Behavioral responses of individual blue whales (Balaenoptera musculus) to mid-frequency military sonar.

This study measured the degree of behavioral responses in blue whales (Balaenoptera musculus) to controlled noise exposure off the southern California coast. High-resolution movement and passive acoustic data were obtained from non-invasive archival tags (n=42) whereas surface positions were obtained with visual focal follows. Controlled exposure experiments (CEEs) were used to obtain direct behavioral measurements before, during and after simulated and operational military mid-frequency active sonar (MFAS), pseudorandom noise (PRN) and controls (no noise exposure). For a subset of deep-feeding animals (n=21), active acoustic measurements of prey were obtained and used as contextual covariates in response analyses. To investigate potential behavioral changes within individuals as a function of controlled noise exposure conditions, two parallel analyses of time-series data for selected behavioral parameters (e.g. diving, horizontal movement and feeding) were conducted. This included expert scoring of responses according to a specified behavioral severity rating paradigm and quantitative change-point analyses using Mahalanobis distance statistics. Both methods identified clear changes in some conditions. More than 50% of blue whales in deep-feeding states responded during CEEs, whereas no changes in behavior were identified in shallow-feeding blue whales. Overall, responses were generally brief, of low to moderate severity, and highly dependent on exposure context such as behavioral state, source-to-whale horizontal range and prey availability. Response probability did not follow a simple exposure-response model based on received exposure level. These results, in combination with additional analytical methods to investigate different aspects of potential responses within and among individuals, provide a comprehensive evaluation of how free-ranging blue whales responded to mid-frequency military sonar.

From Their Perspective: The Connection between Life Stressors and Health Care Service Use Patterns of Homeless Frequent Users of the Emergency Department.

The perspective of homeless adults on their health care service utilization is not well studied. This article describes a study that used in-depth, semistructured interviews with 18 individuals to highlight the viewpoints of homeless people who are frequent users of the emergency department (ED) about the influence of life events on service utilization. Participants reported high levels of pain and comorbid psychiatric, substance use, and medical conditions. They also reported an identifiable pattern of health care utilization, often centered on a crisis event, influenced by high perceived medical needs, inability to cope after crisis, predisposing vulnerability from social determinants of health, and health care system factors. A social work case management intervention often led to a period of stability and use of ED alternatives. Modifiable targets for intervention at the health care system and local levels include improving trust and convenience of ED alternatives, enhancing consistency of care at ED-alternative sites, and educating those at risk of frequent ED use about community alternatives.

Hydrodynamic properties of fin whale flippers predict maximum rolling performance.

Maneuverability is one of the most important and least understood aspects of animal locomotion. The hydrofoil-like flippers of cetaceans are thought to function as control surfaces that effect maneuvers, but quantitative tests of this hypothesis have been lacking. Here, we constructed a simple hydrodynamic model to predict the longitudinal-axis roll performance of fin whales, and we tested its predictions against kinematic data recorded by on-board movement sensors from 27 free-swimming fin whales. We found that for a given swimming speed and roll excursion, the roll velocity of fin whales calculated from our field data agrees well with that predicted by our hydrodynamic model. Although fluke and body torsion may further influence performance, our results indicate that lift generated by the flippers is sufficient to drive most of the longitudinal-axis rolls used by fin whales for feeding and maneuvering.

Population pharmacokinetics of inhaled fluticasone furoate and vilanterol in adult and adolescent patients with asthma.

OBJECTIVES: Population pharmacokinetic (PK) methods were used to characterize the PK of fluticasone furoate (FF) and vilanterol (VI) in patients with asthma following once daily inhaled FF/VI and FF and to identify significant covariates that impact the PK. MATERIALS AND METHODS: Four of the five studies in the meta-analysis were conducted in patients with asthma (> 90%), the fifth in healthy subjects. FF data were described by a two-compartment model with first order absorption and elimination. VI data were described by a three-compartment model with zero-order absorption and first order elimination. RESULTS: Race was a significant covariate on inhaled clearance (CL/F) of FF PK. AUC(0-24) for Asian patients was on average 33 - 53% higher than for non-Asians. Race was also a significant covariate on VI PK, with lower (81%) central volume of distribution (Vc/F) for Asian patients compared with non-Asians; VI C(max) was 220 - 287% higher in Asian patients. Treatment (combination or monotherapy), predicted percentage FEV(1), and other demographic variables did not influence the PK of FF or VI. CONCLUSIONS: Combination of FF/VI does not appear to affect the PK of FF or VI. The effect of race on PK of FF or VI does not have impact on dosage adjustments for FF/VI in East Asian patients with asthma.

