The Development of a Communication Tool to Aid Parent-Centered Communication between Parents and Healthcare Professionals: A Quality Improvement Project.

Good communication is central to good healthcare. As a result of poor communication between parents and healthcare professionals (HCPs) in clinical settings, this study aimed to address this problem by developing a communication tool to empower parents and act as a prompt for HCPs to talk about the child's care and gather information at the point of admission to hospital about what is important to families, therefore supporting patient-centered communication. A design thinking process was used to develop a physical copy of Chloe's card and evaluate its use. Design thinking is a problem-solving approach, which uses an empathetic lens to integrate viewpoints of different stakeholders throughout the process of creating solutions. Design thinking involves five processes: (1) empathise-including a literature review and data synthesis, (2) define-by completing semi-structured interviews with parents about their experience of communication and HCPs perceptions of parent's experience of communication, (3) ideate-iterate the design of Chloe's card with parents and HCPs, (4) prototype-develop the design of Chloe's card, and (5) test-pilot test in clinical practice. Results from this initial study suggest that a small hand-held card, with emoticons and a place to write concerns, was acceptable to parents and feasible to use in clinical practice. Parents do not always feel heard by HCPs and a tool such as Chloe's card may help facilitate sharing of information about matters important to them and their child. However, some HCPs felt the need for a communication tool undermined their clinical skills. Feedback from HCP participants suggests that the idea of Chloe's card was acceptable and perceived as potentially being useful in clinical practice. Further work is required, as part of a larger study, to further refine this communication tool, identify those parents who would benefit most from Chloe's card, as well as to further refine the HCP process prior to implementing it into clinical settings. It was noted future iterations would benefit from a digital version linked with a child's electronic record, as well as multi-language versions and information for parents.

Community-Delivered Collaborative and Proactive Solutions and Parent Management Training for Oppositional Youth: A Randomized Trial.

The aim of this study was to examine the relative effectiveness of Collaborative and Proactive Solutions (CPS) and Parent Management Training (PMT) for youth with oppositional defiant disorder (ODD) in a community setting. Based on a semistructured diagnostic interview, 160 youth with ODD (ages 7-14; 72% male; ethnicity representative of the wider Australian population) were randomized to CPS (n = 81) or PMT (n = 79) for up to 16 weekly sessions. The primary hypothesis was that participants in the CPS group, treated in a community setting, would exhibit significant improvement in ODD, equivalent to that of an evidence-based treatment, PMT. Assessment was conducted at baseline, post-intervention, and at 6-month follow-up, using independently rated semistructured diagnostic interviews, parent ratings of ODD symptoms, and global ratings of severity and improvement. Analyses were conducted with hierarchical growth linear modeling, ANCOVA, and equivalence testing using an intent-to-treat sample. Both treatments demonstrated similar outcomes, with 45-50% of youth in the nonclinical range after treatment, and 67% considered much improved. No differences were found between groups, and group equivalency was shown on the independent clinician and parent-rated measures. Gains were maintained at the 6-month follow-up. In conclusion, CPS works as effectively as the well-established treatment, PMT, for youths with ODD, when implemented in a community-based setting. As such, CPS provides a viable choice for families who seek alternate treatments.

Predictors and Moderators Two Treatments of Oppositional Defiant Disorder in Children.

OBJECTIVE: The aim of this study was to examine predictors and moderators of behavioral improvement in children with Oppositional Defiant Disorder (ODD) following treatment with Parent Management Training (PMT) and Collaborative and Proactive Solutions (CPS). Initial problem severity, inconsistent discipline, parental attributions of child misbehavior, and child lagging cognitive skills were examined. METHOD: One hundred and forty-five children aged between 7 and 14 (103 males, M = 8.88 years, ethnicity representative of the wider Australian population) were randomly assigned to PMT and CPS. Assessment was conducted at baseline, post-intervention, and at 6-month follow-up, using independently rated semi-structured diagnostic interviews and parent-ratings of ODD symptoms. Using an intent-to-treat sample in this secondary analysis (Murrihy et al., 2022), linear regressions and PROCESS (Hayes, 2017) were used to examine these predictors and possible moderators of treatment. RESULTS: Higher pre-treatment levels of conduct problems, lagging skills, and inconsistent discipline predicted poorer behavioral outcomes following both treatments. The only characteristic that moderated treatment outcome was child-responsible attributions - mothers who were more likely to attribute their child's problematic behaviors to factors in the child had significantly poorer outcomes in PMT than CPS at 6-month follow-up. CONCLUSIONS: CPS may be a more beneficial treatment than PMT for families who have been identified as having higher levels of child-responsible attributions before commencing treatment for ODD. While tentative, this provides promising insights as to how treatment outcomes for children with ODD may be improved.

