a colleague while reflecting on both the scale of this largely unacknowledged problem and the stigma that prevents our profession from adequately addressing it. Physicians are as vulnerable to depression as is the general population, but they seek care at lower rates and commit suicide at higher rates. Fears regarding loss of professional stature and respect often prevent depressed physicians from accessing needed mental health services. This same stigma can also compound the mourning process of the colleagues and family of those physicians who complete suicide. As a profession, physicians must strengthen existing resources for impaired colleagues and work collaboratively to destigmatize treatment for mental illnesses.