Pharmacokinetics of fluticasone furoate, umeclidinium, and vilanterol as a triple therapy in healthy volunteers.

OBJECTIVE: Two single-center, four-way, single-dose, crossover studies assessed the systemic exposure, systemic pharmacodynamics (PD), and safety profile of the closed triple fluticasone furoate/ umeclidinium/vilanterol (FF/UMEC/VI) therapy compared with dual therapies. These are the first studies where pharmacokinetic (PK) profile assessment was possible for this inhaled triple fixed-dose combination product. METHODS: Healthy volunteers were randomized to receive 4 consecutive inhalations (each administered as a single dose) via a single ELLIPT® dry powder inhaler: in study 1 (CTT116415/NCT01691547), FF/UMEC/VI at total doses of 400/500/100 µg, FF/UMEC 400/500 µg, UMEC/VI 500/100 µg, or FF/VI 400/100 µg; in study 2 (200587/NCT01894386), FF/UMEC/VI at total doses of 400/500/100 µg or 400/250/100 µg, FF/VI 400/100 µg, or UMEC/VI 250/100 µg. PK and PD parameters and safety were assessed. RESULTS: Of 88 subjects, 95% completed both studies and received all planned treatments. Total systemic exposure was similar for FF, UMEC, and VI when administered as a triple therapy compared with FF/VI and UMEC/VI. No clinically significant systemic PD findings were detected. The incidence of adverse events was low and similar across treatment arms. CONCLUSIONS: Systemic exposure to all three components of the closed triple therapy, following single-dose delivery, was similar to that seen with the dual therapies FF/VI and UMEC/VI. The delivered lung dose and safety profile of all three agents, delivered via a single inhaler, are expected to be similar to those of the dual therapies.

Pharmacokinetics and pharmacodynamics of intravenous and inhaled fluticasone furoate in healthy Caucasian and East Asian subjects.

AIM: The aim of the study was to evaluate the pharmacokinetics (PK) of inhaled and intravenous (i.v.) fluticasone furoate (FF) in healthy Caucasian, Chinese, Japanese and Korean subjects. METHOD: This was an open label, randomized, two way crossover study in healthy Caucasian, Chinese, Japanese and Korean subjects (n = 20 per group). Inhaled FF (200 µg for 7 days, then 800 µg for 7 days from a dry powder inhaler [DPI]) was administered in one treatment period and i.v.FF (250 µg infusion) in the other. FF PK and serum cortisol (inhaled 200 µg only) were compared between the ethnic groups using analysis of variance. P450 CYP3A4 activity and safety were also assessed. RESULTS: Ethnic differences in i.v. FF PK were accounted for by body weight differences. CYP3A4 activity was similar across the groups. Higher FF systemic exposure was seen following inhaled dosing in Chinese, Japanese and Korean subjects compared with Caucasian subjects. Absolute bioavailability was greater (36%-55%) in all East Asian groups than for Caucasian subjects following inhaled FF 800 µg. Deconvolution analysis suggested inhaled FF resided in the lung of East Asian subjects longer than for Caucasians (time for 90% to be absorbed [t90]: 29.1-30.8 h vs. 21.4 h). In vitro simulation method predicted comparable delivered lung dose across ethnic groups. Serum cortisol weighted mean was similar between Caucasians and Chinese or Koreans, while in Japanese was on average 22% lower than in Caucasians. All FF treatments were safe and well tolerated. CONCLUSION: Modestly higher (<50%) FF systemic exposure seen in East Asian subjects following inhaled dosing was not associated with a clinically significant effect on serum cortisol, suggesting that a clinical dose adjustment in East Asian subjects is not required.

A repeat-dose thorough QT study of inhaled fluticasone furoate/vilanterol combination in healthy subjects.