Trusting in the online 'community': An interview study exploring internet use in young people with chronic pain.

Background: Chronic pain in young people is prevalent in the UK. Young people are digital natives, yet there has not been any online intervention developed in a UK context to help them manage chronic pain. Key to understanding the context in which young people engage with online interventions is better understanding their internet use for chronic pain management. The overarching aim of this study was to explore young peoples' experiences of searching for information about chronic pain using the internet. This included experiences of using search engines (e.g. Google), health information websites (e.g. the National Health Service [NHS] website) and social media (e.g. Facebook and Instagram). Methods: Semi-structured interviews were conducted with young people aged 16-24-years (n = 24), online, via Microsoft (MS) Teams. The study was advertised online and via patient partner charities. Interview data was analysed using reflexive thematic analysis. Results: Participants presented with a variety of chronic pain conditions, including joint hypermobility syndrome (n = 6), chronic headache and/or migraine (n = 4) and fibromyalgia (n = 3). Four themes were generated: 'Trustworthy information, or experiences?', 'Diagnostic labels in a digital world', 'The online chronic pain community' and 'A mind and body approach to self-management'. Young people trust advice from others in their online community and having a diagnostic label help them find relevant pain management strategies and support networks online. Conclusions: This study is the first qualitative exploration of internet use in UK-based young people with chronic pain. Findings highlight the importance of considering internet use when developing new online interventions for young people with pain and that internet use, particularly social media use, is an important psychosocial consideration in pain management. Young people should be encouraged to verify practical pain management techniques found online with their doctor and be empowered in the safe use of appropriate psychology-based self-management resources.

Evaluation of the Immobilization of Coexisting Heavy Metal Ions of Pb2+, Cd2+ , and Zn2+ from Water by Dairy Manure-Derived Biochar: Performance and Reusability.

Heavy metals including Cd, Pb, and Zn are prevalent stormwater and groundwater contaminants derived from natural and human activities, and there is a lack of cost-effective treatment for their removal. Recently, biochar has been increasingly recognized as a promising low-cost sorbent that can be used to remediate heavy metal contaminated water. This study evaluates the immobilization/release performance of dairy manure-derived biochar (DM-BC) as a sustainable material for competitive removal of coexisting heavy metal ions from water and explains the underlying mechanism for regeneration/reusability of biochar. Results showed that the metal ions exhibited competitive removal in the order of Pb2+ ≫ Zn2+ > Cd2+. The pH played a decisive role in influencing metal ion speciation affecting the electrostatic attraction/repulsion and surface complexation. Higher pH led to greater removal for Pb2+ and Cd2+, whereas Zn2+ showed maximum removal at pH ≈ 7.5. Diffuse reflectance infrared spectroscopy, scanning electron microscopy, and X-ray diffraction confirmed the interactions and precipitation reactions of oxygen-containing functional groups (e.g., ─OH, CO32-, and Si─O) as key participants in metal immobilization. Langmuir, Freundlich, and Redlich-Peterson isotherm modeling data showed varied and unique results depending on the metal ion and concentration. The removal kinetics and model fitting showed that the three steps of intraparticle diffusion might be more representative for describing the immobilization processes of metal ions on the external surface and internal pores. In the flow-through columns, DM-BC effectively retained the mixed metal ions of Cd2+, Pb2+, and Zn2+ showing 100% removal for the duration of the column run over three cycles of regeneration and reuse.

Online paediatric chronic pain management: assessing the needs of UK adolescents and parents, using a cross-sectional survey.

BACKGROUND: Adolescent chronic pain is prevalent, and interdisciplinary treatment is recommended. Although it is well known that technology is a key part of adolescents' daily lives, there have not been any online, interdisciplinary interventions developed for adolescents with chronic pain in a UK healthcare context. Little is known about how adolescents currently use online resources to manage chronic pain, or what guidance they seek. METHODS: Ninety-five participants from the community answered this mixed-methods, online survey (adolescent n = 54, parent n = 41), which assessed the needs of UK-based adolescents for a new online chronic pain management resource. RESULTS: Findings indicated that, at the time of the survey, adolescents frequently used social media platforms, such as Instagram, for chronic pain management. Desired techniques for a new interdisciplinary resource for adolescents included 'advice on explaining chronic pain to others' (86.7% of adolescents) and sleep hygiene (82.2% of adolescents), though access to a range of pain management techniques was desired. Qualitative results indicated endorsement of a new programme by adolescents and parents. CONCLUSIONS: Adolescents and parents had a positive outlook towards the development of a UK-specific online resource to help manage chronic pain. Such an intervention should aim to be made accessible via the National Health Service. Adolescent use of social media platforms to seek support for chronic pain requires further exploration in future research.

