Part 4: Value-informed nursing practice depends on nursing innovation.

With the adoption of value-based payments which tie reimbursement to patient outcomes and costs, days when nursing is viewed primarily as a cost to hospitals will soon be over. Already the backbone of high-quality care delivery and patient outcomes, nurses are becoming key drivers of health care organizations' financial outcomes, too. The first three articles published in this 6-part series on value-informed nursing practice-practice that considers both the outcomes and the cost of producing the outcomes-described what value-informed nursing practice means, its economic, policy, and ethical impetuses, and how value-informed nursing practice helps improve environmental sustainability of health systems. Here, in Part 4, we focus on the importance of nursing innovation in implementing value-informed nursing practice. We begin by discussing how innovation is connected to value and then examine the false dichotomy, perceived by many, between innovation and evidence-based care. Following this, we examine how health care organizations and systems can support nursing innovation, before concluding with recommendations for nursing educators.

Pupillary Light Reflex Is Not Abolished by Epinephrine and Atropine Given During Advanced Cardiac Life Support in Patients Who Achieve Return of Spontaneous Circulation.

INTRODUCTION: Absence of pupillary light reflex (PLR) is a well-studied indicator of poor neurologic recovery after cardiac arrest. Interpretation of absent PLR is difficult in patients with hypothermia or hypotension, or who have electrolyte or acid-base disturbances. Additionally, many studies exclude patients who receive epinephrine or atropine from their analysis on the basis that these drugs are thought to abolish the PLR. This observational cohort study assessed for presence or absence of PLR in in-hospital cardiac arrest patients who received epinephrine with or without atropine during advanced cardiac life support and achieved return of spontaneous circulation (ROSC). METHODS: Pupil size and reactivity were assessed in adult patients who had an in-hospital cardiac arrest, received epinephrine with or without atropine, and achieved ROSC. Measurements were taken using a NeurOptics NPi-200 infrared pupillometer. RESULTS: Forty patients had pupillometry performed within 1 hour (median: 6 minutes) after ROSC. Of these only 1 (2.5%) patient had nonreactive pupils at first measurement after ROSC. The remaining 39 (97.5%) had reactive pupils. Of the 19 patients who had pupils checked within 3 minutes of ROSC, 100% had reactive pupils. Degree of pupil responsiveness was not correlated with cumulative dose of epinephrine. Ten patients received atropine in addition to epinephrine, including the sole patient with nonreactive pupils. The remaining 9 (90%) had reactive pupils. CONCLUSION: Epinephrine and atropine do not abolish the PLR in patients who achieve ROSC after in-hospital cardiac arrest. Lack of pupillary response in the post-arrest patient should not be attributed to these drugs.

Change in physical activity from adolescence to early adulthood: a systematic review and meta-analysis of longitudinal cohort studies.

OBJECTIVE: To systematically review and meta-analyse how physical activity (PA) changes from adolescence to early adulthood (13-30 years). DATA SOURCES: Seven electronic databases were searched: Medline, Embase, PsycInfo, SCOPUS, ASSIA, SPORTdiscus and Web of Science. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: English-language, longitudinal studies (from 01/1980 to 01/2017) assessing PA ≥twice, with the mean age of ≥1 measurement in adolescence (13-19 years) and ≥1 in young adulthood (16-30 years) were included. Where possible, data were converted to moderate-to-vigorous physical activity (MVPA) min/day, and meta-analyses were conducted between weighted mean differences (WMDs) in adolescence and adulthood. Heterogeneity was explored using meta-regression. RESULTS: Of 67 included studies, 49 were eligible for meta-analysis. PA was lower during adulthood than adolescence WMD (95% CI) -5.2 (-7.3 to -3.1) min/day MVPA over mean (SD) 3.4 (2.6) years; heterogeneity was high (I2 >99.0%), and no predictors explained this variation (all p>0.05). When we restricted analysis to studies with data for males (n=29) and females (n=30) separately, there were slightly larger declines in WMD (-6.5 (-10.6 to -2.3) and -5.5 (-8.4 to -2.6) min/day MVPA) (both I2 >99.0%). For studies with accelerometer data (n=9), the decline was -7.4 (-11.6 to -3.1) and longer follow-up indicated more of a decline in WMD (95% CI) (-1.9 (-3.6 to -0.2) min/day MVPA), explaining 27.0% of between-study variation. Of 18 studies not eligible for meta-analysis, nine statistically tested change over time: seven showed a decline and two showed no change. CONCLUSION: PA declines modestly between adolescence and young adulthood. More objective longitudinal PA data (eg, accelerometry) over this transition would be valuable, as would investigating how PA change is associated with contemporaneous social transitions to better inform PA promotion interventions. REGISTRATION: PROSPERO ref:CRD42015030114.