AIMS: This study was designed as a thorough QT (TQT) study to evaluate the effects of fluticasone furoate (FF)/vilanterol (VI) in healthy subjects. Supportive data from a TQT study conducted with FF are also presented. METHODS: This was a randomized, placebo- and positive-controlled, double-dummy, double-blind, four-way crossover study, in which healthy subjects (n = 85) were randomized to 7 days of once-daily treatment of FF/VI (200/25 or 800/100 µg) or placebo or single-dose oral moxifloxacin (single-blind, 400 mg). In the supportive TQT study, subjects (n = 40) were randomized to single-dose inhaled FF (4000 µg), oral moxifloxacin (400 mg) or placebo. RESULTS: There was a lack of effect of FF/VI (200/25 µg) on QTcF (Fridericia's correction); all time-matched mean differences from baseline relative to placebo (0-24 h) were <5 ms, with upper 90% confidence intervals (CI) of <10 ms. At 800/100 µg, FF/VI had no significant clinical effect on QTcF except at 30 min postdose when the 90% CI was >10 ms [mean (90% CI), 9.6 ms (7.2, 12.0)]. No effect on QTci (individually corrected) was observed at either strength of FF/VI, with mean time-matched treatment differences <5 ms at all time points [upper 90% CIs <10 ms (0-24 h)]. Assay sensitivity was confirmed; moxifloxacin prolonged QTcF and QTci, with time-matched mean differences from baseline relative to placebo of >10 ms (1-8 h postdose). CONCLUSIONS: Repeat once-daily dosing of FF/VI (200/25 µg), which is the highest therapeutic strength used in phase III studies, is not associated with QTc prolongation in healthy subjects. Supratherapeutic strength FF/VI (800/100 µg) demonstrated a small transient effect on QTcF but not on QTci.

Characteristics of Pediatric Hospital Medicine Fellowship Program Directors.

BACKGROUND AND OBJECTIVES: Rapid growth in pediatric hospital medicine (PHM) fellowships has occurred, yielding many new program directors (PDs). Characteristics of PDs have potential implications on the field. To describe characteristics (demographic, educational) and scholarly interests of PHM fellowship PDs. METHODS: We developed and distributed a 15-question, cross-sectional national survey to the PHM PDs listserv. Questions were pilot tested. The survey was open for 4 weeks with weekly reminders. Responses were summarized using descriptive statistics. RESULTS: Fifty-six current fellowship leaders (40 PDs, 16 associate PDs [APDs]) responded, including at least 1 from 43 of 59 active PHM fellowship programs (73%). Most respondents identified as female (71%) and ≤50 years old (80%). Four (7%, n = 2 PD, 2 APD) leaders identified as underrepresented in medicine. About half (n = 31, 55.4%) completed a fellowship themselves (APDs > PDs; 87.5% vs 42.5%), and 53.5% (n = 30) had advanced nonmedical degrees (eg, Master of Science, Doctor of Philosophy; APDs > PDs; 62% vs 45%). Most leaders (59%, n = 33) chose multiple domains when asked to select a "primary domain of personal scholarship." Education was the most frequently selected (n = 37), followed by quality improvement (n = 29) and then clinical research (n = 19). CONCLUSIONS: This survey confirms a high percentage of women as PHM fellowship leaders and highlights the need to increase diversity. Less than half of senior PDs completed a fellowship in any specialty. Leaders report interest in multiple domains of scholarship; few focus solely on clinical research.

The effect of ketoconazole on the pharmacokinetics and pharmacodynamics of inhaled fluticasone furoate and vilanterol trifenatate in healthy subjects.

AIM: To investigate the effects of the cytochrome P450 3A4 (CYP3A4) inhibitor ketoconazole on the pharmacokinetics (PK) and pharmacodynamics of fluticasone furoate (FF) and vilanterol trifenatate (VI). METHODS: Two double-blind, randomized, placebo-controlled, two-way crossover studies in healthy subjects. In study 1, subjects received single doses of ketoconazole (400 mg) or placebo on days 1-6, with a single dose of inhaled VI (25 µg) on day 5. Pharmacodynamic and PK data were obtained up to 48 h following the VI dose. In study 2, subjects received once daily ketoconazole (400 mg) or placebo for 11 days, with FF/VI (200/25 µg) for the final 7 days. Pharmacodynamic and PK data were obtained up to 48 h following the day 11 dose. RESULTS: In study 1, there was no effect of co-administration of ketoconazole and VI on pharmacodynamic or PK parameters. In study 2, co-administration of ketoconazole and FF/VI had no effect on 0-4 h maximal heart rate or minimal blood potassium {treatment difference [90% confidence interval (CI)] -0.6 beats min(-1) (-5.8, 4.5) and 0.04 mmol l(-1) (-0.03, 0.11), respectively}, whilst there was a 27% decrease in 24 h weighted mean serum cortisol [treatment ratio (90% CI) 0.73 (0.62, 0.86)]. Co-administration of ketoconazole increased [percentage change (90% CI)] FF area under the curve (0-24) and maximal plasma concentration by 36% (16, 59) and 33% (12, 58), respectively, and VI area under the curve (0-t') and maximal plasma concentration by 65% (38, 97) and 22% (8, 38), respectively. CONCLUSION: Co-administration of FF/VI or VI with ketoconazole resulted in a less than twofold increase in systemic exposure to FF and VI. There was no increase in ß-agonist systemic pharmacodynamic effects, while serum cortisol was decreased by 27%. Co-administration of FF/VI with strong CYP3A4 inhibitors has the potential to increase systemic exposure to both fluticasone furoate and vilanterol, which could lead to an increase in the potential for adverse reactions.