Online multidisciplinary interventions for paediatric chronic pain: A content analysis.

BACKGROUND: Many online interventions for paediatric chronic pain have been developed and evaluated. In accordance with the biopsychosocial model, the recommended treatment approach for chronic pain is multidisciplinary. Despite this, multidisciplinary components within existing online interventions have not been examined. The objective of the present review was to summarise and evaluate the content of existing online interventions for paediatric chronic pain by mapping intervention content to evidence-based guidelines for chronic pain management. METHODS: Interventions were identified using an updated systematic review. Nine chronic pain management strategies that reflect evidence-based guidance for multidisciplinary chronic pain management were defined by the authors, examples of which include 'pain education', 'activity pacing' and 'physiotherapy'. Identified interventions were then coded against the target strategies. These codes were compiled descriptively to provide an overview of how well each chronic pain management strategy was represented across the dataset, and which interventions represented the most strategies. RESULTS: Thirty-five articles, relating to 13 unique interventions for paediatric chronic pain management were identified; few encompassed a complete multidisciplinary approach. Many CBT-based interventions included multidisciplinary elements. Across interventions, physiotherapy and non-pharmacological physical therapies were the least represented chronic pain management strategies. CONCLUSIONS: The content analysis revealed a lack of online interventions encompassing complete multidisciplinary pain management. It is important that new interventions for paediatric chronic pain management are evidence-based and reflect current best practice guidelines. Established intervention development approaches should be utilised and include a process evaluation to help identify which intervention components are effective in which contexts. SIGNIFICANCE: This content analysis of online interventions for paediatric chronic pain highlights the need for multidisciplinary practices in pain management to be translated into online interventions. Improving the availability of pain management resources is essential for many families who cannot attend specialist pain clinics, particularly in the context of the COVID-19 pandemic. There is potential for new resources, as well as for established resources, to be further developed to deliver a broader range of pain management content.

Comparative Safety of the TFN-ADVANCED Proximal Femoral Nailing System: Findings from a U.S. Health-Care Database.

BACKGROUND: Proximal femoral fractures are often treated with cephalomedullary nails. Although nail breakages following fracture repair are infrequent, a recent implant retrieval study suggested that the TFN-ADVANCED (TFNA) Proximal Femoral Nailing System (DePuy Synthes) was susceptible to post-implant breakage. It is unclear whether the risk of breakage among patients who receive the TFNA implant is higher than patients who receive other comparable cephalomedullary nails. The current study was designed to evaluate the comparative risk of breakage of the TFNA nail. METHODS: Using data from a large U.S. health-care database, the current study was designed to determine whether TFNA nails have equal, lower, or higher risk of breakage relative to all other comparable, single-head-element (with no additional lag screws), cephalomedullary nails, the Stryker Gamma3 and the Zimmer Natural Nail, referred to in this study as the non-TFNA group. Data were from patients who received the TFNA implant or non-TFNA nails in 365 hospitals between February 1, 2014, and September 30, 2019. Analysis of nail breakage post-implantation was prespecified as the difference between the TFNA group and the non-TFNA group in cumulative incidence at 18 months, with a prespecified equivalence margin of 0.5%, using data balanced on measured covariates by propensity score weighting. RESULTS: Within the first 18 months of implantation, in 14,370 patients with TFNA nails, there were 27 nail breakages, and in 8,260 patients with non-TFNA nails, there were 29 nail breakages. The mean time to nail breakage was 4.72 months for the TFNA group and 4.05 months for the non-TFNA group. In the balanced data, the risk of breakage at 18 months was 0.26% (95% confidence interval [CI], 0.17% to 0.36%) for the TFNA group and 0.25% (95% CI, 0.05% to 0.45%) for the non-TFNA group, with a risk difference of 0.01% (95% CI, -0.21% to 0.24%). This result indicates that the cumulative incidence of nail breakage was equivalent (between -0.5% and 0.5%) for both nail groups. The risk differences were also within the equivalence margin in subgroup analyses: pertrochanteric fractures only (-0.08% [95% CI, -0.34% to 0.19%]), pertrochanteric or subtrochanteric fractures (-0.04% [95% CI, -0.29% to 0.21%]), and those with International Classification of Diseases, Tenth Revision (ICD-10) data only (0.03% [95% CI, -0.18% to 0.25%]). CONCLUSIONS: The risk of nail breakage was equivalent for TFNA and comparator cephalomedullary nails. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Parental and Familial Predictors and Moderators of Parent Management Treatment Programs for Conduct Problems in Youth.

