Evidence-informed consensus statements to guide COVID-19 patient visitation policies: results from a national stakeholder meeting.

PURPOSE: Hospital policies forbidding or limiting families from visiting relatives on the intensive care unit (ICU) has affected patients, families, healthcare professionals, and patient- and family-centered care (PFCC). We sought to refine evidence-informed consensus statements to guide the creation of ICU visitation policies during the current COVID-19 pandemic and future pandemics and to identify barriers and facilitators to their implementation and sustained uptake in Canadian ICUs. METHODS: We created consensus statements from 36 evidence-informed experiences (i.e., impacts on patients, families, healthcare professionals, and PFCC) and 63 evidence-informed strategies (i.e., ways to improve restricted visitation) identified during a modified Delphi process (described elsewhere). Over two half-day virtual meetings on 7 and 8 April 2021, 45 stakeholders (patients, families, researchers, clinicians, decision-makers) discussed and refined these consensus statements. Through qualitative descriptive content analysis, we evaluated the following points for 99 consensus statements: 1) their importance for improving restricted visitation policies; 2) suggested modifications to make them more applicable; and 3) facilitators and barriers to implementing these statements when creating ICU visitation policies. RESULTS: Through discussion, participants identified three areas for improvement: 1) clarity, 2) accessibility, and 3) feasibility. Stakeholders identified several implementation facilitators (clear, flexible, succinct, and prioritized statements available in multiple modes), barriers (perceived lack of flexibility, lack of partnership between government and hospital, change fatigue), and ways to measure and monitor their use (e.g., family satisfaction, qualitative interviews). CONCLUSIONS: Existing guidance on policies that disallowed or restricted visitation in intensive care units were confusing, hard to operationalize, and often lacked supporting evidence. Prioritized, succinct, and clear consensus statements allowing for local adaptability are necessary to guide the creation of ICU visitation policies and to optimize PFCC.

RéSUMé: OBJECTIF: Les politiques hospitalières interdisant ou limitant les visites des familles à des proches à l'unité de soins intensifs (USI) ont affecté les patients, les familles, les professionnels de la santé et les soins centrés sur le patient et la famille (SCPF). Nous avons cherché à affiner les déclarations de consensus fondées sur des données probantes afin de guider la création de politiques de visite aux soins intensifs pendant la pandémie actuelle de COVID-19 et les pandémies futures, et dans le but d'identifier les obstacles et les critères facilitants à leur mise en œuvre et à leur adoption répandue dans les unités de soins intensifs canadiennes. MéTHODE: Nous avons créé des déclarations de consensus à partir de 36 expériences fondées sur des données probantes (c.-à-d. impacts sur les patients, les familles, les professionnels de la santé et les SCPF) et 63 stratégies fondées sur des données probantes (c.-à-d. moyens d'améliorer les restrictions des visites) identifiées au cours d'un processus Delphi modifié (décrit ailleurs). Au cours de deux réunions virtuelles d'une demi-journée tenues les 7 et 8 avril 2021, 45 intervenants (patients, familles, chercheurs, cliniciens, décideurs) ont discuté et affiné ces déclarations de consensus. Grâce à une analyse descriptive qualitative du contenu, nous avons évalué les points suivants pour 99 déclarations de consensus : 1) leur importance pour l'amélioration des politiques de restriction des visites; 2) les modifications suggérées pour les rendre plus applicables; et 3) les critères facilitants et les obstacles à la mise en œuvre de ces déclarations lors de la création de politiques de visite aux soins intensifs. RéSULTATS: En discutant, les participants ont identifié trois domaines à améliorer : 1) la clarté, 2) l'accessibilité et 3) la faisabilité. Les intervenants ont identifié plusieurs critères facilitants à la mise en œuvre (énoncés clairs, flexibles, succincts et hiérarchisés disponibles dans plusieurs modes), des obstacles (manque perçu de flexibilité, manque de partenariat entre le gouvernement et l'hôpital, fatigue du changement) et des moyens de mesurer et de surveiller leur utilisation (p. ex., satisfaction des familles, entrevues qualitatives). CONCLUSION: Les directives existantes sur les politiques qui interdisaient ou limitaient les visites dans les unités de soins intensifs étaient déroutantes, difficiles à mettre en oeuvre et manquaient souvent de données probantes à l'appui. Des déclarations de consensus hiérarchisées, succinctes et claires permettant une adaptabilité locale sont nécessaires pour guider la création de politiques de visite en soins intensifs et pour optimiser les soins centrés sur le patient et la famille.

