Factors Associated with Cancer Screening Among Hopi Men.

Cancer screening rates remain low among American Indian men, and cancer screening behaviors and barriers to cancer screening among American Indian men are not well understood. This study evaluated cancer screening behaviors in 102 Hopi men who were 50 years of age or older from the Hopi Survey of Cancer and Chronic Disease. Reported cancer screening frequencies were 15.7%, 45.1%, and 35.3% for fecal occult blood test (FOBT), colonoscopy, and prostate-specific antigen (PSA) test, respectively. Among men who reported having had a FOBT, 81.2% had the test more than 1 year ago. Among men who reported a colonoscopy, 60.8% had colonoscopy within the past 3 years. Similarly, among men who reported having had PSA, 72.3% had PSA within the past 3 years. "No one told me" was the most common answer for not undergoing FOBT (33.7%), colonoscopy (48.2%), and PSA (39.4%). Men who reported having had a PSA or digital rectal exam were three times as likely to also report having a FOBT or colonoscopy (odds ratio [OR] 3.19, 95% confidence interval [CI]: 1.21-8.46). Younger age (< 65) was associated with reduced odds of ever having prostate cancer screening (OR 0.28, 95% CI: 0.10-0.77). Ever having colorectal cancer screening and previous diagnosis of cancer increased odds of ever having prostate cancer screening (OR 3.15, 95% CI: 1.13-8.81 and OR 5.28, 95% CI: 1.15-24.18 respectively). This study illustrates the importance of community cancer education for men to improve cancer screening participation.

The impact of entrustment assessments on feedback and learning: Trainee perspectives.

CONTEXT: Assessment for and of learning in workplace settings is at the heart of competency-based medical education. In postgraduate medical education (PGME), entrustable professional activities (EPAs) and entrustment scales are increasingly used to assess competence. However, the educational impacts of these assessment approaches remain unknown. Therefore, this study aimed to explore trainee perceptions regarding the impacts of EPAs and entrustment scales on feedback and learning processes in the clinical setting. METHODS: Four focus groups were conducted with postgraduate trainees in anaesthesia, emergency medicine, general internal medicine and nephrology at McMaster University in Hamilton, Ontario, Canada. Data collection and analysis were informed by principles of constructivist grounded theory. RESULTS: Entrustable professional activities representing well-defined tasks are perceived as potentially effective drivers for feedback and learning. Use of EPAs and entrustment scales, however, may augment existing tensions between developmental (for learning) and decision-making (of learning) assessment functions. Three key dilemmas seem to influence the impact of EPA-based assessment approaches on residents' learning: (a) standardisation of outcomes versus flexibility in assessment to align with individual learning experiences; (b) assessment tasks focusing on performance standards versus opportunities for learning, and (c) feedback focusing on numeric entrustment scores versus narrative and dialogue. Use of entrustment as an assessment outcome may impact trainees' motivation and feelings of self-efficacy, further enhancing tensions between learning and performance. CONCLUSIONS: Entrustable professional activities and entrustment scales may support assessment for learning in PGME. However, their successful implementation requires the careful management of dilemmas that arise in EPA-based assessment in order to support competence development.

Does A Low 6-Minute Walk Distance Predict Elevated Postoperative Troponin?

Our study of 100 major vascular and renal transplant patients evaluated the 6-minute walk test (6MWT) as an indicator of perioperative myocardial injury, using troponin as a marker. Using logistic regression and the area under the receiving operator characteristic curve, we compared the 6MWT to the Revised Cardiac Risk Index and metabolic equivalents. Only the 6MWT was associated with elevated postoperative troponins (95% CI, 0.98-0.99). However, the 6MWT area under the receiving operator characteristic curve (0.71 [95% CI, 0.57-0.85]) was not different from the Revised Cardiac Risk Index (P = .23) or metabolic equivalents (P = .14). The 6MWT may have a role in cardiac risk stratification in the perioperative setting.