Despite the established efficacy of Parent Management Training (PMT) for conduct problems in youth, evidence suggests that up to half of all treated youth still display clinical levels of disruptive behavior post-treatment. The reasons for these unsatisfactory outcomes are poorly understood. The aim of the present review was to provide an updated analysis of studies from the past 15 years that examined parental and familial predictors and moderators of improvement in PMT for conduct problems. A systematic literature review of indicated prevention (children with conduct problem symptoms) and intervention (children with clinical diagnoses) studies published between 2004 and 2019 was conducted. This 15-year time period was examined since the last systematic reviews were reported in 2006 and summarized studies completed through mid-2004 (see Lundahl et al. in Clin Psychol Rev 26(1):86-104, 2006; Reyno and McGrath in J Child Psychol Psychiatry 47(1):99-111, 2006). Risk of bias indices was also computed (see Higgins et al. in Revised Cochrane risk of bias tool for randomized trials (RoB 2.0), University of Bristol, Bristol, 2016) in our review. A total of 21 studies met inclusion criteria. Results indicated that a positive parent-child relationship was most strongly associated with better outcomes; however, little additional consistency in findings was evident. Future PMT research should routinely examine predictors and moderators that are both conceptually and empirically associated with treatment outcomes. This would further our understanding of factors that are associated with poorer treatment outcome and inform the development of treatment components or modes of delivery that might likely enhance evidence-based treatments and our clinical science. Protocol Registration Number: PROSPERO CRD42017058996.

Removal of Fluoride from Water Using a Calcium-Modified Dairy Manure-Derived Biochar.

This study investigated the removal of fluoride from water using a calcium-modified dairy manure-derived biochar (Ca-DM500). The Ca-DM500 showed a 3.82 - 8.86 times higher removal of fluoride from water than the original (uncoated) manure-derived biochar (DM500). This is primarily attributed to strong precipitation/complexation between fluoride and calcium. The Freundlich and Redlich-Peterson sorption isotherm models better described the experimental data than the Langmuir model. Additionally, the removal kinetics were well described by the intraparticle diffusion model. The Ca-DM500 showed high reactivity per unit surface area [0.0001, 0.03, 0.16 mg F per m2 for Douglas fir-derived biochar (DF-BC), DM500. and Ca-DM500, respectively] for retention of fluoride reflecting the importance of surface complexation. The copresence of anions reduced removal by Ca-DM500 in the order SO 4 2 - ≈ PO 4 3 - > NO 3 - . The sorption behavior of fluoride in a continuous fixed-bed column was consistent with the Thomas model. Column studies demonstrated that the Ca-DM500 shows a strong affinity for fluoride, a low release potential, and a stable (unreduced) removal capacity through regeneration and reuse cycles.

Detecting schizophrenia early: Prediagnosis healthcare utilization characteristics of patients with schizophrenia may aid early detection.

INTRODUCTION: Many patients exhibit subsyndromal clinical findings of schizophrenia prior to diagnosis. Early treatment may mitigate schizophrenia development, yet little is known about comorbidities and healthcare resource utilization (HCRU) in these patients before diagnosis. METHODS: This retrospective, longitudinal cohort study, conducted between January 1, 2007 and April 30, 2016, used claims data from the US HealthCore Integrated Research Database. Newly diagnosed patients with schizophrenia (International Classification of Diseases, Ninth Revision: 295.x or ICD 10 F20.%) were identified and matched (1:4) with non-schizophrenia comparators. Patients were 15-54 years of age with either ≥1 inpatient/emergency room claim with a primary schizophrenia diagnosis, or ≥2 claims in any setting with any schizophrenia diagnosis. Demographics, comorbidities, physician specialties, medications, and related services, and other HCRU were compared between cohorts for up to 5 years before diagnosis. RESULTS: The schizophrenia cohort included 6732 patients (57.4% male, mean age 30.3 years for males and 36.2 years for females). All outcomes were more prevalent in the schizophrenia cohort than the comparator cohort. Substantial comorbidity, medication use, and HCRU were observed in the schizophrenia cohort even 4-5 years before diagnosis with increasing findings approaching diagnosis. From 4-5 years to 0-12 months before diagnosis, resource use increased from 20.5% to 53.3% for atypical antipsychotics, 29.3% to 48.2% for antidepressants, and 15.1% to 35.5% for psychiatric diagnostic examinations. CONCLUSIONS: Patients with schizophrenia extensively use healthcare resources up to 5 years before diagnosis. Our findings may help with developing predictive models to identify patients at high risk of schizophrenia.