Identity and Diversity of Human Peripheral Th and T Regulatory Cells Defined by Single-Cell Mass Cytometry.

Human CD3+CD4+ Th cells, FOXP3+ T regulatory (Treg) cells, and T regulatory type 1 (Tr1) cells are essential for ensuring peripheral immune response and tolerance, but the diversity of Th, Treg, and Tr1 cell subsets has not been fully characterized. Independent functional characterization of human Th1, Th2, Th17, T follicular helper (Tfh), Treg, and Tr1 cells has helped to define unique surface molecules, transcription factors, and signaling profiles for each subset. However, the adequacy of these markers to recapitulate the whole CD3+CD4+ T cell compartment remains questionable. In this study, we examined CD3+CD4+ T cell populations by single-cell mass cytometry. We characterize the CD3+CD4+ Th, Treg, and Tr1 cell populations simultaneously across 23 memory T cell-associated surface and intracellular molecules. High-dimensional analysis identified several new subsets, in addition to the already defined CD3+CD4+ Th, Treg, and Tr1 cell populations, for a total of 11 Th cell, 4 Treg, and 1 Tr1 cell subsets. Some of these subsets share markers previously thought to be selective for Treg, Th1, Th2, Th17, and Tfh cells, including CD194 (CCR4)+FOXP3+ Treg and CD183 (CXCR3)+T-bet+ Th17 cell subsets. Unsupervised clustering displayed a phenotypic organization of CD3+CD4+ T cells that confirmed their diversity but showed interrelation between the different subsets, including similarity between Th1-Th2-Tfh cell populations and Th17 cells, as well as similarity of Th2 cells with Treg cells. In conclusion, the use of single-cell mass cytometry provides a systems-level characterization of CD3+CD4+ T cells in healthy human blood, which represents an important baseline reference to investigate abnormalities of different subsets in immune-mediated pathologies.

Alloantigen-specific type 1 regulatory T cells suppress through CTLA-4 and PD-1 pathways and persist long-term in patients.

Type 1 regulatory T (Tr1) cells are inducible, interleukin (IL)-10+FOXP3− regulatory T cells that can suppress graft-versus-host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We have optimized an in vitro protocol to generate a Tr1-enriched cell product called T-allo10, which is undergoing clinical evaluation in patients with hematological malignancies receiving a human leukocyte antigen (HLA)­mismatched allo-HSCT. Donor-derived T-allo10 cells are specific for host alloantigens, are anergic, and mediate alloantigen-specific suppression. In this study, we determined the mechanism of action of T-allo10 cells and evaluated survival of adoptively transferred Tr1 cells in patients. We showed that Tr1 cells, in contrast to the non-Tr1 population, displayed a restricted T cell receptor (TCR) repertoire, indicating alloantigen-induced clonal expansion. Tr1 cells also had a distinct transcriptome, including high expression of cytotoxic T lymphocyte­associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1). Blockade of CTLA-4 or PD-1/PD-L1 abrogated T-allo10­mediated suppression, confirming that these proteins, in addition to IL-10, play key roles in Tr1-suppressive function and that Tr1 cells represent the active component of the T-allo10 product. Furthermore, T-allo10­derived Tr1 cells were detectable in the peripheral blood of HSCT patients up to 1 year after T-allo10 transfer. Collectively, we revealed a distinct molecular phenotype, mechanisms of action, and in vivo persistence of alloantigen-specific Tr1 cells. These results further characterize Tr1 cell biology and provide essential knowledge for the design and tracking of Tr1-based cell therapies.

[Validating mid-upper arm circumference (MUAC) measurement for detecting acute malnutrition in 6-59 month-old children in emergency and disaster situations]. / Validez de la cinta braquial para detección de desnutrición aguda en niñas y niños entre 6 y 59 meses de edad en escenarios de emergencias y desastres.

