Implementation of Best Practices in Obesity Prevention in Child Care Facilities: The Arizona Empower Program, 2013-2015.

INTRODUCTION: Obesity is a major health concern in every US age group. Approximately one in 4 children in Arizona's Special Supplemental Nutrition Program for Women, Infants, and Children is overweight or obese. The Arizona Department of Health Services developed the Empower program to promote healthy environments in licensed child care facilities. The program consists of 10 standards, including one standard for each of these 5 areas: physical activity and screen time, breastfeeding, fruit juice and water, family-style meals, and staff training. The objective of this evaluation was to determine the level of implementation of these 5 Empower standards. METHODS: A self-assessment survey was completed from July 2013 through June 2015 by 1,850 facilities to evaluate the level of implementation of 5 Empower standards. We calculated the percentage of facilities that reported the degree to which they implemented each standard and identified common themes in comments recorded in the survey. RESULTS: All facilities reported either full or partial implementation of the 5 standards. Of 1,678 facilities, 21.7% (n = 364) reported full implementation of all standards, and 78.3% (n = 1,314) reported at least partial implementation. Staff training, which has only one component, had the highest level of implementation: 77.4% (n = 1,299) reported full implementation. Only 44.0% (n = 738) reported full implementation of the standard on a breastfeeding-friendly environment. CONCLUSION: Arizona child care facilities have begun to implement the Empower program, but facilities will need more education, technical assistance, and support in some areas to fully implement the program.

Family physicians who have focused practices in oncology: results of a national survey.

OBJECTIVE: To characterize the demographic characteristics, practice profile, and current work life of general practitioners in oncology (GPOs) for the first time. DESIGN: National Web survey performed in March 2011. SETTING: Canada. PARTICIPANTS: Members of the national GPO organization. Respondents were asked to forward the survey to non-member colleagues. MAIN OUTCOME MEASURES: Profile of work as GPOs and in other medical roles, training received, demographic characteristics, and professional satisfaction. RESULTS: The response rate was 73.3% for members of the Canadian Association of General Practitioners in Oncology; overall, 120 surveys were completed. Respondents worked in similar proportions in small and larger communities. About 60% of them had participated in formal training programs. Most respondents worked part-time as GPOs and also worked in other medical roles, particularly palliative care, primary care practice, teaching, and hospital work. More GPOs from cities with populations of greater than 100 000 worked solely as GPOs than those from smaller communities (P = .0057). General practitioners in oncology played a variety of roles in the cancer care system, particularly in systemic therapy, palliative care, inpatient care, and teaching. As a group, more than half of respondents were involved in the care of each of the 11 common cancer types. Overall, 87.8% of respondents worked in outpatient care, 59.1% provided inpatient care, and 33.0% provided on-call services; 92.8% were satisfied with their work as GPOs. CONCLUSION: General practitioners in oncology are involved in all cancer care settings and usually combine this work with other roles, particularly with palliative care in rural Canada. Training is inconsistent but initiatives are under way to address this. Job satisfaction is better than that of Canadian FPs in general. As generalists, FPs bring a valuable skill set to their work as GPOs in the cancer care system.

Psychiatric patients are at increased risk of falling and choking.

Acutely ill psychiatric patients experience symptoms and take medications that increase their risk of both falling and choking; however, nurses and other caregivers may not be keenly aware of these risks. This article will provide a brief review of the literature related to risk factors for falls and choking and interventions to prevent falls and choking. Increased education for nursing students and staff employed at inpatient psychiatric units has the potential to reduce both incidence and injuries related to falls and choking.

Trafficking and signaling in mammalian autophagy.

Macroautophagy, here called autophagy, is literally a "self-eating" catabolic process, which is evolutionarily conserved. Autophagy is initiated by cellular stress pathways, resulting in the sequestration or engulfment of cytosolic proteins, membranes, and organelles in a double membrane structure that fuses with endosomes and lysosomes, thus delivering the sequestered material for degradation. Autophagy is implicated in a number of human diseases, many of which can either be characterized by an imbalance in protein, organelle, or cellular homeostasis, ultimately resulting in an alteration of the autophagic response. Here, we will review the recent progress made in understanding the induction of autophagy, with emphasis on the contributions from our laboratory.

