"If I knew I could get that every hour instead of alcohol, I would take the cannabis": need and feasibility of cannabis substitution implementation in Canadian managed alcohol programs.

BACKGROUND: While there is robust evidence for strategies to reduce harms of illicit drug use, less attention has been paid to alcohol harm reduction for people experiencing severe alcohol use disorder (AUD), homelessness, and street-based illicit drinking. Managed Alcohol Programs (MAPs) provide safer and regulated sources of alcohol and other supports within a harm reduction framework. To reduce the impacts of heavy long-term alcohol use among MAP participants, cannabis substitution has been identified as a potential therapeutic tool. METHODS: To determine the feasibility of cannabis substitution, we conducted a pre-implementation mixed-methods study utilizing structured surveys and open-ended interviews. Data were collected from MAP organizational leaders (n = 7), program participants (n = 19), staff and managers (n = 17) across 6 MAPs in Canada. We used the Consolidated Framework for Implementation Research (CFIR) to inform and organize our analysis. RESULTS: Five themes describing feasibility of CSP implementation in MAPs were identified. The first theme describes the characteristics of potential CSP participants. Among MAP participants, 63% (n = 12) were already substituting cannabis for alcohol, most often on a weekly basis (n = 8, 42.1%), for alcohol cravings (n = 15, 78.9%,) and withdrawal (n = 10, 52.6%). Most MAP participants expressed willingness to participate in a CSP (n = 16, 84.2%). The second theme describes the characteristics of a feasible and preferred CSP model according to participants and staff. Participants preferred staff administration of dry, smoked cannabis, followed by edibles and capsules with replacement of some doses of alcohol through a partial substitution model. Themes three and four highlight organizational and contextual factors related to feasibility of implementing CSPs. MAP participants requested peer, social, and counselling supports. Staff requested education resources and enhanced clinical staffing. Critically, program staff and leaders identified that sustainable funding and inexpensive, legal, and reliable sourcing of cannabis are needed to support CSP implementation. CONCLUSION: Cannabis substitution was considered feasible by all three groups and in some MAPs residents are already using cannabis. Partial substitution of cannabis for doses of alcohol was preferred. All three groups identified a need for additional supports for implementation including peer support, staff education, and counselling. Sourcing and funding cannabis were identified as primary challenges to successful CSP implementation in MAPs.

A 3-day 'stroke camp' addressed chronic disease self-management elements and perceived stress of survivors of stroke and their caregivers reduced: Survey results from the 14 US camps.

BACKGROUND: Stroke is a leading cause of disability for persons with stroke (PWS). Difficulty coping with long-term stress for PWS and their caregivers (CG) contributes to their poor health. Variations of chronic-disease self-management programs (CDSMPs) have reduced long-term stress in PWS and CGs. CDSMPs include training for decision-making, problem-solving, resource utilization, peer support, developing a patient-provider relationship, and environmental support. OBJECTIVE: This study examined whether a user-designed stroke camp addressed CDSMP domains, used consistent activities, and decreased stress in PWS and CG. METHODS: This open cohort survey study followed STROBE guidelines and assessed stress at four timepoints: 1 week before camp, immediately before camp, immediately after camp, and 1 month after camp. Mixed-model analysis examined changes in stress from the two baseline time points to the two post-camp time points. The research team reviewed documents and survey responses to assess activities described in camp documents and CDSMP domains across camps. POPULATION: PWS and CG who attended a camp in 2019. The PWS sample (n = 40) included50% males, aged 1-41-years post stroke, 60% with ischemic, one-third with aphasia, and 37.5% with moderate-severe impairment. CG sample (n = 24) was 60.8% female, aged 65.5 years, and had 7.4 years CG experience. RESULTS: Stress decreased significantly in PWS (Cohen's d = -0.61) and CGs (Cohen's d = -0.87) from pre- to post-camp. Activities addressing all but one CDSMP domains were evident across camps. CONCLUSIONS: Stroke camp is a novel model that addresses CDSMP domains, which may reduce stress in PWS and CG. Larger, controlled studies are warranted.