Equity effects of children's physical activity interventions: a systematic scoping review.

BACKGROUND: Differential effects of physical activity (PA) interventions across population sub-groups may contribute to inequalities in health. This systematic scoping review explored the state of the evidence on equity effects in response to interventions targeting children's PA promotion. The aims were to assess and summarise the availability of evidence on differential intervention effects of children's PA interventions across gender, body mass index, socioeconomic status, ethnicity, place of residence and religion. METHODS: Using a pre-piloted search strategy, six electronic databases were searched for controlled intervention trials, aiming to increase PA in children (6-18 years of age), that used objective forms of measurement. Screening and data extraction were conducted in duplicate. Reporting of analyses of differential effects were summarized for each equity characteristic and logistic regression analyses run to investigate intervention characteristics associated with the reporting of equity analyses. RESULTS: The literature search identified 13,052 publications and 7963 unique records. Following a duplicate screening process 125 publications representing 113 unique intervention trials were included. Although the majority of trials collected equity characteristics at baseline, few reported differential effects analyses across the equity factors of interest. All 113 included interventions reported gender at baseline with 46% of non-gender targeted interventions reporting differential effect analyses by gender. Respective figures were considerably smaller for body mass index, socioeconomic status, ethnicity, place of residence and religion. There was an increased likelihood of studying differential effects in school based interventions (OR: 2.9 [1.2-7.2]) in comparison to interventions in other settings, larger studies (per increase in 100 participants; 1.2 [1.0 - 1.4]); and where a main intervention effect on objectively measured PA was reported (3.0 [1.3-6.8]). CONCLUSIONS: Despite regularly collecting relevant information at baseline, most controlled trials of PA interventions in children do not report analyses of differences in intervention effect across outlined equity characteristics. Consequently, there is a scarcity of evidence concerning the equity effects of these interventions, particularly beyond gender, and a lack of understanding of subgroups that may benefit from, or be disadvantaged by, current intervention efforts. Further evidence synthesis and primary research is needed to effectively understand the impact of PA interventions on existing behavioural inequalities within population subgroups of children. TRIAL REGISTRATION: PROSPERO (PROSPERO 2016: CRD42016034020 ).

Is There a Difference in Revision Risk Between Metal and Ceramic Heads on Highly Crosslinked Polyethylene Liners?

BACKGROUND: The most common bearing surface used among primary THAs worldwide is a metal or ceramic femoral head that articulates against a highly crosslinked ultrahigh-molecular-weight polyethylene (HXLPE) acetabular liner. Despite their widespread use, relatively little is known about the comparative effectiveness of ceramic versus metal femoral heads with respect to risk of revision and dislocation as well as the role of head size in this relationship. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the risk of (1) all-cause revision in metal versus ceramic femoral heads when used with an HXLPE liner, including an evaluation of the effect of head size; and (2) dislocation in metal versus ceramic femoral heads when used with an HXLPE liner as well as an assessment of the effect of head size. METHODS: Data were collected as part of the Kaiser Permanente Total Joint Replacement Registry between 2001 and 2013. Patients in this study were on average overweight (body mass index = 29 kg/m2), 67 years old, mostly female (57%), and had osteoarthritis (93%) as the primary indication for surgery. The material of the femoral head (metal, ceramic) was crossed with head size (< 32, 32, 36, > 36 mm), yielding eight device groupings. Only uncemented devices were evaluated. The primary outcome was all-cause revision (n = 28,772) and the secondary outcome was dislocation within 1 year (n = 19,623). Propensity scores were used to adjust for potential confounding at the implant/patient level using between-within semiparametric survival models that control for surgeon and hospital confounding and adjust estimates for the within-cluster correlation among observations on the response. RESULTS: For all-cause revision, there was no difference between ceramic versus metal (reference) heads in combination with an HXLPE liner (hazard ratio [HR] = 0.82 [0.65-1.04], p = 0.099). Smaller metal head sizes of < 32 mm were associated with increased risk of revision relative to 36 mm (HR = 1.66 [1.20-2.31], p = 0.002, adjusted p = 0.025). For dislocation, ceramic heads increased risk relative to metal at < 32 mm only (HR = 4.39 [1.72-11.19], p = 0.002, adjusted p = 0.020). Head sizes < 32 mm were associated with increased risk of dislocation relative to 36 mm for metal (HR = 2.99 [1.40-6.39], p = 0.005, adjusted p = 0.047) and ceramic heads (HR = 15.69 [6.07-40.55], p < 0.001, adjusted p < 0.001). CONCLUSIONS: The results did not provide evidence for use of one femoral head material over another when used with HXLPE liners for the outcome of revision, but for dislocation, metal performed better than ceramic with < 32-mm heads. Overall, the findings suggest increased risk of revision/dislocation with head sizes < 32 mm. LEVEL OF EVIDENCE: Level III, therapeutic study.