The safety, pharmacokinetics and pharmacodynamics of a combination of fluticasone furoate and vilanterol in healthy Japanese subjects.

OBJECTIVE: To evaluate the safety, pharmacokinetics and pharmacodynamics of fluticasone furoate (FF) and vilanterol (VI) administered alone or in combination in three Phase I studies in healthy Japanese male subjects. MATERIALS: FF, VI and FF/VI inhalation powder in a novel dry powder inhaler (nDPI). METHODS: Study A: 48 subjects received the first dose on Day 1, followed by a 4-day washout and once-daily (OD) repeat doses of FF 200, 400 or 800 µg or placebo from Day 5 to Day 11 (7 days). Study B: 32 subjects received repeat doses of VI (12.5, 25 µg) OD for 7 days. Study C: 16 subjects received single doses of FF (800 µg), VI (50 µg), FF/VI (800/50 µg) and placebo. RESULTS: Overall, there were no safety concerns and no major differences were found in treatment-related adverse events when FF and VI were administered alone or in combination. Peak plasma concentration of FF and VI following repeat dosing was up to two times higher compared with the single dose. Individual pharmacokinetic parameters of FF and VI differed when co-administered but the differences from monotherapy were not clinically significant. Repeat dosing of FF affected weighted mean (0 - 24 hours) serum cortisol with FF 200, 400 and 800 µg resulting in respective reductions from placebo of 32%, 38% and 97%, respectively. Mean maximum heart rate (0 - 4 hours) was comparable between placebo, VI 12.5 and 25 µg over 7 days of dosing; for single dosing of FF/VI 800/50 and VI 50 µg, heart rate was comparable (70 and 73 bpm, respectively) and this was higher than FF 800 µg (66 bpm) or placebo (64 bpm), but the difference was not clinically significant. CONCLUSIONS: In healthy Japanese subjects, no safety concerns were found following repeat dosing of FF and VI or single dosing of FF, VI and FF/VI. Systemic exposure to FF and VI increased in a dose-dependent manner. Serum cortisol level was suppressed by 97% after 7 days repeat administration of FF at a dose of 800 µg. Heart rate with a single dose of VI 50 µg was higher than that of placebo, though not to a clinically significant extent.

Inpatient Pediatric Care and Clinician Workforce in Wisconsin: The State of the State.

INTRODUCTION: Availability of inpatient pediatric services declined across the United States from 2008 through 2018, with rural areas experiencing steepest declines. Despite the movement of pediatric care to children's centers, most children are still cared for in community hospitals nationally. Assessing the availability and providers of inpatient pediatric care in Wisconsin is an important step in ensuring the health care needs of children in the state continue to be met. METHODS: A cross-sectional survey was distributed to Wisconsin hospitals to determine pediatric services and physician workforce. The response rate was 130/138 (94%), including 56/58 (97%) critical access hospitals. Results of specific inpatient pediatric subdivisions were analyzed by descriptive statistics. RESULTS: Hospitals that provide inpatient newborn care are mostly staffed by pediatricians and family physicians, while critical access hospitals are staffed by family physicians. Hospitals with neonatal intensive care units are staffed by neonatologists, with telemedicine utilized in critical access hospitals. Hospitals with general pediatric admissions are staffed by pediatricians or family physicians, while critical access hospitals are staffed by family physicians. Hospitals with pediatric intensive care units are staffed by pediatric intensivists. CONCLUSIONS: Despite workforce disparities and shortages, hospitals across Wisconsin, including many critical access hospitals, continue to provide inpatient pediatric services. Family physicians play a major role in the pediatric health care delivery in Wisconsin hospitals. Robust inpatient pediatric training of family physicians may enable rural health authorities to continue addressing the gaps that persist in inpatient pediatric care accessibility.