OBJECTIVES: Validating the results of mid-upper arm circumference (MUAC) measurement in 6-59 month-old children when MUAC was measured by community agents in areas where an emergency had been declared. Evaluating the cut-offs used for identifying children suffering from acute malnutrition in Colombia today. METHODOLOGY: Previously trained community agents and a nutritionist carried out a cross-sectional study for evaluating MUAC agreement, reproducibility and sensitivity in detecting acute malnutrition. Three hundred and six children were assessed in three municipalities where an emergency had been declared in the Cordoba department of Colombia. RESULTS: A Bland and Altman plot gave high agreement regarding measurements taken by the community agents and the nutritionist, 94 % of the measurements coming within the agreement limits. The intra-class correlation coefficient gave 0.87 reproducibility; however, validating the criterion for calculating the area below the ROC curve, sensitivity and the impact of the children's age on MUAC measurements highlighted problems in using 11.5 centimeters as the cut-off. CONCLUSIONS: MUAC measurement was reliable, had good reproducibility and led to rapid diagnosis of nourishment status in 6-59 month-old children living in areas where an emergency had been declared. Validating the criterion, sensitivity, the impact of the children's age on MUAC measurement results and improved nourishment status concerning children aged less than 5 years old in Colombia highlighted the need for changing the current cut-off and using 14 centimeters instead.

Efectividad del proceso de formación de escolares de 32 colegios públicos en habilidades psicosociales y hábitos saludables en Engativá-Bogotá D. C / Effectiveness of the Process Used to Instruct 32 Public School Children in Engativá (Bogotá D. C.) on Psychosocial Skills and Healthy Habits / Efetividade do processo de formação de estudantes de 32 colégios públicos em habilidades psicossociais e hábitos saudáveis em Engativá - Bogotá DC

RESUMEN Objetivo: evaluar la efectividad del trabajo realizado por docentes para fortalecer habilidades psicosociales y hábitos saludables en escolares. Metodología: estudio cuasi-experimental, longitudinal analítico con medición pre y postintervención educativa. El instrumento, elaborado a partir de la encuesta EDEX, fue utilizado para el estudio en 32 colegios públicos de Engativá entre 2013 y 2014; en el análisis se utilizó la prueba t de Student y la prueba exacta de Fisher para tablas de contingencia; los cambios en habilidades psicosociales y hábitos saludables se establecieron mediante estadísticos de Rasch. Resultados: se aplicaron 930 encuestas iniciales y 549 finales. Habilidades psicosociales: i) mejora de 0,18 lógitos en el promedio, equivalente a 11,6 % de escolares; ii) las habilidades cognitivas y sociales mejoraron, mientras las emocionales desmejoraron; iii) las mujeres obtuvieron resultados superiores estadísticamente significativos en habilidades cognitivas y sociales; iv) las personas con mayor tiempo en el programa mostraron mejores resultados, estadísticamente significativos, en habilidades cognitivas. Hábitos saludables: comparando resultados de estadísticos de Rasch, los hábitos saludables desmejoraron y no hubo diferencias por sexo o años en el programa. Conclusiones: los resultados concuerdan con la prioridad que dieron los docentes al trabajo en habilidades psicosociales y hábitos saludables; se observaron resultados importantes de efectividad. Se debe seguir investigando para aprender más sobre el fortalecimiento de las habilidades psicosociales y los hábitos saludables.

ABSTRACT Objective: Evaluate the effectiveness of the work done by teachers to strengthen psychosocial skills and healthy habits among schoolchildren. Methodology: This is a quasi-experimental, analytical longitudinal study with pre and post education intervention. The instrument, based on the EDEX survey, was used to conduct the study at 32 public schools in Engativá between 2013 and 2014. The student t-test was employed in the analysis, along with Fisher's exact test for the contingency tables. Changes in psychosocial skills and healthy habits were determined using Rasch statistics. Results: 930 initial and 549 final surveys were applied. Psychosocial skills: i) there was an improvement of 0.18 log odd units, on average, equivalent to 11.6% of the schoolchildren; ii) cognitive and social skills improved, while emotional ones deteriorated; (iii) females scored statistically significantly higher in cognitive and social skills; and iv) students with more time in the program demonstrated better and statistically significant results for cognitive abilities. Healthy habits: a comparison of the Rasch statistic results showed healthy habits deteriorated and there were no differences by gender or years in the program. Conclusions: The results coincide with the priority teachers give to work on psychosocial skills and healthy habits. Significant results in terms of effectiveness were observed. Further research is needed to learn more about strengthening psychosocial skills and healthy habits.

