A parent-implemented embedded AAC intervention for teaching navigational requests and other communicative functions to children with Autism spectrum disorder.

This study evaluated the effectiveness of an embedded naturalistic intervention for teaching augmentative and alternative communication (AAC) application responses to three preschool-aged males with autism spectrum disorder (ASD). Parents were taught to embed opportunities for their child to communicate with a grid-based AAC application during every-day routines such as play or mealtime. Communication targets included requesting objects using two-step taxonomic navigational responses, and requesting assistance, rejecting items, or making social comments/responses using a two-step message-strip response. During intervention, parents used strategies such as time delay, prompting, reinforcement, and device proximity (faded over time) to encourage target responses. Display formats and intervention targets were selected in consideration of prior dynamic assessment results. Effects of intervention were evaluated using a multiple probe across participants design. For functional navigational AAC item requesting, all three participants showed an immediate increase in responding that maintained at high levels. Functional AAC responding for other communicative purposes also increased, but at a more gradual pace. All three participants showed generalized responding when new items were added to displays, and when display pages with a larger array of folders and vocabulary items were introduced. Generalization to labeling tasks was mixed.

Dynamic assessment of augmentative and alternative communication application grid formats and communicative targets for children with autism spectrum disorder.

Six children with autism spectrum disorder (ASD) participated in dynamic assessment to determine whether the complexity of grid-based augmentative and alternative communication (AAC) application displays impacted the level of instructional supports needed for responding across different communicative functions/parts of speech. Dynamic assessment was integrated into a single-case multi-element design. The researchers examined the effects of three different display formats that varied in (a) array size, and (b) the number of steps needed to make a response, on the average levels of support needed to make item requests and action/social word responses. Three participants demonstrated high levels of independence when requesting items with displays that utilized small arrays and did not require navigation. These participants also showed rapid increases in their ability to make item requests with displays that required two-step navigation, and began to use action and social words across displays with decreasing levels of support. In comparison, the three remaining participants did not demonstrate consistent independence with any display or communicative function, but did show differences in levels of supports (e.g., overall less support needed for less complex displays and for item requests in comparison to action and social words). Implications for individualized AAC assessment and display selection for children with ASD are discussed.

Assessment of Community Event-Based Surveillance for Ebola Virus Disease, Sierra Leone, 2015.

In 2015, community event-based surveillance (CEBS) was implemented in Sierra Leone to assist with the detection of Ebola virus disease (EVD) cases. We assessed the sensitivity of CEBS for finding EVD cases during a 7-month period, and in a 6-week subanalysis, we assessed the timeliness of reporting cases with no known epidemiologic links at time of detection. Of the 12,126 CEBS reports, 287 (2%) met the suspected case definition, and 16 were confirmed positive. CEBS detected 30% (16/53) of the EVD cases identified during the study period. During the subanalysis, CEBS staff identified 4 of 6 cases with no epidemiologic links. These CEBS-detected cases were identified more rapidly than those detected by the national surveillance system; however, too few cases were detected to determine system timeliness. Although CEBS detected EVD cases, it largely generated false alerts. Future versions of community-based surveillance could improve case detection through increased staff training and community engagement.

Unintended adverse consequences of a clinical decision support system: two cases.

Many institutions have implemented clinical decision support systems (CDSSs). While CDSS research papers have focused on benefits of these systems, there is a smaller body of literature showing that CDSSs may also produce unintended adverse consequences (UACs). Detailed here are 2 cases of UACs resulting from a CDSS. Both of these cases were related to external systems that fed data into the CDSS. In the first case, lack of knowledge of data categorization in an external pharmacy system produced a UAC; in the second case, the change of a clinical laboratory instrument produced the UAC. CDSSs rely on data from many external systems. These systems are dynamic and may have changes in hardware, software, vendors, or processes. Such changes can affect the accuracy of CDSSs. These cases point to the need for the CDSS team to be familiar with these external systems. This team (manager and alert builders) should include members in specific clinical specialties with deep knowledge of these external systems.

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.

IMPORTANCE: The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. OBJECTIVE: To provide new and updated evidence-based recommendations for the prevention of SSI. EVIDENCE REVIEW: A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. FINDINGS: Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. CONCLUSIONS AND RELEVANCE: This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

Community Event-Based Surveillance for Ebola Virus Disease in Sierra Leone: Implementation of a National-Level System During a Crisis.

INTRODUCTION:  There are few documented examples of community networks that have used unstructured information to support surveillance during a health emergency. In January 2015, the Ebola Response Consortium rapidly implemented community event-based surveillance for Ebola virus disease at a national scale in Sierra Leone. METHODS: Community event based surveillance uses community health monitors in each community to provide an early warning system of events that are suggestive of Ebola virus disease transmission. The Ebola Response Consortium, a consortium of 15 nongovernmental organizations, applied a standardized procedure to implement community event-based surveillance across nine of the 14 districts. To evaluate system performance during the first six months of operation (March to August 2015), we conducted a process evaluation. We analyzed the production of alerts, conducted interviews with surveillance stakeholders and performed rapid evaluations of community health monitors to assess their knowledge and reported challenges. RESULTS: The training and procurement of supplies was expected to begin in January 2015 and attain full scale by March 2015. We found several logistical challenges that delayed full implementation until June 2015 when the epidemic was past its peak. Community health monitors reported 9,131 alerts during this period. On average, 82% of community health monitors reported to their supervisor at least once per week. Most alerts (87%) reported by community health monitors were deaths unrelated to Ebola. During the rapid evaluations, the mean recall by community health monitors was three of the six trigger events. Implementation of the national system achieved scale, but three months later than anticipated. DISCUSSION: Community event based surveillance generated consistent surveillance information during periods of no- to low-levels of transmission across districts. We interpret this to mean that community health monitors are an effective tool for generating useful, unstructured information at the village level. However, to maximize validity, the triggers require more training, may be too many in number, and need increased relevance to the context of the tail end of the epidemic.