A comparison of revision and rerupture rates of ACL reconstruction between autografts and allografts in the skeletally immature.

PURPOSE: Anterior cruciate ligament reconstructions (ACLRs) in skeletally immature patients are increasing. The purpose of this study is to describe the demographics, graft usage, revision, and re-operation rates in skeletally immature ACLRs in the Kaiser Permanente healthcare system. METHODS: Skeletally immature patients (<17.0 years old with open physes) were identified using the Kaiser Permanente ACLR registry. Multi-ligament reconstructions and physeal-sparing ACLRs were excluded. Aseptic revision and same-knee re-operation were the outcomes of interest. Exposure of interest was graft type; bone-patellar-tendon-bone (BPTB) autograft, hamstring autograft, and any type of allograft. Age, gender, body mass index (BMI), and race were evaluated as confounders. Cox proportional hazard models stratified by surgeon were used to analyse the risk of revision and re-operation. RESULTS: A total of 534 primary ACLR cases were evaluated with a mean follow-up of 2.9 years. The majority were hamstring autografts (n = 388, 72.7%), male (n = 339, 63.9%), and White (n = 232, 43.4%). Median age was 14.9 years, and median BMI was 21.9 kg/m(2). There were 44 (8.2%) aseptic revisions and 48 (9.0%) same-knee re-operations. The incidence rate for revision was BPTB autograft 5.5%, hamstring autograft 7.5%, and allograft 13.2%. After adjusting for confounders and surgeon clustering effect, the risk of aseptic revision and revision between allograft and hamstring autograft did not reach statistical significance. CONCLUSION: Graft selection differs in skeletally immature patients with a preponderance of surgeries being performed with hamstring tendon autografts. High revision rates were identified for all graft types used, though differences in revision rates across different graft types did not reach statistical significance. Surgeons should be aware of high rates of revision in this skeletally immature young population, although type of graft used did not appear to make a difference. LEVEL OF EVIDENCE: III.

Total joint replacement: A multiple risk factor analysis of physical activity level 1-2 years postoperatively.

Background and purpose - The effect of total joint arthroplasty (TJA) on physical activity is not fully understood. We investigated the change in physical activity after TJA and patient factors associated with change. Patients and methods - Using a total joint replacement registry, primary total hip arthroplasty (THA) patients (n = 5,678) and knee arthroplasty (TKA) patients (n = 11,084) between January 1, 2010 and December 31, 2012 were identified. Median age at THA was 68 and median age at TKA was 67. Change in self-reported physical activity (minutes per week) from before TJA (within 1 year of surgery) to after TJA (1-2 years) was the outcome of interest. Patient demographics and comorbidities were evaluated as risk factors. Multiple linear regression was used. Results - Median physical activity before surgery was 50 min/week (IQR: 0-140) for THA patients and 58 (IQR: 3-143) for TKA patients. Median physical activity after surgery was 150 min/week (IQR: 60-280) for both THA patients and TKA patients. Following TJA, 50% of patients met CDC/WHO physical activity guideline criteria. Higher body mass index was associated with lower change in physical activity (THA: -7.1 min/week; TKA: -5.9 min/week). Females had lower change than males (THA: -11 min/week; TKA: -9.1 min/week). In TKA patients, renal failure was associated with lower change (-17 min/week), as were neurological disorders (-30 min/week). Interpretation - Self-reported minutes of physical activity increased from before to after TJA, but 50% of TJA patients did not meet recommended physical activity guideline criteria. Higher body mass index, female sex, and specific comorbidities were found to be associated with low change in physical activity. Patient education on the benefits of physical activity should concentrate on these subgroups of patients.

Metal-on-conventional polyethylene total hip arthroplasty bearing surfaces have a higher risk of revision than metal-on-highly crosslinked polyethylene: results from a US registry.