Sustained reduction in antimicrobial use and decrease in methicillin-resistant Staphylococcus aureus and Clostridium difficile infections following implementation of an electronic medical record at a tertiary-care teaching hospital.

OBJECTIVES: we evaluated the effect of implementation of an electronic medical record (EMR) on the use of antimicrobial agents and on the rates of infections with Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA). METHODS: this was a retrospective, observational study conducted between 1 January 2005 and 31 December 2009. Antimicrobial drug use, rates of nosocomial C. difficile infection (CDI) and MRSA infection, the number of medical charts reviewed and number of antimicrobial recommendations made and accepted were compared before and after implementing the EMR utilizing interrupted time-series analysis. RESULTS: compared with the 10 quarters prior to implementing the EMR, there was a 36.6% increase in the number of charts reviewed (P < 0.0001), a 98.1% increase in the number of antimicrobial recommendations made (P < 0.0001) and a 124% increase in the number of recommendations accepted (P < 0.0001). There was a 28.8% decrease in the use of 41 commonly used antibacterial agents (P < 0.0001). Nosocomial CDI decreased by 18.7% (P = 0.07) and nosocomial MRSA infections decreased by 45.2% (P < 0.0001) following implementation of the EMR. CONCLUSIONS: adoption of an EMR facilitated a significant increase in chart reviews and antimicrobial recommendations, which resulted in a sustained decrease in antimicrobial use. There were decreased nosocomial infections with MRSA and a trend towards decreasing CDIs following implementation of the EMR.

Reciprocal learning and chronic care model implementation in primary care: results from a new scale of learning in primary care.

BACKGROUND: Efforts to improve the care of patients with chronic disease in primary care settings have been mixed. Application of a complex adaptive systems framework suggests that this may be because implementation efforts often focus on education or decision support of individual providers, and not on the dynamic system as a whole. We believe that learning among clinic group members is a particularly important attribute of a primary care clinic that has not yet been well-studied in the health care literature, but may be related to the ability of primary care practices to improve the care they deliver.To better understand learning in primary care settings by developing a scale of learning in primary care clinics based on the literature related to learning across disciplines, and to examine the association between scale responses and chronic care model implementation as measured by the Assessment of Chronic Illness Care (ACIC) scale. METHODS: Development of a scale of learning in primary care setting and administration of the learning and ACIC scales to primary care clinic members as part of the baseline assessment in the ABC Intervention Study. All clinic clinicians and staff in forty small primary care clinics in South Texas participated in the survey. RESULTS: We developed a twenty-two item learning scale, and identified a five-item subscale measuring the construct of reciprocal learning (Cronbach alpha 0.79). Reciprocal learning was significantly associated with ACIC total and sub-scale scores, even after adjustment for clustering effects. CONCLUSIONS: Reciprocal learning appears to be an important attribute of learning in primary care clinics, and its presence relates to the degree of chronic care model implementation. Interventions to improve reciprocal learning among clinic members may lead to improved care of patients with chronic disease and may be relevant to improving overall clinic performance.

CT artifacts after contrast media injection in chest imaging: evaluation of post-processing algorithms, virtual monoenergetic images and their combination for artifact reduction.