Epigenetic Regulation of iASPP-p63 Feedback Loop in Cutaneous Squamous Cell Carcinoma.

Keratinocyte skin cancer, comprising cutaneous squamous (cSCC) and basal cell carcinoma, is the most common malignancy in the United Kingdom. P53 is frequently mutated in cSCC. iASPP is a key inhibitor of p53 and NF-κB signaling pathways and has been documented as highly expressed in several types of human cancer. We have previously identified an autoregulatory feedback loop between iASPP and p63, which is critical in epidermal homeostasis. We hypothesized a potential role for dysregulation of this axis in the pathogenesis of keratinocyte malignancies. Immunostaining of 116 cSCC clinical samples revealed increased iASPP and ΔNp63 expression, but also highlighted a significant alteration of iASPP cellular localization, with consequent deregulation of its function. Expression patterns, functionality, and gene and microRNA expression analysis were further investigated in 10 cSCC cell lines. Our data suggest that while direct effects of iASPP and p63 upon each other's expression are maintained in cSCC, epigenetic dysregulation of the feedback loop occurs at the microRNA level by a previously unreported mechanism controlling p63 expression. We demonstrate that this autoregulatory feedback loop controls cell migration in cSCC by blocking epithelial-mesenchymal transition and promoting proliferation, and provides future directions for clinical biomarker and therapeutic target discovery in cutaneous SCC.

Development of Electronic Chemotherapy Roadmaps for Pediatric Oncology Patients.

A chemotherapy roadmap is a summary of the chemotherapy plan for a pediatric oncology patient. Chemotherapy roadmaps exist as paper documents for most, if not all, pediatric oncology programs. Paper chemotherapy roadmaps are associated with risks that can negatively affect the safety of the chemotherapy process. This institution explored the feasibility of converting paper chemotherapy roadmaps into an electronic form. The pediatric information systems team developed an innovative computer application that can generate electronic chemotherapy roadmaps, and the pediatric oncology program established a novel workflow that can operationalize them. Electronic chemotherapy roadmaps have been produced for 36 treatment protocols, and 369 electronic chemotherapy roadmaps have been used for 352 pediatric oncology patients. They have functioned as designed and have not had any unintended effects. In the 5 years after their implementation, the average proportion of patient safety events involving paper or electronic chemotherapy roadmaps decreased by 78.7%. This report is the first to demonstrate the feasibility of creating and implementing electronic chemotherapy roadmaps. Continued expansion of the current library will be necessary to formally test the hypothesis that electronic chemotherapy roadmaps can decrease the risks associated with their paper counterparts and increase the safety of the chemotherapy process.

The Diagnostic Shift of SIDS to Undetermined: Are There Unintended Consequences?

Over the last two decades, a diagnostic shift in regards to the certification of sudden deaths in infancy has emerged with reassignment of deaths previously certified as sudden infant death syndrome (SIDS) to a trend utilizing the classification of undetermined or asphyxia. The consequences of this shift outside the medicolegal death investigation (MDI) community is unknown. We surveyed US organizations working in the field of sudden infant death as well as bereaved parents to understand their perceptions of the current diagnostic trends. Two online anonymous surveys were utilized. Sixty-seven organizations and 55 parents with an infant death diagnosis of SIDS, sudden unexplained infant death (SUID), undetermined, or asphyxia participated. Just over 50% (34/67) of the organizations perceived the shift had an effect on their organization including barriers to bereavement support and education. Forty percent (22/55) of parent respondents stated they did not understand the final diagnosis of their infant's death. The highest frequency of themes elicited from parents were frustration that the diagnosis (regardless of terminology) did not fully explain the death, detrimental mental health effects, and negative perceptions towards the medical and public health communities. However, parents of children whose death was classified as SIDS were spared from negative perceptions towards the medical field, described the least amount of confusion, and reported the most instances of positives effects. Legal implications, perceived social stigmas, and research obstacles were also described. Recommendations from this study include the integration of collaborative efforts to combat sudden infant death with all stakeholders, in and outside of MDI, to achieve better understanding and eradication of these tragedies, improved public education, and effective care of all bereaved.

Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer.