Behavioural responses of fin whales to military mid-frequency active sonar.

The effect of active sonars on marine mammal behaviour is a topic of considerable interest and scientific investigation. Some whales, including the largest species (blue whales, Balaenoptera musculus), can be impacted by mid-frequency (1-10 kHz) military sonars. Here we apply complementary experimental methods to provide the first experimentally controlled measurements of behavioural responses to military sonar and similar stimuli for a related endangered species, fin whales (Balaenoptera physalus). Analytical methods include: (i) principal component analysis paired with generalized additive mixed models; (ii) hidden Markov models; and (iii) structured expert elicitation using response severity metrics. These approaches provide complementary perspectives on the nature of potential changes within and across individuals. Behavioural changes were detected in five of 15 whales during controlled exposure experiments using mid-frequency active sonar or pseudorandom noise of similar frequency, duration and source and received level. No changes were detected during six control (no noise) sequences. Overall responses were more limited in occurrence, severity and duration than in blue whales and were less dependent upon contextual aspects of exposure and more contingent upon exposure received level. Quantifying the factors influencing marine mammal responses to sonar is critical in assessing and mitigating future impacts.

Gender Difference in Teaching Evaluation Scores of Pediatric Faculty.

OBJECTIVE: To evaluate associations between faculty gender and milestone-based teaching assessment scores assigned by residents. METHODS: We performed a retrospective cohort study of milestone-based clinical teaching assessments of pediatric faculty completed by pediatric residents at a mid-sized residency program from July 2016 to June 2019. Assessments included 3 domains (Clinical Interactions, Teaching Skills, Role Modeling/Professionalism) comprised of a total of 11 sub-competency items. We used multilevel logistic regression accounting for repeat measures and clustering to evaluate associations between faculty gender and assessment scores in the 1) top quartile, 2) bottom quartile, or 3) top-box (highest score). Findings were adjusted for faculty rank and academic track, and resident year and gender. RESULTS: Over 3 years, 2889 assessments of 104 faculty were performed by 91 residents. Between assessments of women and men faculty, there were no significant differences in the odds of receiving a score in the top quartile for the 3 domains (Clinical aOR 0.99, P = .86; Teaching aOR 0.99, P = .93; Role Modeling aOR 0.87, P = .089). However, assessments of women were more likely to receive a score in the bottom quartile in both Teaching (aOR 1.23, P = .019) and Role Modeling (aOR 1.26, P = .008). Assessments of women also had lower odds of receiving the highest score in 6 of 11 sub-competencies. CONCLUSION: Results suggest that gender bias may play a role in resident assessments of pediatric faculty. Future studies are needed to determine if findings are replicated in other settings and to identify opportunities to reduce the gender gap in pediatric academic medicine.

SDIX RapidChek Listeria F.A.S.T. environmental test system for the detection of Listeria species on environmental surfaces.

The SDIX RapidChek Listeria F.A.S.T. test system was validated against the U.S. Department of Agriculture-Food Safety and Inspection Service (USDA-FSIS) cultural reference method for the detection of Listeria species on stainless steel, plastic, rubber, and painted concrete. The SDIX method uses a proprietary RapidChek Listeria enrichment media for a one-step, 24-40 h enrichment at 30 degrees C, and detects Listeria on an immunochromatographic lateral flow device in 10 min. Different Listeria species were used to spike each of the environmental surfaces. Environmental surfaces were spiked at levels ranging from 50 to 400 CFU/surface (1 in.2 swabs for painted concrete, 4 in.(2) for sponge). A total of 120 spiked samples were tested by the SDIX method at 24 and 40 h and the cultural reference method. Total confirmed positives were 49, 54, and 48 for the SDIX 24 h method, the SDIX 40 h method, and the USDA-FSIS cultural reference method, respectively. Nonspiked samples from all environmental surfaces were reported as negative for Listeria spp. by all methods. The overall Chi square was 0.017 (P = 0.104) and 0.611 (P= 0.566) after a 24 and 40 h enrichment, respectively, indicating that the test method was equivalent in performance to the reference method at both enrichment times. The SDIX method was evaluated for the detection of 50 Listeria and 35 non-Listeria bacterial strains. All 50 Listeria strains were detected by the method (100% sensitivity). Five out of 35 non-Listeria species gave light test signals when grown in nonselective broth culture and tested undiluted. However, when grown in the RapidChek Listeria F.A.S.T. proprietary media, only one bacterial strain (Staphylococcus aureus) was detected, giving a very low test signal (97% specificity). The method was shown to be robust toward several alterations in testing and storage conditions.