BACKGROUND: After injection into a brachial vein, high contrast media concentration in axillary and subclavian veins can cause artifacts that impair diagnostic utility. This study assessed artifact reduction by artifact-reduction-algorithms (ARA) and virtual-monoenergetic-images (VMI), as well as their combination (VMIARA) compared to conventional CT-images (CI). METHODS: Forty-six spectral-detector-CT (SDCT) examinations of patients that received ARA-reconstructions due to perivenous-artifacts were included in this retrospective study. CI, ARA, VMI, and VMIARA (range: 70-200 keV) were reconstructed. Objective analysis was performed with ROI-based assessment of mean and standard deviation of attenuation (HU) in hypo- and hyperdense artifacts and impaired muscle and arteries as well as artifact-free reference-tissue. Extent of artifact reduction, assessment of surrounding soft tissue and vessels, and appearance of new artifacts were rated visually by two radiologists. RESULTS: Hypo- and hyperdense artifacts showed significant improvement as evidenced by decreasing attenuation differences between artifact impaired and artifact-free reference tissue in ARA, VMI ≥80 keV, and VMIARA between 70-200 keV (e.g., CI/ARA/VMI100keV/VMIARA100keV: hypodense artifacts, (-)264.8±150.9/(-)87.1±78.9/(-)48.6±64.6/9.9±63.9 HU; P<0.001); hyperdense artifacts, 164.2±51.1/82.1±73.2/7.9±34.7/(-)17.3±50.7 HU; P<0.001). Artifacts impairing surrounding muscle and arteries were also reduced by all three approaches. In visual assessment, ARA, VMI ≥100 keV, and VMIARA between 70-200 keV also showed significant artifact reduction and improved assessment; however, for assessment of arteries improvement was not significant using ARA alone. New artifacts were reported, particularly at higher keV-values. CONCLUSIONS: In presence of perivenous-artifacts, ARA, VMI and their combination allow for significant artifact reduction; however, their combination and VMI as a standalone approach yielded best results and should therefore be used, if available.

Abdominal vessel depiction on virtual triphasic spectral detector CT: initial clinical experience.

PURPOSE: To evaluate vessel assessment in virtual monoenergetic images (VMI40keV) and virtual-non-contrast images (VNC) derived from venous phase spectral detector computed tomography (SDCT) acquisitions in comparison to arterial phase and true non-contrast (TNC) images. METHODS: Triphasic abdominal SDCT was performed in 25 patients including TNC, arterial and venous phase. VMI40keV and VNC were reconstructed from the venous phase and compared to conventional arterial-phase images (CIart), TNC and conventional venous-phase images (CIven). Vessel contrast and virtual contrast removal were analyzed with region-of-interest-based measurements and in a qualitative assessment. RESULTS: Quantitative analysis revealed no significant attenuation differences between TNC and VNC in arterial vessels (p-range 0.07-0.47) except for the renal artery (p = 0.011). For venous vessels, significant differences between TNC and VNC were found for all veins (p < 0.001) except the inferior vena cava (p = 0.26), yet these differences remained within a 10 HU range in most patients. No significant attenuation differences were found between CIart/VMI40keV in arterial vessels (p-range 0.06-0.86). Contrast-to-noise ratio provided by VMI40keV and CIart was equivalent for all arterial vessels assessed (p-range 0.14-0.91). Qualitatively, VMI40keV showed similar enhancement of abdominal and pelvic arteries as CIart and VNC were rated comparable to TNC. CONCLUSION: Our study suggests that VNC and VMI40keV derived from single venous-phase SDCT offer comparable assessment of major abdominal vessels as provided by routine triphasic examinations, if no dynamic contrast information is required.

Primary care physicians' decisions about discharging patients from their practices.

OBJECTIVE: There are few data available about factors which influence physicians' decisions to discharge patients from their practices. To study general internists' and family medicine physicians' attitudes and experiences in discharging patients from their practices. DESIGN: A cross-sectional mailed survey was used. PARTICIPANTS: One thousand general internists and family medicine physicians participated in this study. MEASUREMENTS AND MAIN RESULTS: We studied the likelihood physicians would discharge 12 hypothetical patients from their practices, and whether they had actually discharged such patients. The effect of demographic data on the number of scenarios in which patients were likely to be discharged, and the number of patients actually discharged were analyzed via ANOVA and multiple logistic regression analysis. Of 977 surveys received by subjects, 526 (54%) were completed and returned. A majority of respondents were willing to discharge patients in 5 of 12 hypothetical scenarios. Eighty-five percent had actually discharged at least one patient from their practices. Most respondents (71%) had discharged 10 or fewer patients, but 14% had discharged 11 to 200 patients. Respondents who were in private practice (p < 0.000001) were more likely to discharge both hypothetical and actual patients from their practices. Older physicians (> or =48 years old) were more likely to discharge actual patients from their practices (p = 0.005) as were physicians practicing in rural settings (p = 0.003). CONCLUSIONS: Most physicians in our sample were willing to discharge actual and hypothetical patients from their practices. This tendency may have significant implications for the initiation of pay-for-performance programs. Physicians should be educated about the importance of the patient-physician relationship and their fiduciary obligations to the patient.