BACKGROUND: The administration of chemotherapy to hospitalized children with cancer is a complex and high-risk process. A team divided the process into three areas--prescribing, dispensing, and administration--and used Failure Mode and Effects Analysis (FMEA) to identify the elements of risk and implement appropriate strategies. For each area, potential failures within subprocesses were assigned risk priority numbers (RPNs), reflecting their frequency, severity, and detectability. STRATEGIES FOR RISK REDUCTION: The team made prescribing and administration, the areas with the highest RPNs, the focus of most of its strategies, which were introduced and completed in 2002. POSTIMPLEMENTATION RESULTS: The potential prescribing error rate decreased from 23% to 14%; use of preprinted standard order sets increased from 22% to 45% in 2003 (one year after the FMEA was conducted) and 76% in 2005. Actual dispensing errors decreased from 3 to 1, and the actual administration errors from 4 to 3. FINAL REFLECTIONS: Computerized order entry systems would only affect prescribing, dispensing, and administering, which would still be done manually, resulting in potential for failure. The FMEA project will be an ongoing part of providing safe chemotherapy treatments.

Best Practices for Chemotherapy Administration in Pediatric Oncology: Quality and Safety Process Improvements (2015).

The administration of chemotherapy to children with cancer is a high-risk process that must be performed in a safe and consistent manner with high reliability. Clinical trials play a major role in the treatment of children with cancer; conformance to chemotherapy protocol requirements and accurate documentation in the medical record are critical. Inconsistencies in the administration and documentation of chemotherapy were identified as opportunities for errors to occur. A major process improvement was initiated to establish best practices for nurses who administer chemotherapy to children. An interdisciplinary team was formed to evaluate the current process and to develop best practices based on current evidence, protocol requirements, available resources, and safety requirements. The process improvement focused on the establishment of standardized and safe administration techniques, exact administration times, and consistent electronic documentation that could easily be retrieved in medical record audits. Quality improvement tools including SBAR (Situation, Background, Assessment, Recommendation), process mapping, PDSA (Plan, Do. Study, Act) cycles, and quality metrics were used with this process improvement. The team established best practices in chemotherapy administration to children that have proven to be safe and reliable. Follow-up data have demonstrated that the project was highly successful and improved accuracy, patient and nurse safety, and effectiveness of chemotherapy administration.

Constitutive Autophagy and Nucleophagy during Epidermal Differentiation.

Epidermal keratinocytes migrate through the epidermis up to the granular layer where, on terminal differentiation, they progressively lose organelles and convert into anucleate cells or corneocytes. Our report explores the role of autophagy in ensuring epidermal function providing the first comprehensive profile of autophagy marker expression in developing epidermis. We show that autophagy is constitutively active in the epidermal granular layer where by electron microscopy we identified double-membrane autophagosomes. We demonstrate that differentiating keratinocytes undergo a selective form of nucleophagy characterized by accumulation of microtubule-associated protein light chain 3/lysosomal-associated membrane protein 2/p62 positive autolysosomes. These perinuclear vesicles displayed positivity for histone interacting protein, heterochromatin protein 1α, and localize in proximity with Lamin A and B1 accumulation, whereas in newborn mice and adult human skin, we report LC3 puncta coincident with misshaped nuclei within the granular layer. This process relies on autophagy integrity as confirmed by lack of nucleophagy in differentiating keratinocytes depleted from WD repeat domain phosphoinositide interacting 1 or Unc-51 like autophagy activating kinase 1. Final validation into a skin disease model showed that impaired autophagy contributes to the pathogenesis of psoriasis. Lack of LC3 expression in psoriatic skin lesions correlates with parakeratosis and deregulated expression or location of most of the autophagic markers. Our findings may have implications and improve treatment options for patients with epidermal barrier defects.

Glycogenin activity and mRNA expression in response to volitional exhaustion in human skeletal muscle.