Evolution and Transmission of Carbapenem-Resistant Klebsiella pneumoniae Expressing the blaOXA-232 Gene During an Institutional Outbreak Associated With Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Whole-genome sequencing (WGS) is an emerging and powerful technique by which to perform epidemiological studies in outbreak situations. METHODS: WGS was used to identify and evaluate an outbreak of OXA-232-expressing carbapenem-resistant Klebsiella pneumoniae (CRKP) transmitted to 16 patients over the course of 40 weeks via endoscopic retrograde cholangiopancreatography procedures at a single institution. WGS was performed on 32 OXA-232 CRKP isolates (1-7 per patient) and single-nucleotide variants (SNVs) were analyzed, with reference to the index patient's isolate. RESULTS: Interhost genetic diversity of isolates was between 0 and 15 SNVs during the outbreak; molecular clock calculations estimated 12.31 substitutions per genome per year (95% credibility interval, 7.81-17.05). Both intra- and interpatient diversification at the plasmid and transposon level was observed, significantly impacting the antibiogram of outbreak isolates. The majority of isolates evaluated (n = 27) harbored a blaCTX-M-15 gene, but some (n = 5) lacked the transposon carrying this gene, which resulted in susceptibility to aztreonam and third- and fourth-generation cephalosporins. Similarly, an isolate from a colonized patient lacked the transposon carrying rmtF and aac(6')lb genes, resulting in susceptibility to aminoglycosides. CONCLUSIONS: This study broadens the understanding of how bacteria diversify at the genomic level over the course of a defined outbreak and provides reference for future outbreak investigations.

Duodenoscope-Related Outbreak of a Carbapenem-Resistant Klebsiella pneumoniae Identified Using Advanced Molecular Diagnostics.

Background: Carbapenem-resistant Klebsiella pneumoniae infections are increasingly prevalent in North American hospitals. We describe an outbreak of carbapenem-resistant K. pneumoniae containing the blaOXA-232 gene transmitted by contaminated duodenoscopes during endoscopic retrograde cholangiopancreatography (ERCP) procedures. Methods: An outbreak investigation was performed when 9 patients with blaOXA-232 carbapenem-resistant K. pneumoniae infections were identified at a tertiary care hospital. The investigation included 2 case-control studies, review of duodenoscope reprocessing procedures, and culture of devices. Carbapenem-resistant Enterobacteriacieae (CRE) isolates were evaluated with polymerase chain reaction analysis for carbapenemase genes, and isolates with the blaOXA-232 gene were subjected to whole-genome sequencing and chromosome single-nucleotide polymorphism analysis. On recognition of ERCP as a key risk factor for infection, targeted patient notification and CRE screening cultures were performed. Results: Molecular testing ultimately identified 17 patients with blaOxa-232 carbapenem-resistant K. pneumoniae isolates, including 9 with infections, 7 asymptomatic carriers who had undergone ERCP, and 1 additional patient who had been hospitalized in India and was probably the initial carrier. Two case-control studies established a point-source outbreak associated with 2 specific duodenoscopes. A field investigation of the use, reprocessing, and storage of deuodenoscopes did not identify deviations from US Food and Drug Administration or manufacturer recommendations for reprocessing. Conclusions: This outbreak demonstrated the previously underappreciated potential for duodenoscopes to transmit disease, even after undergoing high-level disinfection according to manufacturers' guidelines.

Risk factors associated with the transmission of carbapenem-resistant Enterobacteriaceae via contaminated duodenoscopes.

BACKGROUND AND AIMS: The duodenoscopes used to perform ERCP have been implicated in several outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) infection. The risk factors for CRE transmission via contaminated duodenoscopes remain unclear. METHODS: In this retrospective, single-center, case-control study, all patients who underwent ERCP with either 1 of 2 contaminated duodenoscopes were evaluated. We compared the patients who acquired CRE (active infection or colonization) with those who did not. RESULTS: Between October 3, 2014, and January 28, 2015, a total of 125 procedures were performed on 115 patients by using either of the contaminated duodenoscopes. Culture data were available for 104 of the 115 exposed patients (90.4%). Among these patients, 15 (14.4%) became actively infected (n = 8, 7.7%) or colonized (n = 7, 6.7%) with CRE. On univariate analysis, recent antibiotic exposure (66.7% vs 37.1%; P = .046), active inpatient status (60.0% vs 28.1%; P = .034), and a history of cholangiocarcinoma (26.7% vs 3.4%; P = .008) were patient characteristics associated with an increased risk of CRE infection. Biliary stent placement (53.3% vs 22.5%; P = .024) during ERCP was a significant procedure-related risk factor. After adjusting for cholangiocarcinoma, biliary stent placement (odds ratio 3.62; 95% confidence interval, 1.12-11.67), and active inpatient status (odds ratio 3.74; 95% confidence interval, 1.15-12.12) remained independent risk factors for CRE transmission. CONCLUSIONS: In patients undergoing ERCP with a contaminated duodenoscope, biliary stent placement, a diagnosis of cholangiocarcinoma, and active inpatient status are associated with an increased risk of CRE transmission.

Formative Assessment to Improve Cancer Screenings in American Indian Men: Native Patient Navigator and mHealth Texting.