Gender-Based Linguistic Analysis of Pediatric Clinical Faculty Evaluations.

BACKGROUND: Gendered stereotypes are embedded in the culture of medicine. Women are stereotypically expected to act collaboratively and less assertively, while men are expected to act with authority and power. Whether gender-biased language is expressed in academic pediatric teaching evaluations is unknown. OBJECTIVE: Determine whether stereotypic gender-based linguistic differences exist in resident evaluations of pediatric faculty. METHODS: We performed a retrospective cross-sectional study of clinical faculty evaluations by pediatric residents in a single program from July 2016 to June 2019. Using Linguistic Inquiry and Word Count, responses to 2 open-ended questions were analyzed for stereotypic language. Categories were reported as a percent of total words written. Comparisons between gender groups were conducted using nonparametric Wilcoxon rank sum tests. Rates of word use within each category were analyzed using logistic regression where faculty and resident gender were included as predictor variables. RESULTS: A total of 6436 free-text responses from 3218 unique evaluations were included. As hypothesized, evaluations of women faculty were less likely than those of men to include certain agentic language like power (odds ratio [OR] 0.9, P < .001) and insight (OR 0.9, P < .001), and research words (OR 0.6, P = .003). As expected, evaluations of women were more likely to include grindstone words, like "hardworking" (OR 1.2, P = .012). Contrary to our hypothesis, women received fewer teaching words like "mentor" (OR 0.9, P = .048) and communal words like "friendly" (OR 0.6, P = .001). CONCLUSION: Certain stereotypic language was demonstrated in clinical teaching evaluations of pediatric faculty. These findings should be further examined to improve gender inequities in academic pediatrics.

RapidChek SELECT Salmonella enteritidis test system for the detection of Salmonella enteritidis in poultry house drag swabs, shell egg pools, and chicken carcass rinsates.

The RapidChek SELECT Salmonella Enteritidis Test System was validated for the detection of Salmonella Enteritidis (SE) in poultry house drag swabs, shell egg pools, and chicken carcass rinsates. The method utilizes RapidChek SELECT Salmonella (AOAC PTM License No. 080601) proprietary primary and secondary enrichment media. Following enrichment, an immunochromatographic test strip is inserted into the tube containing the secondary enrichment broth, developed for 10 min, and interpreted. Salmonella Enteritidis-inoculated samples (1-5 CFU SE/analytical unit) were tested by the test method as well as the appropriate cultural reference method U.S. Food and Drug Administration-Bacteriological Analytical Manual (drag swabs and egg pools) or U.S. Department of Agriculture-Food Safety and Inspection Service (chicken carcass rinsates). A total of 80 samples were tested by both methods in the study. Fifty-two samples were positive by the RapidChek SELECT Salmonella Enteritidis method and 38 were found positive by the respective reference method. The sensitivity of the method was 100% and the specificity was 100%. The accuracy of the test method was 137%, indicating that the method was more sensitive than the reference method. The RapidChek SELECT Salmonella Enteritidis method was tested with 82 Salmonella Group D1 strains including 63 Salmonella Enteritidis strains as well as 32 non-Salmonella Group D1 strains representing 10 bacteria genera. The test method detected all 82 Group D1 strains (100% sensitivity). None of the non-Salmonella Group D1 or other genera of bacteria were detected, indicating a specificity of 100%. The method was shown to be highly robust and stable under control and accelerated stability conditions.

RapidChek SELECT Salmonella. Performance Tested Method 080601.