Diagnostic accuracy of intravascular ultrasound-derived minimal lumen area compared with fractional flow reserve.

INTRODUCTION: The use of fractional flow reserve (FFR) as the gold standard for functional assessment of intermediate coronary stenosis has been well documented. Intracoronary imaging techniques such as intravascular ultrasound (IVUS) have been used for additional coronary lesion resolution and some of its anatomic parameters have been studied as having possible correlation with FFR, particularly IVUS minimal lumen area (MLA). We performed a comprehensive review of the available literature in the area. EVIDENCE ACQUISITION: A Pubmed search was performed for all the literature involving comparison of diagnostic accuracy of IVUS-MLA with FFR. EVIDENCE SYNTHESIS: An extensive description of all the available data regarding IVUS-MLA diagnostic value regarding the FFR of stenotic lesions, for both non-left main (non-LM) and left main (LM) lesions. CONCLUSIONS: For non-LM lesions IVUS-MLA cutoff values to identify specific FFR thresholds have marked heterogeneity and perform particularly poorly in terms of specificity and positive predictive value. For LM lesions IVUS-MLA performs better and shows a better correlation with FFR, though more data is needed to confirmed that trend.

A multi-center study of fidaxomicin use for Clostridium difficile infection.

PURPOSE: Fidaxomicin use in real-world clinical practice, especially for severe Clostridium difficile infection (CDI), is mainly based on single-center observational studies. The purpose of this pharmacoepidemiology study was to assess outcomes of patients given fidaxomicin based on episode number and use of concomitant antibiotics. METHODS: Fidaxomicin use over time across included hospitals in the United States was assessed using a large inpatient drug utilization database. A multicenter retrospective chart review was also conducted of hospitalized patients with CDI that received fidaxomicin between 2011 and 2013. Fidaxomicin utilization and clinical outcomes were stratified by use of fidaxomicin for first or second episode (early episodes) versus greater than or equal to episodes (later episodes). RESULTS: The overall fidaxomicin use rate was 2.16 % which increased from 0.22 % in the last two quarters of 2011 to 3.16 % in the first two quarters of 2013. A total of 102 hospitalized patients that received fidaxomicin from 11 hospitals were identified in the multicenter study. Sixty-nine patients received fidaxomicin for early (68 % with severe CDI) and 33 received for later episodes. The majority of patients received other CDI therapy including 61 patients (88 %) for early episodes and 27 (82 %) for later episodes. Concomitant non-CDI antibiotics were received by 48 patients (47 %). Rates of clinical outcomes were similar regardless of CDI episode. CONCLUSION: This study demonstrated a slow but steady increase in fidaxomicin utilization over time; most of which was combined with other systemic antibiotics. Antimicrobial stewardship teams should provide guidance on appropriate use of fidaxomicin to optimize therapy and assess the need to continue other antibiotics during CDI treatment.

Cellulose-degrading bacteria associated with the invasive woodwasp Sirex noctilio.

Sirex noctilio is an invasive wood-feeding wasp that threatens the world's commercial and natural pine forests. Successful tree colonization by this insect is contingent on the decline of host defenses and the ability to utilize the woody substrate as a source of energy. We explored its potential association with bacterial symbionts that may assist in nutrient acquisition via plant biomass deconstruction using growth assays, culture-dependent and -independent analysis of bacterial frequency of association and whole-genome analysis. We identified Streptomyces and γ-Proteobacteria that were each associated with 94% and 88% of wasps, respectively. Streptomyces isolates grew on all three cellulose substrates tested and across a range of pH 5.6 to 9. On the basis of whole-genome sequencing, three Streptomyces isolates have some of the highest proportions of genes predicted to encode for carbohydrate-active enzymes (CAZyme) of sequenced Actinobacteria. γ-Proteobacteria isolates grew on a cellulose derivative and a structurally diverse substrate, ammonia fiber explosion-treated corn stover, but not on microcrystalline cellulose. Analysis of the genome of a Pantoea isolate detected genes putatively encoding for CAZymes, the majority predicted to be active on hemicellulose and more simple sugars. We propose that a consortium of microorganisms, including the described bacteria and the fungal symbiont Amylostereum areolatum, has complementary functions for degrading woody substrates and that such degradation may assist in nutrient acquisition by S. noctilio, thus contributing to its ability to be established in forested habitats worldwide.