Health Care Resource Utilization and Cost Before Initial Schizophrenia Diagnosis.

BACKGROUND: The management of schizophrenia, a chronic, multifaceted mental health condition, is associated with considerable health care resource utilization (HCRU) and costs. Current evidence indicates that a high-risk and costly prodromal period, during which patients are likely symptomatic, precedes diagnosis. Better characterization and disease management during this stage could help to improve patient outcomes. OBJECTIVE: To describe and compare HCRU and costs for up to 5 years before diagnosis in a cohort with schizophrenia versus a demographically matched cohort without schizophrenia in a commercially insured U.S. METHODS: This retrospective study identified newly diagnosed schizophrenia patients using enrollee claims in the HealthCore Integrated Research Database between January 1, 2007, and April 30, 2016. The index date was defined as the date of the first medical claim with a schizophrenia diagnosis code. Schizophrenia patients were directly matched (1:4) by age, sex, and region to comparators without schizophrenia who were assigned the same index dates as their matched schizophrenia counterparts. Observation periods were 0-12, 13-24, 25-36, 37-48, and 49-60 months before the index date. Outcomes included HCRU and costs for inpatient admissions, emergency room visits, outpatient care (office visits and other outpatient services), and medications. Means, standard deviations, medians, and 95% confidence intervals were calculated for continuous variables; relative frequencies and percentages were calculated for categorical variables. Cohorts were compared with t-tests for continuous variables and chi-square tests for categorical variables. Differences across cohorts were estimated with individual generalized linear models for each observation period, controlling for gender, age, geographic region of residence, health plan type and subscriber status, behavioral pre-index comorbidities and chronic comorbidities during the period before diagnosis. RESULTS: 6,732 schizophrenia patients were matched to 26,928 patients without schizophrenia. All-cause inpatient admissions were more prevalent among schizophrenia patients than their comparators for all time periods (49-60 months prediagnosis: 9% vs. 4%; 0-12 months prediagnosis: 33% vs. 4%). The schizophrenia cohort had higher adjusted all-cause per-patient per-month health care costs relative to comparators from the earliest period of 49-60 months prediagnosis ($557 [95% CI = 474-639] vs. $321 [95% CI = 288-355]) through 0-12 months prediagnosis ($1,058 [95% CI = 998-1,115] vs. $338 [95% CI = 320-355]). Behavioral health-related costs were different in each time period as were cost ratios (schizophrenia costs: comparator costs), which increased from 5.4 in the earliest period to 14.8 in the year before diagnosis. CONCLUSIONS: Schizophrenia patients had higher all-cause and behavioral health-related HCRU and costs before diagnosis than matched controls. Costs increased from 5 years to 1 year prediagnosis for schizophrenia patients driven primarily by inpatient hospital stays and prescription drug costs, but remained stable for comparators. Additional research is needed for the development of predictive models to aid in the identification of high-risk patients. DISCLOSURES: This study was sponsored by Boehringer Ingelheim Pharmaceuticals. Barron is an employee of HealthCore, which received funding from Boehringer Ingelheim to conduct this study. Wallace and York were employed by HealthCore at time of this study. Isenberg is an employee of Anthem. Franchino-Elder, Sidovar, and Sand are employees of Boehringer Ingelheim.

Health Care Resource Utilization and Cost Before Initial Schizophrenia Diagnosis.