Glycogenolysis results in the selective catabolism of individual glycogen granules by glycogen phosphorylase. However, once the carbohydrate portion of the granule is metabolized, the fate of glycogenin, the protein primer of granule formation, is not known. To examine this, male subjects (n = 6) exercised to volitional exhaustion (Exh) on a cycle ergometer at 75% maximal O2 uptake. Muscle biopsies were obtained at rest, 30 min, and Exh (99 +/- 10 min). At rest, total glycogen concentration was 497 +/- 41 and declined to 378 +/- 51 mmol glucosyl units/kg dry wt following 30 min of exercise (P < 0.05). There were no significant changes in proglycogen, macroglycogen, glycogenin activity, or mRNA in this period (P > or = 0.05). Exh resulted in decreases in total glycogen, proglycogen, and macroglycogen as well as glycogenin activity (P < 0.05). These decrements were associated with a 1.9 +/- 0.4-fold increase in glycogenin mRNA over resting values (P < 0.05). Glycogenolysis in the initial exercise period (0-30 min) was not adequate to induce changes in glycogenin; however, later in exercise when concentration and granule number decreased further, decrements in glycogenin activity and increases in glycogenin mRNA were demonstrated. Results show that glycogenin becomes inactivated with glycogen catabolism and that this event coincides with an increase in glycogenin gene expression as exercise and glycogenolysis progress.

Norepinephrine but not serotonin reuptake inhibitors enhance theta and gamma activity of the septo-hippocampal system.

Current neurobiological concepts attribute a central role of the hippocampal formation in cognitive and affective processes. Recent studies indicate that the hippocampus is affected in human depression, and antidepressant drugs induce hippocampal adaptive changes that are thought to be associated with their therapeutic action. In the present study, we investigated the action of various antidepressant drugs on the activity of the septo-hippocampal system, its oscillatory activity in particular. The acute effects of the norepinephrine (NE) reuptake inhibitors reboxetine and desipramine, and the selective serotonin reuptake inhibitor fluvoxamine were evaluated. Extracellular single-unit recordings were performed from the medial septum/diagonal band of Broca (MS/DBv), with simultaneous hippocampal EEG recordings of anesthetized rats. Systemic administration of reboxetine synchronized hippocampal EEG, resulting in a significant increase in power at theta frequency, and an increase in frequency and power of gamma-wave activity. Parallel to EEG synchrony, reboxetine induced or enhanced theta oscillation of MS/DBv neurons. Oscillatory frequencies of MS/DBv neurons were identical, and phase locked to the corresponding hippocamapal theta frequencies. Under the same experimental conditions, reboxetine induced a two-fold increase in extracellular NE (but not serotonin) levels in the hippocampus as revealed by microdialysis. Desipramine, but not the serotonin reuptake inhibitor fluvoxamine, evoked responses similar to those of reboxetine regarding septo-hippocampal theta activity. The present findings indicate that even though both NE and serotonin reuptake inhibitors are clinically effective antidepressant drugs, their action on the septo-hippocampal oscillatory behavior is different. It is presumed that selective NE reuptake inhibitors could modulate various cognitive processes associated with hippocampal oscillatory activity.

Seasonal changes in the pigments of Norway spruce, Picea abies (L.) Karst, and the influence of summer ozone exposures.

There are always significant pigment changes in Norway spruce [Picea abies (L.) Karst.] needles with time in different year classes, even through the winter, but no significant changes in current year needles occur either during summer exposure due to ozone (70 nl i-1 ) or in the winter following. Effects of summer ozone fumigation on pigment levels, however, are very evident in 1- (and 2-)yr-old needles. These include significant decreases of total amounts of chlorophyll a and b, violaxanthin, antheraxanthin, and lutein. The only increase in pigment of 1-yr-old needles in the summer caused by ozone is that of 5, 6-epoxy-lutein; consequently, the 5, 6-epoxy-lutein/lutein ratio rises. Although traces of 5, 6-epoxy-lutein also occur in the winter afterwards, they are not significant but significant decreases in levels of chlorophylls, vioiaxanthin, antheraxanthin, lutein and ß-carotene persist. The fall in chlorophyll a levels are greater than those of chlorophyll b so a significant fall in the chlorophyll a/b ratio also occurs. Similarly, the declines in amount of ß-carotene are not as great as those of chlorophyll a and therefore significant increases in the ratio of ß-carotene to chlorophyll a are observed. No time x treatment interactions occur after ozone fumigation of 1-yr-old needles has been stopped but time x ozone interactions are observed during fumigation in both chlorophyll a/b and violaxanthin/antheraxanthin ratios. Most pigment changes in 2-yr-old needles due to summer ozone exposure are complementary to those which occurred in 1-yr-old needles in response to ozone the summer before.

Influence of episodes of summer O3 on δ5 and δ9 fatty acids in autumnal lipids of Norway spruce [Picea abies (L.) Karst].