Cancer screening rates among American Indian men remain low, without programs specifically designed for men. This paper describes the Community-Based Participatory Research processes and assessment of cancer screening behavior and the appropriateness of the mHealth approach for Hopi men's promotion of cancer screenings. This Community-Based Participatory Research included a partnership with H.O.P.I. (Hopi Office of Prevention and Intervention) Cancer Support Services and the Hopi Community Advisory Committee. Cellular phone usage was assessed among male participants in a wellness program utilizing text messaging. Community surveys were conducted with Hopi men (50 years of age or older). The survey revealed colorectal cancer screening rate increased from 51% in 2012 to 71% in 2018, while prostate cancer screening rate had not changed (35% in 2012 and 37% in 2018). Past cancer screening was associated with having additional cancer screening. A cellular phone was commonly used by Hopi men, but not for healthcare or wellness. Cellular phone ownership increased odds of prostate cancer screening in the unadjusted model (OR 9.00, 95% CI: 1.11-73.07), but not in the adjusted model. Cellular phones may be applied for health promotion among Hopi men, but use of cellular phones to improve cancer screening participation needs further investigation.

Prevalence and risks factors of age-related macular degeneration in Oklahoma Indians: the Vision Keepers Study.

OBJECTIVE: To determine the prevalence of age-related macular degeneration (AMD) and to identify its risk factors in an Oklahoma Indian population. DESIGN: Cross-sectional study design. PARTICIPANTS: Included 1019 Oklahoma Indians who participated in baseline and second examinations of the Strong Heart Study. METHODS: Retinal photographs of at least 1 eye were obtained and graded for AMD by the University of Wisconsin Ocular Epidemiology Reading Center. Retinal photographs of 986 participants were considered gradable and were included in the study. MAIN OUTCOME MEASURES: Age-related macular degeneration (early and late). RESULTS: The overall prevalence of AMD in the study was 35.2%, including a prevalence of 0.81% for late AMD. The prevalence of early AMD increased from 30.6% in those aged 48 to 59 years to 46.1% in those 70 to 82 years of age. When potential risk factors were analyzed individually (univariate analyses), men with hypertension had a significantly higher prevalence of AMD (P = 0.02) than those without hypertension. In women, high-density lipoprotein cholesterol and sun exposure were associated positively with the prevalence of AMD (P = 0.01), whereas a history of using multivitamins was associated with lower AMD prevalence (P = 0.005). When multiple risk factors were analyzed simultaneously using logistic regression, only age showed significant association with AMD in both men (P = 0.02) and women (P<0.0001) and was the only significant risk factor in men. In women, multivitamin use and total cholesterol had a significant inverse association with AMD, whereas sun exposure and high-density lipoprotein cholesterol had a positive association. When men and women were combined, age and high-density lipoprotein cholesterol had significant positive associations, whereas total cholesterol, multivitamin use, and current alcohol use showed a significant inverse association with AMD. CONCLUSIONS: This study was the first to report a detailed prevalence of AMD in Oklahoma Indians and its risk factors. The prevalence seemed to be relatively high compared with that in other ethnic groups. Some of the modifiable risk factors identified confirmed previous findings and can be used to design preventive programs to reduce the burden of AMD, although longitudinal data are still needed.

Multidrug Resistant Acinetobacter baumanii: A 15-Year Trend Analysis.

From 2000 to 2009, rates of multidrug-resistant Acinetobacter baumanii increased 10-fold to 0.2 per 1,000 patient days. From 2010 to 2015, however, rates markedly declined and have stayed below 0.05 per 1,000 patient days. Herein, we present a 15-year trend analysis and discuss interventions that may have led to the decline.Infect Control Hosp Epidemiol 2018;39:608-611.

Noninfectious Hospital Adverse Events Decline After Elimination of Contact Precautions for MRSA and VRE.