BACKGROUND: The management of schizophrenia, a chronic, multifaceted mental health condition, is associated with considerable health care resource utilization (HCRU) and costs. Current evidence indicates that a high-risk and costly prodromal period, during which patients are likely symptomatic, precedes diagnosis. Better characterization and disease management during this stage could help to improve patient outcomes. OBJECTIVE: To describe and compare HCRU and costs for up to 5 years before diagnosis in a cohort with schizophrenia versus a demographically matched cohort without schizophrenia in a commercially insured U.S. METHODS: This retrospective study identified newly diagnosed schizophrenia patients using enrollee claims in the HealthCore Integrated Research Database between January 1, 2007, and April 30, 2016. The index date was defined as the date of the first medical claim with a schizophrenia diagnosis code. Schizophrenia patients were directly matched (1:4) by age, sex, and region to comparators without schizophrenia who were assigned the same index dates as their matched schizophrenia counterparts. Observation periods were 0-12, 13-24, 25-36, 37-48, and 49-60 months before the index date. Outcomes included HCRU and costs for inpatient admissions, emergency room visits, outpatient care (office visits and other outpatient services), and medications. Means, standard deviations, medians, and 95% confidence intervals were calculated for continuous variables; relative frequencies and percentages were calculated for categorical variables. Cohorts were compared with t-tests for continuous variables and chi-square tests for categorical variables. Differences across cohorts were estimated with individual generalized linear models for each observation period, controlling for gender, age, geographic region of residence, health plan type and subscriber status, behavioral pre-index comorbidities and chronic comorbidities during the period before diagnosis. RESULTS: 6,732 schizophrenia patients were matched to 26,928 patients without schizophrenia. All-cause inpatient admissions were more prevalent among schizophrenia patients than their comparators for all time periods (49-60 months prediagnosis: 9% vs. 4%; 0-12 months prediagnosis: 33% vs. 4%). The schizophrenia cohort had higher adjusted all-cause per-patient per-month health care costs relative to comparators from the earliest period of 49-60 months prediagnosis ($557 [95% CI = 474-639] vs. $321 [95% CI = 288-355]) through 0-12 months prediagnosis ($1,058 [95% CI = 998-1,115] vs. $338 [95% CI = 320-355]). Behavioral health-related costs were different in each time period as were cost ratios (schizophrenia costs: comparator costs), which increased from 5.4 in the earliest period to 14.8 in the year before diagnosis. CONCLUSIONS: Schizophrenia patients had higher all-cause and behavioral health-related HCRU and costs before diagnosis than matched controls. Costs increased from 5 years to 1 year prediagnosis for schizophrenia patients driven primarily by inpatient hospital stays and prescription drug costs, but remained stable for comparators. Additional research is needed for the development of predictive models to aid in the identification of high-risk patients. DISCLOSURES: This study was sponsored by Boehringer Ingelheim Pharmaceuticals. Barron is an employee of HealthCore, which received funding from Boehringer Ingelheim to conduct this study. Wallace and York were employed by HealthCore at time of this study. Isenberg is an employee of Anthem. Franchino-Elder, Sidovar, and Sand are employees of Boehringer Ingelheim.