BACKGROUND: Although studies have reported lower radiological wear in highly crosslinked polyethylene (HXLPE) versus conventional polyethylene in total hip arthroplasty (THA), there is limited clinical evidence on the risk of revision of these polyethylene THA bearing surfaces. QUESTIONS/PURPOSES: We asked: (1) Do primary THAs with a metal-on-conventional polyethylene bearing surface have a higher risk of revision (all-cause or aseptic) than metal-on-HXLPE? (2) Is the risk of revision (all-cause or aseptic) higher for conventional polyethylene versus HXLPE when the effect of femoral and acetabular components is controlled for in prosthesis-specific analyses? METHODS: The Kaiser Permanente's Total Joint Replacement Registry was used to identify metal-on-conventional polyethylene and metal-on-HXLPE primary THAs (N = 26,823) performed between April 2001 and December 2011. The registry has 95% voluntary participation and 8% were lost to followup during the 10-year study period. Endpoints of interest were all-cause and aseptic revisions. Descriptive statistics and marginal Cox regression models with propensity score adjustments were applied to compare risk of revision for metal-on-conventional polyethylene versus metal-on-HXLPE THAs and to evaluate two specific manufacturers' hip implant designs while controlling for femoral and acetabular components. Of the 26,823 THAs included in the study, 1815 (7%) were metal-on-conventional polyethylene and 25,008 (93%) were metal-on-HXLPE. RESULTS: At 7 years followup, the cumulative incidence of revision was 5.4% (95% confidence interval [CI], 4.4%-6.7%) for metal-on-conventional and 2.8% (95% CI, 2.6%-3.2%) for metal-on-HXLPE. There was a higher adjusted risk of all-cause (hazard ratio [HR], 1.75; 95% CI, 1.37-2.24; p < 0.001) and aseptic (HR, 1.91; 95% CI, 1.46-2.50; p < 0.001) revisions among metal-on-conventional polyethylene bearing surface hips compared with metal-on-HXLPE. Results were similar within manufacturer hip designs with the same femoral and acetabular components. Conclusions Metal-on-conventional polyethylene THA bearing surfaces have a higher risk of revision compared with metal-on-HXLPE bearing surfaces. Clinicians should consider the use of HXLPE when using a polyethylene bearing in THA. LEVEL OF EVIDENCE: Level II, cohort study.

Is there a difference in total knee arthroplasty risk of revision in highly crosslinked versus conventional polyethylene?

BACKGROUND: Highly crosslinked polyethylene (HXLPE) was introduced to reduce wear and associated osteolysis in total knee arthroplasty (TKA). However, there is limited clinical evidence that HXLPE is more effective than conventional polyethylene (CPE) in TKA. QUESTIONS/PURPOSES: (1) Do primary TKAs with HXLPE tibial inserts have a lower risk of revision (all-cause, aseptic, and septic) than TKAs with CPE tibial inserts? (2) In NexGen TKA (Zimmer Inc, Warsaw, IN, USA) bearings, do HXLPE tibial inserts have a lower risk of revision (all-cause, aseptic, and septic) than CPE tibial inserts? (3) In Press-Fit Condylar TKA (PFC or PFC Sigma; DePuy Inc, Warsaw, IN, USA), do HXLPE tibial inserts have a lower risk of revision (all-cause, aseptic, and septic) than procedures performed with CPE tibial inserts? METHODS: The Kaiser Permanente Total Joint Replacement Registry was used to identify primary TKAs (N = 77,084) performed during the study period (April 2001 to December 2011) with cobalt-chromium alloy on CPE (CoCr-CPE) and CoCr-HXLPE bearings. The registry has 95% voluntary participation and less than 9% were loss to followup during the 10-year study period. A total of 60,841 (79%) had CoCr-CPE bearings, 11,048 (14%) had CoCr-HXLPE bearings, and 5195 (7%) were unknown. Specific knee implant designs (NexGen, Zimmer and PFC-Sigma, DePuy Inc) were also evaluated. These implants represented 41% (31,793) and 49% (37,457), respectively, of the 77,084 TKAs of known implant types registered during that period; implant selection was at the discretion of the attending surgeon. Descriptive statistics and marginal Cox regression models with propensity score adjustments were applied to compare risk of revision for CoCr-CPE versus CoCr-HXLPE TKA bearings. RESULTS: At 5 years followup, cumulative incidence of revision for CoCr-CPE and CoCr-XLPE were 2.7% and 3.1%, respectively. Adjusted risks of all-cause (hazard ratio [HR], 1.05; 95% confidence interval [CI], 0.86-1.29; p = 0.620), aseptic (HR, 1.01; 95% CI, 0.77-1.32; p = 0.954), and septic revision (HR, 1.11; 95% CI, 0.81-1.51; p = 0.519) did not differ in patients with CoCr-XLPE bearings compared with CoCr-CPE. Within TKAs with NexGen components, the adjusted risks of all-cause (HR, 1.14; 95% CI, 0.86-1.51; p = 0.354), aseptic (HR, 1.14; 95% CI, 0.79-1.65; p = 0.493), and septic revision (HR, 1.14; 95% CI, 0.76-1.73; p = 518) were similar in patients with CoCr-XLPE compared with those with CoCr-CPE bearings. Finally, within the TKAs with PFC components, the adjusted risks of all-cause (HR, 0.80; 95% CI, 0.49-1.30; p = 0.369), aseptic (HR, 0.62; 95% CI, 0.62-1.14; p = 0.123), and septic revision (HR, 0.97; 95% CI, 0.51-1.85; p = 0.929) were also similar in patients with CoCr-XLPE compared with those with CoCr-CPE bearings. CONCLUSIONS: In this large study, we did not find differences in risk of revision for CoCr-HXLPE compared with CoCr-CPE bearings at 5 years followup. In selecting HXLPE in TKA, clinicians should consider the increased cost and lack of available evidence of performance for greater than 10 years followup. Future studies are necessary to evaluate longitudinal outcomes of CoCr-HXLPE versus conventional TKA bearings. LEVEL OF EVIDENCE: Level III, therapeutic study.