Current year needles from 5 yr-old Norway spruce trees, which had been exposed to either episodes of atmospheric O3 , or periodic mistings with simulated acid rainwater throughout three summer periods, were-analyzed for changes in molar percentages and ratios of fatty acids isolated from different lipids at the time of maximum winter hardening. No significant changes due to acidic misting were detected but significant decreases in the degree of unsaturation off both C 16 and C18 , fatty acids, the molar percentage of δ5,9,12,15 , and the molar ratio δ5,9 18: 2 to δ9,12 18:2 in monogalactosyl diglyceride (MGDG) due to summer 03 exposures were found. Molar percentages and ratios of fatty acids did not change much in other lipids bur these changes in plastidie MGDG could be traced to a significant effect of summer O3 on the δ4 - and δ12 -desaturases acting upon phosphatidyl choline (PC) in the endoplasmic reticulum. The replacement of the δ6 -subset of C18 fatty acids by an equivalent δ5 -series throughout was confirmed by Gas chromatography and mass spectrometry Molecular modelling also showed that the δ5 forms, which resembled the δ5 -isomers, are very different in shape to the δ5 -series and this may account, in part, for the extremely low winter temperatures from which Norway spruce needles may recover.

Evidence-Based Practice Recommendations for Hydration in Children and Adolescents With Cancer Receiving Intravenous Cyclophosphamide.

Hemorrhagic cystitis is a known complication of cyclophosphamide, an antineoplastic agent used to treat a variety of oncologic diseases in children. Hydration can prevent hemorrhagic cystitis; however, use varies in clinical practice. A team was assembled to develop evidence-based practice recommendations to address the following question: in a population of children with cancer, what is the appropriate pre- and posthydration for the administration of different dose levels of intravenous cyclophosphamide to prevent bladder toxicity? The purpose was to identify the appropriate rate, duration, and route of hydration to prevent bladder toxicity with low, intermediate, and high dose cyclophosphamide. After a systematic search of the literature, 15 pieces of evidence were evaluated and used. There is a moderate level of quality evidence related to hydration for high dose cyclophosphamide and very low quality evidence related to intermediate or low dose cyclophosphamide. Three general recommendations were made for hydration associated with cyclophosphamide. There is a need for further research related to the prevention of bladder toxicity in children with cancer receiving cyclophosphamide.

Nutritional screening and early intervention in children, adolescents, and young adults with cancer.

Children and adolescents with cancer who receive chemotherapy and/or radiation treatments are at risk for malnutrition due to side effects such as nausea, vomiting, anorexia, and mouth sores. Malnutrition during treatment for childhood cancer increases the risk of infection, decreases tolerance to treatment, and even affects overall survival. A retrospective analysis of 79 children, adolescents, and young adults was conducted to evaluate nutritional screening at baseline and for the first 6 months of treatment. Interventions were also documented. Forty-nine participants had a positive screen for risk of malnutrition. In the patients with a positive screen, 78% had intervention within 24 hours of the identified risk for malnutrition. Thirty-five patients had a nutritional referral, which resulted in a full nutritional assessment and plan. Key independent variables were analyzed to determine if they were associated with an increased risk of malnutrition. In addition, individual risk factors were analyzed to determine their association with malnutrition. Future studies should find whether early intervention is effective in reversing the risk of malnutrition during treatment for childhood cancer.

Attitudes and beliefs about mental health among African American older adults suffering from depression.

Depression among older adults is a major public health concern leading to increased disability and mortality. Less than 3% of older adults utilize professional mental health services for the treatment of depression, less than any other adult age group. And despite similar rates of depression, African Americans are significantly less likely to seek, engage and be retained in professional mental health services than their white counterparts. Cultural differences in the way depression symptoms are manifested, defined, interpreted and labeled may in part explain some of these racial differences in help-seeking behaviors. Focus group methodology was utilized to identify and explore attitudes and beliefs about depression and mental health treatment utilization among 42 older African Americans who had recently suffered a major depressive episode. Thematic analysis of identified six overarching themes: (a) perceptions of depression, (b) the African American experience, (c) seeking treatment as a last resort, (d) myths about treatment, (e) stigma associated with seeking treatment and (f) culturally appropriate coping strategies. We discuss implications for practice, education and research.