Health Care Resource Utilization and Exacerbation Rates in Patients with COPD Stratified by Disease Severity in a Commercially Insured Population.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality and is associated with substantial economic burden. There is a lack of data regarding COPD outcomes and costs in a real-world setting, particularly by Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity. OBJECTIVES: To (a) characterize a commercially insured U.S. population with COPD and (b) assess prevalence of exacerbations, health care resource utilization (HCRU), costs, and treatment patterns in a cohort of patients with confirmed COPD, overall and stratified by GOLD stage. METHODS: This retrospective observational cohort study used administrative claims data from the HealthCore Integrated Research Database to identify patients with ≥ 1 inpatient, emergency room (ER), or office visit claim for COPD between January 1, 2012, and November 30, 2013, and continuous enrollment for 1 year before and 2 years after the first COPD diagnosis date. Patients with a spirometry claim within 12 months were eligible for medical record abstraction to confirm COPD diagnosis (forced expiratory volume in 1 second [FEV1]/forced vital capacity ratio < 0.7) and GOLD 1-4 classification (based on postbronchodilator FEV1 percent predicted). HCRU, costs, treatment patterns, and rate of moderate/severe exacerbation were identified from diagnosis up to 24 months. Outcomes were analyzed by univariate analysis stratified by GOLD classification. Multivariable analysis was conducted to assess associations between GOLD classification and outcomes of interest. RESULTS: 53,484 patients newly diagnosed with COPD were identified who met initial inclusion criteria: 14,293 (27%) had a qualifying spirometry claim, and 1,505 had confirmed COPD (GOLD 1, 333 [22%]; GOLD 2, 823 [55%]; GOLD 3, 317 [21%]; GOLD 4, 32 [2%]). Patients with greater disease severity had higher rates of moderate/severe COPD exacerbations (GOLD 1 and 2, 40.4 and 48.9 per 100 person-years, respectively; GOLD 3 and 4, 83.6 and 89.1 per 100 person-years, respectively). All-cause and COPD-related inpatient admissions, COPD-related office visits, and COPD-related ER visits were more prevalent with more severe GOLD classification. Mean annual COPD-related medical costs increased with GOLD classification ($5,945 for GOLD 1 patients, $18,070 for GOLD 4). COPD maintenance medication was filled by 42%, 56%, 73%, and 75% of patients in GOLD 1-4 (57% overall), respectively; combination corticosteroid/long-acting beta2-agonist inhalers were the most commonly used medication, regardless of GOLD classification. Patients with more severe disease had greater adherence (range 44%-68% of days covered for GOLD 1-4) and persistence (range 107-209 days for GOLD 1-4). CONCLUSIONS: Trends toward increases in exacerbations, HCRU, and costs were observed as airflow limitation worsened. Adherence and persistence with COPD maintenance therapy was suboptimal even with severe disease. DISCLOSURES: This study was supported by Boehringer Ingelheim Pharmaceuticals (Ridgefield, CT), which was given the opportunity to review the manuscript for medical and scientific accuracy, as well as intellectual property considerations. Willey and Singer are employees of HealthCore (parent company Anthem), which received funding from Boehringer Ingelheim to complete this study. Wallace and Shinde were employed by HealthCore at the time of this study. Wallace and Singer report stock ownership in Anthem. Napier is an employee of Anthem. Kaila, Bayer, and Shaikh are employees of Boehringer Ingelheim Pharmaceuticsls. Portions of this research were presented at the following conferences: (a) A. Wallace, S. Kaila, V. Zubek, A. Shaikh, M. Shinde, V. Willey, M. Napier, and J. Singer, Healthcare resource utilization, costs, and exacerbation rates in patients with COPD stratified by GOLD airflow limitation classification in a US commercially insured population, presented at AMCP Nexus 2017; October 16-19, 2017; Dallas, TX; and (b) A.E. Wallace, V. Zubek, S. Kaila, A. Shaikh, M. Shinde, V. Willey, M.B. Napier, and J.R. Singer, Real-world treatment patterns among newly diagnosed COPD patients according to GOLD airflow limitation severity classification in a U.S. commercially insured/Medicare Advantage population, presented at CHEST 2017 Annual Meeting; October 28-November 1, 2017; Toronto, Ontario, Canada.

Adsorptive Removal of Fluoride from Water Using Nanomaterials of Ferrihydrite, Apatite, and Brucite: Batch and Column Studies.

This study investigated the adsorptive removal of fluoride from simulated water pollution using various (hydro)oxide nanomaterials, which have the potential to be used as sorbents for surface water and groundwater remediation. Tested nanomaterials include hematite, magnetite, ferrihydrite, goethite, hematite-alpha, hydroxyapatite (HAP), brucite, and four titanium dioxides (TiO2-A [anatase], TiO2-B [rutile], TiO2-C [rutile], and TiO2-D [anatase]). Among 11 (hydro)oxide nanomaterials tested in this study, ferrihydrite, HAP, and brucite showed two to five times higher removal of fluoride than other nanomaterials from synthetic fluoride solutions. Freundlich and Redlich-Peterson adsorption isotherms better described the adsorptive capacity and mechanism than the Langmuir isotherm based on higher R 2 values, indicating better fit of the regression predictions. In addition, the adsorption kinetics were well described by the intraparticle diffusion model. Column studies in a fixed bed continuous flow through system were conducted to illustrate the adsorption and desorption behavior of fluoride on ferrihydrite, HAP, or brucite. Experimental results fitted well with the Thomas model because of the R 2 values at least 0.885 or higher. By comparisons of the adsorption capacity and the rate constant, columns packed with ferrihydrite exhibited not only faster rates but also higher sorption capacity than those packed with HAP or brucite. Desorption tests in deionized water showed that the adsorbed fluoride could be desorbed at a lower efficiency, ranging from 4.0% to 8.9%. The study implicated that (hydro)oxide nanomaterials of iron calcium and magnesium could be effective sorptive materials incorporated into filtration systems for the remediation of fluoride polluted water.

Comparison of a rapid albuterol pathway with a standard pathway for the treatment of children with a moderate to severe asthma exacerbation in the emergency department.