OBJECTIVETo evaluate the impact of discontinuing routine contact precautions (CP) for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) on hospital adverse events.DESIGNRetrospective, nonrandomized, observational, quasi-experimental study.SETTINGAcademic medical center with single-occupancy rooms.PARTICIPANTSInpatients.METHODSWe compared hospital reportable adverse events 1 year before and 1 year after discontinuation of routine CP for endemic MRSA and VRE (preintervention and postintervention periods, respectively). Throughout the preintervention period, daily chlorhexidine gluconate bathing was expanded to nearly all inpatients. Chart reviews were performed to identify which patients and events were associated with CP for MRSA/VRE in the preintervention period as well as the patients that would have met prior criteria for MRSA/VRE CP but were not isolated in the postintervention period. Adverse events during the 2 periods were compared using segmented and mixed-effects Poisson regression models.RESULTSThere were 24,732 admissions in the preintervention period and 25,536 in the postintervention period. Noninfectious adverse events (ie, postoperative respiratory failure, hemorrhage/hematoma, thrombosis, wound dehiscence, pressure ulcers, and falls or trauma) decreased by 19% (12.3 to 10.0 per 1,000 admissions, P=.022) from the preintervention to the postintervention period. There was no significant difference in the rate of infectious adverse events after CP discontinuation (20.7 to 19.4 per 1,000 admissions, P=.33). Patients with MRSA/VRE showed the largest reduction in noninfectious adverse events after CP discontinuation, with a 72% reduction (21.4 to 6.08 per 1,000 MRSA/VRE admissions; P<.001).CONCLUSIONAfter discontinuing routine CP for endemic MRSA/VRE, the rate of noninfectious adverse events declined, especially in patients who no longer required isolation. This suggests that elimination of CP may substantially reduce noninfectious adverse events.Infect Control Hosp Epidemiol 2018;788-796.

Elimination of Routine Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: A Retrospective Quasi-Experimental Study.

OBJECTIVE To evaluate the impact of discontinuation of contact precautions (CP) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) and expansion of chlorhexidine gluconate (CHG) use on the health system. DESIGN Retrospective, nonrandomized, observational, quasi-experimental study. SETTING Two California hospitals. PARTICIPANTS Inpatients. METHODS We compared hospital-wide laboratory-identified clinical culture rates (as a marker of healthcare-associated infections) 1 year before and after routine CP for endemic MRSA and VRE were discontinued and CHG bathing was expanded to all units. Culture data from patients and cost data on material utilization were collected. Nursing time spent donning personal protective equipment was assessed and quantified using time-driven activity-based costing. RESULTS Average positive culture rates before and after discontinuing CP were 0.40 and 0.32 cultures/100 admissions for MRSA (P=.09), and 0.48 and 0.40 cultures/100 admissions for VRE (P=.14). When combining isolation gown and CHG costs, the health system saved $643,776 in 1 year. Before the change, 28.5% intensive care unit and 19% medicine/surgery beds were on CP for MRSA/VRE. On the basis of average room entries and donning time, estimated nursing time spent donning personal protective equipment for MRSA/VRE before the change was 45,277 hours/year (estimated cost, $4.6 million). CONCLUSION Discontinuing routine CP for endemic MRSA and VRE did not result in increased rates of MRSA or VRE after 1 year. With cost savings on materials, decreased healthcare worker time, and no concomitant increase in possible infections, elimination of routine CP may add substantial value to inpatient care delivery. Infect Control Hosp Epidemiol 2016;1-8.

Routine Use of Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: Which Way Is the Pendulum Swinging?

BACKGROUND Studies have suggested that contact precautions (CP) for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus may have risks that outweigh the benefits. These risks, coupled with more widespread use of horizontal interventions such as daily bathing with chlorhexidine gluconate, have brought into question the value of routine CP for these organisms. OBJECTIVE To assess the state of utilization of CP as well as adjunctive measures to reduce the risk of transmission in US hospitals. DESIGN Cross-sectional survey. PARTICIPANTS Total of 751 physician members of the Emerging Infections Network. METHODS An 8-question electronic survey distributed by email. RESULTS A total of 426/751 (57%) responded to the survey; 337/364 (93%) of respondents use routine CP for methicillin-resistant S. aureus and 335/364 (92%) use routine CP for vancomycin-resistant enterococcus. The most widely used trigger for initiation of CP for both pathogens was positive clinical culture. Practices for discontinuation of isolation varied widely. We found that 325/354 (92%) perform routine chlorhexidine gluconate bathing and 236/353 (67%) perform S. aureus decolonization with mupirocin for 1 or more subsets of inpatients, and 82/356 (23%) reported using either hydrogen peroxide vapor or ultraviolet-C room disinfection at discharge. Free text responses noted frustration and variation in the application, practice, and process for initiation and discontinuation of CP. CONCLUSIONS Use of CP for methicillin-resistant S. aureus and vancomycin-resistant enterococcus remains commonplace, although horizontal interventions such as chlorhexidine gluconate bathing are increasingly used. The heterogeneity of practices and policies was striking. Evidence-based guidelines regarding CP and horizontal interventions are needed. Infect. Control Hosp. Epidemiol. 2015;37(1):36-40.

Investigation of a suspected nosocomial transmission of blaKPC3-mediated carbapenem-resistant Klebsiella pneumoniae by whole genome sequencing.