Are There Modifiable Risk Factors for Hospital Readmission After Total Hip Arthroplasty in a US Healthcare System?

BACKGROUND: Although total hip arthroplasty (THA) is a successful procedure, 4% to 11% of patients who undergo THA are readmitted to the hospital. Prior studies have reported rates and risk factors of THA readmission but have been limited to single-center samples, administrative claims data, or Medicare patients. As a result, hospital readmission risk factors for a large proportion of patients undergoing THA are not fully understood. QUESTIONS/PURPOSES: (1) What is the incidence of hospital readmissions after primary THA and the reasons for readmission? (2) What are the risk factors for hospital readmissions in a large, integrated healthcare system using current perioperative care protocols? METHODS: The Kaiser Permanente (KP) Total Joint Replacement Registry (TJRR) was used to identify all patients with primary unilateral THAs registered between January 1, 2009, and December 31, 2011. The KPTJRR's voluntary participation is 95%. A logistic regression model was used to study the relationship of risk factors (including patient, clinical, and system-related) and the likelihood of 30-day readmission. Readmissions were identified using electronic health and claims records to capture readmissions within and outside the system. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Of the 12,030 patients undergoing primary THAs included in the study, 59% (n = 7093) were women and average patient age was 66.5 years (± 10.7). RESULTS: There were 436 (3.6%) patients with hospital readmissions within 30 days of the index procedure. The most common reasons for readmission were infection and inflammatory reaction resulting from internal joint prosthetic (International Classification of Diseases, 9(th) Revision, Clinical Modification [ICD-9-CM] 996.66, 7.0%); other postoperative infection (ICD-9-CM 998:59, 5.5%); unspecified septicemia (ICD-9-CM 038.9, 4.9%); and dislocation of a prosthetic joint (ICD-9-CM 996.42, 4.7%). In adjusted models, the following factors were associated with an increased likelihood of 30-day readmission: medical complications (OR, 2.80; 95% CI, 1.59-4.93); discharge to facilities other than home (OR, 1.89; 95% CI, 1.39-2.58); length of stay of 5 or more days (OR, 1.80; 95% CI, 1.22-2.65) versus 3 days; morbid obesity (OR, 1.74; 95% CI, 1.25-2.43); surgeries performed by high-volume surgeons compared with medium volume (OR, 1.53; 95% CI, 1.14-2.08); procedures at lower-volume (OR, 1.41; 95% CI, 1.07-1.85) and medium-volume hospitals (OR, 1.81; 95% CI, 1.20-2.72) compared with high-volume ones; sex (men: OR, 1.51; 95% CI, 1.18-1.92); obesity (OR, 1.32; 95% CI, 1.02-1.72); race (black: OR, 1.26; 95% CI, 1.02-1.57); increasing age (OR, 1.03; 95% CI, 1.01-1.04); and certain comorbidities (pulmonary circulation disease, chronic pulmonary disease, hypothyroidism, and psychoses). CONCLUSIONS: The 30-day hospital readmission rate after primary THA was 3.6%. Modifiable factors, including obesity, comorbidities, medical complications, and system-related factors (hospital), have the potential to be addressed by improving the health of patients before this elective procedure, patient and family education and planning, and with the development of high-volume centers of excellence. Nonmodifiable factors such as age, sex, and race can be used to establish patient and family expectations regarding risk of readmission after THA. Contrary to other studies and the finding of increased hospital volume associated with lower risk of readmission, higher volume surgeons had a higher risk of patient readmission, which may be attributable to the referral patterns in our organization. LEVEL OF EVIDENCE: Level III, therapeutic study.