Host plant phenology affects performance of an invasive weevil, Phyllobius oblongus (Coleoptera: Curculionidae), in a northern hardwood forest.

We investigated how host plant phenology and plant species affected longevity, reproduction, and feeding behavior of an invasive weevil. Phyllobius oblongus L. (Coleoptera: Curculionidae) is common in northern hardwood forests of the Great Lakes Region. Adults emerge in spring, feed on foliage of woody understory plants, and oviposit in the soil. Preliminary data indicate that adults often feed on sugar maple, Acer saccharum Marshall, foliage early in the season, then feed on other species such as raspberry, Rubus spp. Whether this behavior reflects temporal changes in the quality of A. saccharum tissue or merely subsequent availability of later-season plants is unknown. We tested adult P. oblongus in laboratory assays using young (newly flushed) sugar maple foliage, old (2-3 wk postflush) sugar maple foliage, and raspberry foliage. Raspberry has indeterminate growth, thus always has young foliage available for herbivores. Survival, oviposition, and leaf consumption were recorded. In performance assays under no-choice conditions, mated pairs were provided one type of host foliage for the duration of their lives. In behavioral choice tests, all three host plants were provided simultaneously and leaf area consumption was compared. Adults survived longer on and consumed greater amounts of young maple and raspberry foliage than old maple foliage. P. oblongus preferred young maple foliage to old maple foliage early in the season, however, later in the growing season weevils showed less pronounced feeding preferences. These results suggest how leaf phenology, plant species composition, and feeding plasticity in host utilization may interact to affect P. oblongus population dynamics.

The role of conversation in health care interventions: enabling sensemaking and learning.

BACKGROUND: Those attempting to implement changes in health care settings often find that intervention efforts do not progress as expected. Unexpected outcomes are often attributed to variation and/or error in implementation processes. We argue that some unanticipated variation in intervention outcomes arises because unexpected conversations emerge during intervention attempts. The purpose of this paper is to discuss the role of conversation in shaping interventions and to explain why conversation is important in intervention efforts in health care organizations. We draw on literature from sociolinguistics and complex adaptive systems theory to create an interpretive framework and develop our theory. We use insights from a fourteen-year program of research, including both descriptive and intervention studies undertaken to understand and assist primary care practices in making sustainable changes. We enfold these literatures and these insights to articulate a common failure of overlooking the role of conversation in intervention success, and to develop a theoretical argument for the importance of paying attention to the role of conversation in health care interventions. DISCUSSION: Conversation between organizational members plays an important role in the success of interventions aimed at improving health care delivery. Conversation can facilitate intervention success because interventions often rely on new sensemaking and learning, and these are accomplished through conversation. Conversely, conversation can block the success of an intervention by inhibiting sensemaking and learning. Furthermore, the existing relationship contexts of an organization can influence these conversational possibilities. We argue that the likelihood of intervention success will increase if the role of conversation is considered in the intervention process. SUMMARY: The generation of productive conversation should be considered as one of the foundations of intervention efforts. We suggest that intervention facilitators consider the following actions as strategies for reducing the barriers that conversation can present and for using conversation to leverage improvement change: evaluate existing conversation and relationship systems, look for and leverage unexpected conversation, create time and space where conversation can unfold, use conversation to help people manage uncertainty, use conversation to help reorganize relationships, and build social interaction competence.

Surprise, Surprise, Surprise! A complexity science view of the unexpected.

Surprise can emanate from two sources: lack of sufficient information or knowledge and the basic dynamics of complex adaptive systems. The authors expand the traditional view of surprise with a complexity perspective that makes it possible to ask new questions and to consider new ways of understanding the world around us. They discuss creativity and learning as two strategies for capitalizing on the surprises that confront organizations.