OBJECTIVE: The objective of this study was to determine if a rapid albuterol delivery pathway with a breath-enhanced nebulizer can reduce emergency department (ED) length of stay (LOS), while maintaining admission rates and side effects, when compared to a traditional asthma pathway with a standard jet nebulizer. METHODS: Children aged 3-18 presenting to a large urban pediatric ED for asthma were enrolled if they were determined by pediatric asthma score to have a moderate to severe exacerbation. Subjects were randomized to either a standard treatment arm where they received up to 2 continuous albuterol nebulizations, or a rapid albuterol arm where they received up to 4 rapid albuterol treatments with a breath-enhanced nebulizer, depending on severity scoring. The primary endpoint was ED LOS from enrollment until disposition decision. Asthma scores, albuterol dose, side effects, and return visits were also recorded. RESULTS: A total of 50 subjects were enrolled (25 in each arm). The study LOS was shorter in the rapid albuterol group (118 vs. 163 minutes, p = 0.0002). When total ED LOS was analyzed, the difference was no longer statistically significant (192 vs. 203 minutes, p = 0.65). There were no statistically significant differences with respect to admission rates, asthma score changes, side effects, or return visits. CONCLUSION: A rapid albuterol treatment pathway that utilizes a breath-enhanced nebulizer is an effective alternative to traditional pathways that utilize continuous nebulizations for children with moderate to severe asthma exacerbations in the ED.

The importance of academic literacy for undergraduate nursing students and its relationship to future professional clinical practice: A systematic review.

OBJECTIVES: This systematic review was designed to assess the importance of academic literacy for undergraduate nursing students and its relationship to future professional clinical practice. It aimed to explore the link between academic literacy and writing in an undergraduate nursing degree and the development of critical thinking skills for their future professional clinical practice. DESIGN: A systematic review of qualitative studies and expert opinion publications. DATA SOURCES: A systematic literature search was undertaken of the following databases: ERIC, PubMed, CINAHL, MEDLINE and Scopus. All papers reviewed were from 2000 to 2016 and were written in English. REVIEW METHODS: We identified 981 studies and expert opinion papers from the selected databases. After reviewing key words and abstracts for the inclusion and exclusion criteria, 48 papers were selected for review. These were read and reread, with 22 papers, including one thesis, selected for quality appraisal. One paper was discarded due to the exclusion criteria. RESULTS: Three major themes were evident from this study. First, students need assistance to develop tertiary level academic literacy skills when they commence their undergraduate nursing degree. Second, that teaching practices need to be consistent in both designing assessments and in giving feedback to students, in order to assist improvement of academic literacy skills. And finally, academic literacy can facilitate critical thinking when students are assessed using discipline specific genres that relate to their future professional nursing practice. CONCLUSIONS: This review highlights the importance of critical thinking in clinical nursing practice and its strong relationship with academic writing skills. It has shown critical thinking is discipline specific and nursing students need to be taught discipline specific literacy genres in undergraduate nursing degrees. Nursing has a diverse educational and cultural mix of students, and educators should not assume academic literacy skills upon commencement of an undergraduate nursing programme.

Prevalence and Predictors of Postdischarge Antibiotic Use Following Mastectomy.

OBJECTIVE Survey results suggest that prolonged administration of prophylactic antibiotics is common after mastectomy with reconstruction. We determined utilization, predictors, and outcomes of postdischarge prophylactic antibiotics after mastectomy with or without immediate breast reconstruction. DESIGN Retrospective cohort. PATIENTS Commercially insured women aged 18-64 years coded for mastectomy from January 2004 to December 2011 were included in the study. Women with a preexisting wound complication or septicemia were excluded. METHODS Predictors of prophylactic antibiotics within 5 days after discharge were identified in women with 1 year of prior insurance enrollment; relative risks (RR) were calculated using generalized estimating equations. RESULTS Overall, 12,501 mastectomy procedures were identified; immediate reconstruction was performed in 7,912 of these procedures (63.3%). Postdischarge prophylactic antibiotics were used in 4,439 procedures (56.1%) with immediate reconstruction and 1,053 procedures (22.9%) without immediate reconstruction (P.05). CONCLUSIONS Prophylactic postdischarge antibiotics are commonly prescribed after mastectomy; immediate reconstruction is the strongest predictor. Stewardship efforts in this population to limit continuation of prophylactic antibiotics after discharge are needed to limit antimicrobial resistance. Infect Control Hosp Epidemiol 2017;38:1048-1054.