Kaiser Permanente implant registries benefit patient safety, quality improvement, cost-effectiveness.

BACKGROUND: In response to the increased volume, risk, and cost of medical devices, in 2001 Kaiser Permanente (KP) developed implant registries to enhance patient safety and quality, and to evaluate cost-effectiveness. METHODS: Using an integrated electronic health record system, administrative databases, and other institutional databases, orthopedic, cardiology, and vascular implant registries were developed in 2001, 2006, and 2011, respectively. These registries monitor patients, implants, clinical practices, and surgical outcomes for KP's 9 million members. Critical to registry success is surgeon leadership and engagement; each geographical region has a surgeon champion who provides feedback on registry initiatives and disseminates registry findings. RESULTS: The registries enhance patient safety by providing a variety of clinical decision tools such as risk calculators, quality reports, risk-adjusted medical center reports, summaries of surgeon data, and infection control reports to registry stakeholders. The registries are used to immediately identify patients with recalled devices, evaluate new and established device technology, and identify outlier implants. The registries contribute to cost-effectiveness initiatives through collaboration with sourcing and contracting groups and confirming adherence to device formulary guidelines. Research studies based on registry data have directly influenced clinical best practices. CONCLUSIONS: Registries are important tools to evaluate longitudinal device performance and safety, study the clinical indications for and outcomes of device implantation, respond promptly to recalls and advisories, and contribute to the overall high quality of care of our patients.

Saliva-Based, COVID-19 RT-PCR Pooled Screening Strategy to Keep Schools Open.

BACKGROUND: As of March 2020, governments throughout the world implemented business closures, work from home policies, and school closures due to exponential increase of coronavirus disease 2019 (COVID-19) cases, leaving only essential workers being able to work on site. For most of the children and adolescent school closures during the first lockdown had significant physical and psychosocial consequences. Here, we describe a comprehensive Return to School program based on a behavior safety protocol combined with the use of saliva-based reverse transcriptase-polymerase chain reaction (RT-PCR) pooled screening technique to keep schools opened. METHODS: The program had 2 phases: before school (safety and preparation protocols) and once at school (disease control program: saliva-based RT-PCR pooled screening protocol and contact tracing). Pooling: Aliquots of saliva from 24 individuals were pooled and 1 RT-PCR test was performed. If positive, the initial 24-pool was then retested (12 pools of 2). Individual RT-PCR tests from saliva samples from positive pools of 2 were performed to get an individual diagnosis. RESULTS: From August 31 until December 20, 2020 (16-wk period) a total of 3 pools, and subsequent 3 individual diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease were reported (2 teachers and 1 staff). CONCLUSION: Until COVID-19 vaccine can be administered broadly to all-age children, saliva-based RT-PCR pooling testing is the missing piece we were searching for to keep schools opened.

Enhancing Student Learning by Integrating Anatomy in Pathology Teaching.

BACKGROUND: Vertically integrating anatomy into pathology curricula is beneficial for student-centered learning. This study investigates the effectiveness of this approach on student learning outcomes. ACTIVITY: Learners received a vertically integrated pathology curriculum; their pre- and post-course test data were collected. RESULTS AND DISCUSSION: Two-hundred thirty-two learners participated in the activity. Upon completing the activity, their average post-course performance was significantly better than that of a control group (P < 0.05), with significantly higher scores on solving pathology case problems (P < 0.05), as well as on retaining anatomy concepts (P < 0.05). Vertically integrating anatomy in pathology instruction is an effective educational approach.

Association between continuity and access in primary care: a retrospective cohort study.

BACKGROUND: Continuity of care is a tenet of primary care. Our objective was to explore the relation between a change in access to a primary care physician and continuity of care. METHODS: We conducted a retrospective cohort study among physicians in a primary care network in southwest Alberta who measured access consistently between 2009 and 2016. We used time to the third next available appointment as a measure of access to physicians. We calculated the provider and clinic continuity, discontinuity and emergency department use based on the physicians' own panels. Physicians who improved, worsened or maintained their level of access within a given year were assessed in multilevel models to determine the association with continuity of care at the physician and clinic levels and the emergency department. RESULTS: We analyzed data from 190 primary care physicians. Physicians with improved access increased provider continuity by 6.8% per year, reduced discontinuity by 2.1% per year, and decreased emergency department encounters by 78 visits per 1000 patients per year compared to physicians with stable access. Physicians with worsening access had a 6.2% decrease in provider continuity and an increased number of emergency department encounters (64 visits per 1000 panelled patients per year) compared to physicians with stable access. INTERPRETATION: Changes in access to primary care can affect whether patients seek care from their own physician, from another clinic or at the emergency department. Improving access by reducing the delay in obtaining an appointment with one's primary care physician may be one mechanism to improve continuity of care.