Interventions that increase use of adult immunization and cancer screening services: a meta-analysis.

PURPOSE: The relative effectiveness of the diverse approaches used to promote preventive care activities, such as cancer screening and adult immunization, is unknown. Despite many high-quality published studies, practices and policymakers attempting to improve preventive care have little definitive information on which to base decisions. Thus, we quantitatively assessed the relative effectiveness of previously studied approaches for improving adherence to adult immunization and cancer screening guidelines. DATA SOURCES: MEDLINE, the Cochrane Effective Practice and Organization of Care Review Group register, previous systematic reviews, and the Medicare Health Care Quality Improvement Project database. STUDY SELECTION: Controlled clinical trials that assessed interventions to increase use of immunizations for influenza and pneumococcal pneumonia and screening for colon, breast, and cervical cancer in adults. DATA EXTRACTION: Two reviewers independently extracted data on characteristics and outcomes from unmasked articles. Intervention components to increase use of services were classified as reminder, feedback, education, financial incentive, legislative action, organizational change, or mass media campaign. DATA SYNTHESIS: Of 552 abstracts and articles, 108 met the inclusion criteria. To assess the effect of intervention components, meta-regression models were developed for immunizations and each cancer screening service by using 81 studies with a usual care or control group. The most potent intervention types involved organizational change (the adjusted odds ratios for increased use of services from organizational change ranged from 2.47 to 17.6). Organizational change interventions included the use of separate clinics devoted to prevention, use of a planned care visit for prevention, or designation of nonphysician staff to do specific prevention activities. The next most effective intervention components were patient financial incentives (adjusted odds ratios, 1.82 to 3.42) and patient reminders (adjusted odds ratios, 1.74 to 2.75); the adjusted odds ratios ranged from 1.29 to 1.53 for patient education and from 1.10 to 1.76 for feedback. CONCLUSIONS: Rates of adult immunization and cancer screening are most likely to improve when a health care organization supports performance of these activities through organizational changes in staffing and clinical procedures. Involving patients in self-management through patient financial incentives and reminders is also likely to positively affect performance.

Reproductive health services for Syrian refugees in Zaatri Camp and Irbid City, Hashemite Kingdom of Jordan: an evaluation of the Minimum Initial Services Package.

BACKGROUND: The Minimum Initial Services Package (MISP) for reproductive health, a standard of care in humanitarian emergencies, is a coordinated set of priority activities developed to prevent excess morbidity and mortality, particularly among women and girls, which should be implemented at the onset of an emergency. The purpose of the evaluation was to determine the status of MISP implementation for Syrian refugees in Jordan as part of a global evaluation of reproductive health in crises. METHODS: In March 2013, applying a formative evaluation approach 11 key informant interviews, 13 health facility assessments, and focus group discussions (14 groups; 159 participants) were conducted in two Syrian refugee sites in Jordan, Zaatri Camp, and Irbid City, respectively. Information was coded, themes were identified, and relationships between data explored. RESULTS: Lead health agencies addressed the MISP by securing funding and supplies and establishing reproductive health focal points, services and coordination mechanisms. However, Irbid City was less likely to be included in coordination activities and health facilities reported challenges in human resource capacity. Access to clinical management of rape survivors was limited, and both women and service provider's knowledge about availability of these services was low. Activities to reduce the transmission of HIV and to prevent excess maternal and newborn morbidity and mortality were available, although some interventions needed strengthening. Some planning for comprehensive reproductive health services, including health indicator collection, was delayed. Contraceptives were available to meet demand. Syndromic treatment of sexually transmitted infections and antiretrovirals for continuing users were not available. In general refugee women and adolescent girls perceived clinical services negatively and complained about the lack of basic necessities. CONCLUSIONS: MISP services and key elements to support implementation were largely in place. Pre-existing Jordanian health infrastructure, prior MISP trainings, dedicated leadership and available funding and supplies facilitated MISP implementation. The lack of a national protocol on clinical management of rape survivors hindered provision of these services, while communities' lack of information about the health benefits of the services as well as perceived cultural repercussions likely contributed to no recent service uptake from survivors. This information can inform MISP programming in this setting.

Mass mailings have little effect on utilization of influenza vaccine among Medicare beneficiaries.

BACKGROUND: We reviewed published and unpublished studies of mass mailings designed to increase utilization of influenza vaccine among Medicare beneficiaries. METHODS: Search of computerized indexes for published studies and the Medicare Peer Review Organization Health Care Quality Improvement Project database for unpublished studies. Study selection criteria were: use of a controlled trial design and use of mass mailings direct to Medicare beneficiaries to increase receipt of influenza vaccinations. Study selection and data extraction were performed in duplicate by physician reviewers with consensus resolution. RESULTS: Six controlled trials of mass mailings were identified. One study, published in the Morbidity and Mortality Weekly Report (MMWR), reported a modest but statistically significant improvement in influenza vaccination rates among patients who received a letter relative to those who did not. This study was cited as justification for mail interventions performed in five subsequent studies, none of which reported clinically meaningful results. None of these five studies was published. CONCLUSIONS: Mass mailings have at best had clinically trivial effects on increasing influenza vaccination among Medicare beneficiaries. Publication bias has contributed to continued use of a relatively ineffective intervention.