A case for revisiting peer review: Implications for professional self-regulation and quality improvement.

BACKGROUND: Quality improvement in healthcare has often been promoted as different from and more valuable than peer review and other professional self-regulation processes. In spite of attempts to harmonize these two approaches, the perception of dichotomous opposition has persisted. A sequence of events in the troubled California prison system fortuitously isolated workforce interventions from more typical quality improvement interventions. Our objectives were to (1) evaluate the relative contributions of professional accountability and quality improvement interventions to an observed decrease in population mortality and (2) explore the organizational dynamics that potentiated positive outcomes. METHODS: Our retrospective mixed-methods case study correlated time-series analysis of mortality with the timing of reform interventions. Quantitative and qualitative evidence was drawn from court documents, public use files, internal databases, and other archival documents. RESULTS: Change point analysis reveals with 98% confidence that a significant improvement in age-adjusted natural mortality occurred in 2007, decreasing from 138.7 per 100,000 in the 1998-2006 period to 106.4 in the 2007-2009 period. The improvement in mortality occurred after implementation of accountability processes, prior to implementation of quality improvement interventions. Archival evidence supports the positive impact of physician competency assessments, robust peer review, and replacement of problem physicians. CONCLUSIONS: Our analysis suggests that workforce accountability provides a critical quality safeguard, and its neglect in scholarship and practice is unjustified. As with quality improvement, effective professional self-regulation requires systemic implementation of enabling policies, processes, and staff resources. The study adds to evidence that the distribution of physician performance contains a heterogeneous left skew of dyscompetence that is associated with significant harm and suggests that professional self-regulation processes such as peer review can reduce that harm. Beyond their responsibility for direct harm, dyscompetent professionals can have negative impacts on group performance. The optimal integration of professional accountability and quality improvement systems merits further investigation.

Community Environmental Contamination of Toxigenic Clostridium difficile.

BACKGROUND: Clostridium difficile infection is often considered to result from recent acquisition of a C difficile isolate in a healthcare setting. However, C difficile spores can persist for long periods of time, suggesting a potentially large community environmental reservoir. The objectives of this study were to assess community environmental contamination of toxigenic C difficile and to assess strain distribution in environmental versus clinical isolates. METHODS: From 2013 to 2015, we collected community environmental swabs from homes and public areas in Houston, Texas to assess C difficile contamination. All positive isolates were tested for C difficile toxins A and B, ribotyped, and compared with clinical C difficile isolates obtained from hospitalized patients in Houston healthcare settings. RESULTS: A total of 2538 environmental samples were collected over the study period. These included samples obtained from homes (n = 1079), parks (n = 491), chain stores (n = 225), fast food restaurants (n = 123), other commercial stores (n = 172), and hospitals (n = 448). Overall, 418 environmental isolates grew toxigenic C difficile (16.5%; P < .001) most commonly from parks (24.6%), followed by homes (17.1%), hospitals (16.5%), commercial stores (8.1%), chain stores (7.6%), and fast food restaurants (6.5%). A similar distribution of ribotypes was observed between clinical and environmental isolates with the exception that ribotype 027 was more common in clinical isolates compared with environmental isolates (P < .001). CONCLUSIONS: We identified a high prevalence of toxigenic C difficile from community environs that were similar ribotypes to clinical isolates. These findings suggest that interventions beyond isolation of symptomatic patients should be targeted for prevention of C difficile infection.

Physical Activity Is Associated With Reduced Risk of Executive Function Impairment in Older Women.

OBJECTIVE: To examine whether baseline levels of physical activity, measured by total caloric expenditure, predicted domain-specific cognitive impairments over a 9-year period. METHOD: Participants included 376 community-dwelling older women aged 70 to 80 years at baseline from the Women's Health and Aging Study II. Cox proportional hazard models were used to evaluate the associations between self-reported physical activity and risk of cognitive impairments in psychomotor speed, executive function, and verbal memory. Models were adjusted for age, race, education, number of chronic illnesses, and number of depressive symptoms at baseline. RESULTS: Greater baseline levels of caloric expenditure were associated with better executive function in the most active quintile of adults compared with the least active quintile. Caloric expenditure was not associated with improved scores for any of the other domains assessed. DISCUSSION: The results of this study suggest that higher levels of physical activity modified risk of incident impairment in executive function.

Impact of the Baltimore Experience Corps Trial on cortical and hippocampal volumes.