RapidChek SELECT Salmonella was previously validated in the Performance Tested Methods program for the detection of Salmonella spp. in raw ground chicken, chicken carcass rinse, sliced cooked turkey, and liquid eggs. The present matrix extension study conducted under the AOAC Research Institute Emergency Response Validation program compared the RapidChek SELECT Salmonella method to the U.S. Food and Drug Administration's Bacteriological Analytical Manual (FDA-BAM) method for the detection of Salmonella Typhimurium in peanut butter. Overall, 27 samples were found positive by the RapidChek SELECT Salmonella method and 27 were found to be positive by the reference method. All RapidChek SELECT Salmonella presumptive positives were confirmed positive by the cultural reference method; additionally, all presumptive negative results were confirmed negative by the cultural reference method. Accordingly 0% false-negative rate and 0% false-positive rate were found. No significant difference between the RapidCheck SELECT Salmonella and FDA-BAM reference method was found; calculated Chi-square was 0. Results indicate that a low level of Salmonella in peanut butter can be successfully recovered and detected in the minimum 24 h enrichment protocol.

Feeding during High-Flow Nasal Cannula for Bronchiolitis: Associations with Time to Discharge.

BACKGROUND: High-flow nasal cannula (HFNC) is increasingly used to treat children hospitalized with bronchiolitis; however, the best practices for feeding during HFNC and the impact of feeding on time to discharge and adverse events are unknown. The study objective was to assess whether feeding exposure during HFNC was associated with time to discharge or feeding-related adverse events. METHODS: This retrospective cohort study included inpatients aged 1-24 months receiving HFNC for bronchiolitis at an academic children's hospital from January 1, 2015 to March 1, 2017. Feeding exposures during HFNC were categorized as fed or not fed. Among fed children, we further evaluated mixed (oral and tube) or exclusive oral feeding. The primary outcome was time to discharge after HFNC cessation. Secondary outcomes were aspiration, intubation after HFNC, and seven-day readmission. RESULTS: Of 123 children treated with HFNC, 45 (37 %) were never fed. A total of 78 children (63%) were fed; 50 (41%) were exclusively orally fed and 28 (23 %) had mixed feeding. Median (interquartile range) time to discharge after HFNC was 29.5 hours (23.5-47.9) and 39.8 hours (26.4-61.5) hours in the fed and not fed groups, respectively. In adjusted models, time to discharge was shorter with any feeding (hazard ratio [HR] 2.17; 95% CI: 1.34-3.50) and with exclusive oral feeding (HR 2.13; 95% CI: 1.31-3.45) compared with no feeding. Time to discharge from HFNC initiation was shorter for exclusive oral feeding versus not feeding (propensity weighted HR 1.97 [95% CI: 1.13-3.43]). Adverse events (one intubation, one aspiration pneumonia, one readmission) occurred in both groups. LIMITATIONS: Assessment of feeding exposure did not account for quantity and duration. DISCUSSION: Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.

Earlier Hospital Discharge With Prospectively Designated Discharge Time in the Electronic Health Record.

BACKGROUND AND OBJECTIVES: Hospital discharge requires multidisciplinary coordination. Insufficient coordination impacts patient flow, resource use, and postdischarge outcomes. Our objectives were to (1) implement a prospective, multidisciplinary discharge timing designation in the electronic health record (EHR) and (2) evaluate its association with discharge timing. METHODS: This quality-improvement study evaluated the implementation of confirmed discharge time (CDT), an EHR designation representing specific discharge timing developed jointly by a patient's family and the health care team. CDT was intended to support task management and coordination of multidisciplinary discharge processes and could be entered and viewed by all team members. Four plan-do-study-act improvement phases were studied: (1) baseline, (2) provider education, (3) provider feedback, and (4) EHR modification. Statistical process control charts tracked CDT use and the proportion of discharges before noon. Length of stay was used as a balancing measure. RESULTS: During the study period from April 2013 through March 2017, 20 133 pediatric discharges occurred, with similar demographics observed throughout all phases. Mean CDT use increased from 0% to 62%, with special cause variations being detected after the provider education and EHR modification phases. Over the course of the study, the proportion of discharges before noon increased by 6.2 percentage points, from 19.9% to 26.1%, whereas length of stay decreased from 47 (interquartile range: 25-95) to 43 (interquartile range: 24-88) hours (both P < .001). CONCLUSIONS: The implementation of a prospective, multidisciplinary EHR discharge time designation was associated with more before-noon discharges. Next steps include replicating results in other settings and determining populations that are most responsive to discharge coordination efforts.