Changes in physical activity, diet, and body weight across the education and employment transitions of early adulthood: A systematic review and meta-analysis.

Early adulthood is a time when individuals go through important life transitions, such as moving from high school into higher education or employment, but the impact of these life transitions on changes in body weight, diet, and physical activity is not known. We searched six electronic databases to July 2019 for longitudinal observational studies providing data on adiposity, diet, and/or physical activity across education or employment transitions in young people aged between 15 and 35 years. We found 19 studies, of which 17 assessed changes in physical activity, three body weight, and five diet or eating behaviours. Meta-analysis (n=9) found that leaving high school was associated with a decrease of -7.04 (95% CI, -11.26, -2.82) min/day of moderate-to-vigorous physical activity. Three studies reported increases in body weight on leaving high school. A small number of studies suggested decreases in diet quality on leaving high school (n=2/4 papers) and leaving university (n=1) but not on starting employment (n=1). Studies suggested no change in physical activity on leaving university (n=4) but decreases in physical activity on starting employment (n=2/3). The transition of leaving high school is an important time to support individuals to prevent decreases in physical activity and gains in body weight.

Becoming a parent: A systematic review and meta-analysis of changes in BMI, diet, and physical activity.

Obesity prevalence rises fastest during young adulthood when weight, diet, and physical activity may be influenced by life events, including becoming a parent, but the impact is uncertain. We searched six electronic databases to July 2019 for longitudinal studies (both sexes) aged 15 to 35 years with a prospective pre-pregnancy/parenthood and post-delivery outcome. Of 11 studies (across 15 papers), six studies (women only) were eligible for meta-analysis of the difference in change in body mass index (BMI; kg/m2 ) between remaining without children and becoming a parent. Mean (±SD) BMI gain for non-mothers was 2.8 ± 1.3 kg/m2 (~7.5 kg for 164-cm woman) over 5.6 ± 3.1 years; 12.3% of baseline BMI (22.8 ± 2.5 kg/m2 ). Becoming a mother was associated with an additional BMI increase of 0.47 ± 0.26 kg/m2 (~1.3 kg), 4.3% of baseline BMI (22.8 ± 5.6 kg/m2 ); the one study including men reported no difference in change. Physical activity results were equivocal; 2/4 studies (women) and 2/2 (men) showed a greater decline in parents versus non-parents; diet (three studies) varied by dietary measure, mostly indicating no difference. Becoming a mother is associated with 17% greater absolute BMI gain than remaining childless. Motherhood BMI gain is additional to an alarming BMI increase among young women, highlighting the need for obesity prevention among all young women, including mothers.

Short and longer-term effects of creatine supplementation on exercise induced muscle damage.

The purpose of this investigation was to determine if creatine supplementation assisted with reducing the amount of exercise induced muscle damage and if creatine supplementation aided in recovery from exercise induced muscle damage. Two groups of subjects (group 1 = creatine; group 2 = placebo) participated in an eccentric exercise protocol following 7 and 30 days of creatine or placebo supplementation (20 g.d(-1) for 7 d followed by 6g.d(-1) for 23 d = 30 d). Prior to the supplementation period, measurements were obtained for maximal dynamic strength, maximal isometric force, knee range of motion, muscle soreness, and serum levels of creatine kinase (CK) and lactate dehydrogenase (LDH). Following 7 days of creatine supplementation, on day 8, subjects began consuming 6 g.d(-1) of creatine for 23 days. Additionally on days 8 and 31, subjects performed an eccentric exercise protocol using the knee extensors to induce muscle damage. Indirect markers of muscle damage, including maximal isometric force, knee range of motion, muscle soreness, and serum levels of CK and LDH, were collected at 12, 24, and 48 hours following each exercise bout. The results indicated that acute bouts of creatine have no effect on indirect markers of muscle damage for the acute (7 days) bout. However, maximal isometric force was greater for the creatine group versus placebo for the chronic (30 days) bout. This suggests that the ergogenic effect of creatine following 30 days of supplementation may have a positive impact on exercise induced muscle damage. Key pointsEccentric muscle actions highly associated with exercise induced muscle damage.Creatine supplementation has ergogenic effect to increase protein synthesis.Creatine supplementation does not attenuate exercise induced muscle damage with short term supplementation (7 days).Increased maximal isometric force seen with creatine supplementation after 30 days following exercise induced muscle damage.Ergogenic effect of creatine supplementation may contribute to reduced exercise induced muscle damage.