INTRODUCTION: There is a substantial interest in identifying interventions that can protect and buffer older adults from atrophy in the cortex and particularly, the hippocampus, a region important to memory. We report the 2-year effects of a randomized controlled trial of an intergenerational social health promotion program on older men's and women's brain volumes. METHODS: The Brain Health Study simultaneously enrolled, evaluated, and randomized 111 men and women (58 interventions; 53 controls) within the Baltimore Experience Corps Trial to evaluate the intervention impact on biomarkers of brain health at baseline and annual follow-ups during the 2-year trial exposure. RESULTS: Intention-to-treat analyses on cortical and hippocampal volumes for full and sex-stratified samples revealed program-specific increases in volumes that reached significance in men only (P's ≤ .04). Although men in the control arm exhibited age-related declines for 2 years, men in the Experience Corps arm showed a 0.7% to 1.6% increase in brain volumes. Women also exhibited modest intervention-specific gains of 0.3% to 0.54% by the second year of exposure that contrasted with declines of about 1% among women in the control group. DISCUSSION: These findings showed that purposeful activity embedded within a social health promotion program halted and, in men, reversed declines in brain volume in regions vulnerable to dementia. CLINICAL TRIAL REGISTRATION: NCT0038.

Evaluation of enzyme immunoassays and real-time PCR for detecting Shiga toxin-producing Escherichia coli in Southern Alberta, Canada.

Two immunoassays (Shiga Toxin Chek and Shiga Toxin Quik Chek) and real-time PCR were used to detect Shiga toxin-producing Escherichia coli. For enriched culture, the sensitivity and specificity of the three methods ranged from 80.0% to 98.2% and 98.0% to 100.0%, respectively. STEC isolates were identified in 2.6% of the 784 samples.

Increases in lifestyle activities as a result of experience Corps® participation.

Experience Corps® (EC) was designed to simultaneously increase cognitive, social, and physical activity through high-intensity volunteerism in elementary school classrooms. It is, therefore, highly likely that EC participation may alter pre-existing patterns of lifestyle activity. This study examined the impact of "real-world" volunteer engagement on the frequency of participation in various lifestyle activities over a 2-year period. Specifically, we examined intervention-related changes on reported activity levels at 12 and 24 months post-baseline using Intention-to-Treat (ITT) and Complier Average Causal Effect (CACE) analyses, which account for the amount of program exposure. ITT analyses indicated that, compared to the control group, EC participants reported modest increases (approximately half a day/month) in overall activity level, especially in intellectual and physical activities 12 months post-baseline. Increases in activity were not found at the 24-month assessment. CACE models revealed similar findings for overall activity as well as for intellectual and physical activities at 12 months. Additionally, CACE findings suggested modest increases in social activity at 12 months and in intellectual and passive activities at 24 months post-baseline. This community-based, health promotion intervention has the potential to impact lifestyle activity, which may lead to long-term increases in activity and to other positive cognitive, physical, and psychosocial health outcomes.

A systematic review of strategies to foster activity engagement in persons with dementia.

Dementia is a growing public health issue. Activity, a positive therapeutic modality, has potential to enhance quality of life and reduce behavioral symptoms in persons with dementia--outcomes eluding pharmacological treatments. However, it is unclear how to effectively engage persons with dementia in activities for them to derive desired benefits. We present a systematic review of 28 studies involving 50 tests of different ways of modifying activities to enhance engagement and reduce behavioral and psychological symptoms for this group. Of 50 tests, 22 (44%) evaluated changes to objects and properties (e.g., introducing activities with intrinsic interest), 6 (12%) evaluated changes to space demands (e.g., lighting, noise levels), 8 (16%) evaluated changes to social demands (e.g., prompts, praise), and 14 (28%) combined two or more activity modifications. No modifications were made to the sequence and timing of activities. Although modifications to objects and properties were the most common, outcomes for engagement and behaviors were mixed. Modifications to space and social demands were less frequently tested, but consistently yielded positive outcomes. No modifications resulted in negative behavioral outcomes or decreased engagement. Methodological strengths of studies included direct observation of outcomes and fidelity assessments. Few studies however involved persons with dementia at home. Our review revealed a growing evidentiary base for different modifications to foster engagement in activities and reduce behavioral and psychological symptoms. Future studies should evaluate how contextual factors (e.g., physical environment, activity type) and caregiver ability to employ activity modifications affect engagement.

Interactions of marine mammals and birds with offshore membrane enclosures for growing algae (OMEGA).