Whole genome sequencing (WGS) was compared to pulse-field gel electrophoresis (PFGE) of XbaI-digested genomic DNA, as methods by which to evaluate a potential transmission of carbapenem-resistant Klebsiella pneumoniae between 2 hospital inpatients. PFGE result demonstrated only 1-band difference between the isolates, suggesting probable relatedness. In contrast, while WGS data demonstrated the same sequence type and very similar chromosomal sequences, over 20 single nucleotide variants were identified between the isolates, bringing into question whether there was a transmission event. WGS also identified an additional plasmid, with an XbaI restriction site in the isolates of the second patient that was not identified by PFGE. While WGS provided additional information that was not available by PFGE, in this study, neither method could definitively conclude the relatedness between the isolates.

Visual impairment and eye abnormalities in Oklahoma Indians.

OBJECTIVE: To determine the prevalence of visual impairment and eye abnormalities in Oklahoma Indians. METHODS: The cross-sectional study included 1019 Oklahoma Indians, aged 48 to 82 years; 60.2% were women. All participants gave a personal interview, and all underwent an eye examination, including the determination of best-corrected visual acuity and an ophthalmoscopic examination. In addition, two 45 degrees fundus photographs were taken of each eye, and these photographs were graded by the Fundus Photography Reading Center at the University of Wisconsin, Madison. RESULTS: Among the 1019 participants, 77.4% had a visual acuity of 20/20 or better, 19.5% and 2.5% had visual acuities of between 20/25 and 20/40 and between 20/50 and 20/190, respectively; and 0.6% were legally blind, all in the better eye. Cataract was the most frequent contributing cause and age-related macular degeneration the second most frequent contributing cause of visual impairment. The overall prevalence proportions of age-related macular degeneration, cataract, diabetic retinopathy, and definite glaucoma were 33.6%, 39.6%, 20.1%, and 5.6%, respectively. Most of the other eye abnormalities were rare in the study participants, except for pinguecula (42.4%) and dermatochalasis (30.1%). CONCLUSIONS: Oklahoma Indians have a higher prevalence of visual impairment, age-related macular degeneration, and diabetic retinopathy than other ethnic groups. The implementation of adequate treatment and prevention programs for eye diseases is indicated.

Discord among performance measures for central line-associated bloodstream infection.

BACKGROUND: Central line-associated bloodstream infection (CLABSI) is a national target for mandatory reporting and a Centers for Medicare and Medicaid Services target for value-based purchasing. Differences in chart review versus claims-based metrics used by national agencies and groups raise concerns about the validity of these measures. OBJECTIVE: Evaluate consistency and reasons for discordance among chart review and claims-based CLABSI events. METHODS: We conducted 2 multicenter retrospective cohort studies within 6 academic institutions. A total of 150 consecutive patients were identified with CLABSI on the basis of National Healthcare Safety Network (NHSN) criteria (NHSN cohort), and an additional 150 consecutive patients were identified with CLABSI on the basis of claims codes (claims cohort). All events had full-text medical record reviews and were identified as concordant or discordant with the other metric. RESULTS: In the NHSN cohort, there were 152 CLABSIs among 150 patients, and 73.0% of these cases were discordant with claims data. Common reasons for the lack of associated claims codes included coding omission and lack of physician documentation of bacteremia cause. In the claims cohort, there were 150 CLABSIs among 150 patients, and 65.3% of these cases were discordant with NHSN criteria. Common reasons for the lack of NHSN reporting were identification of non-CLABSI with bacteremia meeting Centers for Disease Control and Prevention (CDC) criteria for an alternative infection source. CONCLUSION: Substantial discordance between NHSN and claims-based CLABSI indicators persists. Compared with standardized CDC chart review criteria, claims data often had both coding omissions and misclassification of non-CLABSI infections as CLABSI. Additionally, claims did not identify any additional CLABSIs for CDC reporting. NHSN criteria are a more consistent interhospital standard for CLABSI reporting.

A common mechanism for mitotic inactivation of C2H2 zinc finger DNA-binding domains.

Many nuclear proteins are inactivated during mitotic entry, presumably as a prerequisite to chromatin condensation and cell division. C2H2 zinc fingers define the largest transcription factor family in the human proteome. The linker separating finger motifs is highly conserved and resembles TGEKP in more than 5000 occurrences. However, the reason for this conservation is not fully understood. We demonstrate that all three linkers in the DNA-binding domain of Ikaros are phosphorylated during mitosis. Phosphomimetic substitutions abolished DNA-binding and pericentromeric localization. A linker within Sp1 was also phosphorylated, suggesting that linker phosphorylation provides a global mechanism for inactivation of the C2H2 family.