Are school-based physical activity interventions effective and equitable? A meta-analysis of cluster randomized controlled trials with accelerometer-assessed activity.

The prevalence of childhood obesity is increasing at epidemic rates globally, with widening inequalities between advantaged and disadvantaged groups. Despite the promise of schools as a universal context to access and influence all children, the potential of school-based interventions to positively impact children's physical activity behaviour, and obesity risk, remains uncertain. We searched six electronic databases to February 2017 for cluster randomized trials of school-based physical activity interventions. Following data extraction, authors were sent re-analysis requests. For each trial, a mean change score from baseline to follow-up was calculated for daily minutes of accelerometer-assessed moderate-to-vigorous physical activity (MVPA), for the main effect, by gender, and by socio-economic position (SEP). Twenty-five trials met the inclusion criteria; 17 trials provided relevant data for inclusion in the meta-analyses. The pooled main effect for daily minutes of MVPA was nonexistent and nonsignificant. There was no evidence of differential effectiveness by gender or SEP. This review provides the strongest evidence to date that current school-based efforts do not positively impact young people's physical activity across the full day, with no difference in effect across gender and SEP. Further assessment and maximization of implementation fidelity is required before it can be concluded that these interventions have no contribution to make.

Socioeconomic and ethnic differences in children's vigorous intensity physical activity: a cross-sectional analysis of the UK Millennium Cohort Study.

OBJECTIVE: To investigate if daily vigorous physical activity (VPA), adjusted for minutes of moderate physical activity (MPA) performed, differs by socioeconomic position or ethnicity in a large sample of UK children with objectively measured physical activity. DESIGN: Nationally representative prospective cohort study. SETTING: UK children born between 2000 and 2002. PARTICIPANTS: 5172 children aged 7-8 with valid accelerometer data for ≥10 hour on ≥3 days, including 1 weekend day. MAIN OUTCOME MEASURES: Time spent in VPA (>3841 counts per min). EXPLANATORY MEASURES: Maternal education, annual household Organisation for Economic Co-Operation and Development equivalised income, ethnicity. RESULTS: Multivariable linear regression models fitted to explore differences in average daily minutes of VPA (adjusted for MPA, mean accelerometer wear time, season of measurement, age and sex), revealed significantly higher amounts of VPA accumulated as a child's socioeconomic position increased (highest vs lowest level of maternal education: ß: 2.96, p: 0.00; annual household equivalised income: ß: 0.58, p: 0.00, per £10 000 annual increase). Additionally, children from certain minority ethnicities (Bangladeshi and Pakistani: ß: -3.34, p: 0.00; other ethnic groups: ß:-2.27, p: 0.02) accrued less daily VPA compared with their white British counterparts. CONCLUSIONS: The socioeconomic and ethnic patterning of vigorous activity observed in this study mirrors parallel inequalities in rates of childhood obesity. Given the stronger association of VPA with adiposity than of MPA, intensity specific differences may be contributing to widening inequalities in obesity. Accordingly, these findings suggest that the current global focus on overall moderate-to-vigorous intensity activity may mask important behavioural inequalities.

Methods and Purposes for Conducting Students' Course Evaluations Reported by North American Dental School and Dental Hygiene Program Leaders: A Preliminary Survey Study.

The aim of this preliminary survey study was to determine the perceptions of leaders of dental schools and dental hygiene programs regarding methods of and purposes for conducting students' course evaluations and their role in course improvement, curriculum design, and faculty assessment. A short electronic survey was distributed in 2016 to the academic deans of all 76 dental schools in the U.S. and Canada and a convenience sample of program directors of 232 of the total 332 accredited dental hygiene programs. Individuals from 93 institutions responded for an overall response rate of 30%: 30 of 76 dental schools (39.5% response rate) and 63 of the 232 dental hygiene programs (27% response rate). All of the respondents (100%) reported that their institutions' full-time faculty members were assessed by students in course evaluations for each course and semester they taught. However, only 78% reported that their part-time faculty members were evaluated by students. Course evaluations were mandatory in 62% (n=58) of the responding institutions, with the remaining 38% (n=35) optional. Respondents indicated course directors received the evaluation results for purposes of annual review (n=73, 78%) and instructional review (n=70, 75%). Further investigation of the use and effects of student evaluations is needed to better understand their role in faculty assessment and other aspects of the administration of dental schools and dental hygiene programs.