BACKGROUND: OMEGA is an integrated aquatic system to produce biofuels, treat and recycle wastewater, capture CO2, and expand aquaculture production. This system includes floating photobioreactors (PBRs) that will cover hundreds of hectares in marine bays. To assess the interactions of marine mammals and birds with PBRs, 9 × 1.3 m flat panel and 9.5 × 0.2 m tubular PBRs were deployed in a harbor and monitored day and night from October 10, 2011 to Janurary 22, 2012 using infrared video. To observe interactions with pinnipeds, two trained sea lions (Zalophus californianus) and one trained harbor seal (Phoca vitulina richardii) were observed and directed to interact with PBRs in tanks. To determine the forces required to puncture PBR plastic and the effects of weathering, Instron measurements were made with a sea otter (Enhydra lutris) tooth and bird beaks. RESULTS: A total of 1,445 interactions of marine mammals and birds with PBRs were observed in the 2,424 hours of video recorded. The 95 marine mammal interactions, 94 by sea otters and one by a sea lion had average durations of three minutes (max 44 min) and represented about 1% of total recording time. The 1,350 bird interactions, primarily coots (Fulica americana) and gulls (Larus occidentalis and L. californicus) had average durations of six minutes (max. 170) and represented 5% of recording time. Interactive behaviors were characterized as passive (feeding, walking, resting, grooming, and social activity) or proactive (biting, pecking, investigating, and unspecified manipulating). Mammal interactions were predominantly proactive, whereas birds were passive. All interactions occurred primarily during the day. Ninety-six percent of otter interactions occurred in winter, whereas 73% of bird interactions in fall, correlating to their abundance in the harbor. Trained pinnipeds followed most commands to bite, drag, and haul-out onto PBRs, made no overt undirected interactions with the PBRs, but showed avoidance behavior to PBR tethers. Instron measurements indicated that sea-otter teeth and gull beaks can penetrate weathered plastic more easily than new plastic. CONCLUSIONS: Otter and bird interactions with experimental PBRs were benign. Large-scale OMEGA systems are predicted to have both positive and negative environmental consequences.

Cognitive performance profiles by latent classes of drug use.

BACKGROUND AND OBJECTIVES: The relationship between substance use and cognitive deficits is complex and requires innovative methods to enhance understanding. The present study is the first to use LCA to examine associations of drug use patterns with cognitive performance. METHODS: Cocaine/heroin users (N = 552) completed questionnaires, and cognitive measures. LCA identified classes based on past-month drug use and adjusted for probabilities of group membership when examining cognitive performance. Latent indicators were: alcohol (ALC), cigarettes (CIG), marijuana (MJ), crack smoking (CS), nasal heroin (NH), injection cocaine (IC), injection heroin (IH), and injection speedball (IS). Age and education were included as covariates in model creation. RESULTS: Bootstrap likelihood ratio test (BLRT) supported a 5-class model. Prevalent indicators (estimated probability of over 50%) for each class are as follows: "Older Nasal Heroin/Crack Smokers" (ONH/CS, n = 166.9): ALC, CIG, NH, CS; "Older, Less Educated Polysubstance" (OLEP, n = 54.8): ALC, CIG, CS, IH, IC, and IS; "Younger Multi-Injectors" (MI, n = 128.7): ALC, CIG, MJ, IH, IC, and IS; "Less Educated Heroin Injectors" (LEHI, n = 87.4): CIG, IH; and "More Educated Nasal Heroin" users (MENH, n = ALC, CIG, NH. In general, all classes performed worse than established norms and older, less educated classes performed worse, with the exception that MENH demonstrated worse cognitive flexibility than YMI. DISCUSSION AND CONCLUSIONS: This study demonstrated novel applications of a methodology for examining complicated relationships between polysubstance use and cognitive performance. SCIENTIFIC SIGNIFICANCE: Education and/or nasal heroin use are associated with reduced cognitive flexibility in this sample of inner city drug users.

The Alzheimer's Disease Neuroimaging Initiative: Annual change in biomarkers and clinical outcomes.

BACKGROUND: The Alzheimer's Disease Neuroimaging Initiative Phase 1 (ADNI-1) is a multisite prospective study designed to examine potential cerebrospinal fluid and imaging markers of Alzheimer's disease (AD) and their relationship to cognitive change. The objective of this study was to provide a global summary of the overall results and patterns of change observed in candidate markers and clinical measures over the first 2 years of follow-up. METHODS: Change was summarized for 210 normal controls, 357 mild cognitive impairment, and 162 AD subjects, with baseline and at least one cognitive follow-up assessment. Repeated measures and survival models were used to assess baseline biomarker levels as predictors. Potential for improving clinical trials was assessed by comparison of precision of markers for capturing change in hypothetical trial designs. RESULTS: The first 12 months of complete data on ADNI participants demonstrated the potential for substantial advances in characterizing trajectories of change in a range of biomarkers and clinical outcomes, examining their relationship and timing, and assessing the potential for improvements in clinical trial design. Reduced metabolism and greater brain atrophy in the mild cognitive impairment at baseline are associated with more rapid cognitive decline and a higher rate of conversion to AD. Use of biomarkers as study entry criteria or as outcomes could reduce the number of participants required for clinical trials. CONCLUSIONS: Analyses and comparisons of ADNI data strongly support the hypothesis that measurable change occurs in cerebrospinal fluid, positron emission tomography, and magnetic resonance imaging well in advance of the actual diagnosis of AD.