RESUMO Objetivo: avaliar a efetividade do trabalho realizado por docentes para fortalecer habilidades psicossociais e hábitos saudáveis em estudantes. Metodologia: estudo quase-experimental, longitudinal analítico com medida pré e pós-intervenção educativa. O instrumento, elaborado a partir da pesquisa EDEX, foi utilizado para o estudo em 32 colégios públicos de Engativá entre 2013 e 2014; na análise utilizou-se o Teste t de Student e o teste exato de Fisher para tabelas de contingência; as mudanças em habilidades psicossociais e hábitos saudáveis estabeleceram-se mediante o modelo Rasch. Resultados: aplicaram-se 930 questionários iniciais e 549 finais. Habilidades psicossociais: i) melhora de 0,18 logitos na média, equivalente a 11,6 % de estudantes; ii) as habilidades cognitivas e sociais melhoraram, enquanto as emocionais desmelhoraram; iii) as mulheres obtiveram resultados superiores estatisticamente significativos em habilidades cognitivas e sociais; iv) as pessoas com maior tempo no programa mostraram melhores resultados, estatisticamente significativos, em habilidades cognitivas. Hábitos saudáveis: comparando resultados do modelo Rasch, os hábitos saudáveis desmelhoraram e não houve diferenças por sexo ou idade no programa. Conclusões: os resultados concordam com a prioridade que deram os docentes ao trabalho em habilidades psicossociais e hábitos saudáveis; observaram-se resultados importantes de efetividade. Deve-se continuar pesquisando para aprender mais sobre o fortalecimento das habilidades psicossociais e os hábitos saudáveis.

Validez de la cinta braquial para detección de desnutrición aguda en niñas y niños entre 6 y 59 meses de edad en escenarios de emergencias y desastres / Validating mid-upper arm circumference (MUAC) measurement for detecting acute malnutrition in 6-59 month-old children in emergency and disaster situations

Objetivos Establecer la validez de resultados en medición del contorno medio del brazo CMB de menores de 6 a 59 meses utilizando la cinta braquial por agentes comunitarios en situaciones de emergencia y evaluar puntos de corte utilizados para identificar desnutrición aguda en el contexto colombiano actual. Metodología Se realizó estudio trasversal para evaluar concordancia, reproducibilidad y sensibilidad en la detección de desnutrición aguda mediante uso de cinta braquial por agente comunitario capacitado y profesional en nutrición. Se valoraron 306 menores en tres municipios en emergencia del departamento de Córdoba, Colombia. Resultados La concordancia en las mediciones por agente comunitario y profesional según Bland y Altman, fue alta con el 94 % de las medidas dentro de límites de acuerdo; la reproducibilidad de resultados utilizando el coeficiente de correlación intraclase, fue de 0.87. Por su parte, la validez de criterio calculando el área bajo la curva de ROC, la sensibilidad y la influencia de la edad de los menores en resultados de la medida del CMB, mostraron problemas en el uso de 11.5 cms como punto de corte. Conclusiones La cinta braquial, utilizada por agentes comunitarios capacitados, es fiable, tiene muy buena reproducibilidad y permite el diagnóstico rápido del estado nutricional de menores entre 6 y 59 meses en situación de emergencia. La validez de criterio, sensibilidad, influencia de la edad de los menores en resultados de la medición del CMB y mejora en la situación nutricional en Colombia, mostraron la necesidad de cambiar el punto de corte a 14 centímetros.

Objectives Validating the results of mid-upper arm circumference (MUAC) measurement in 6-59 month-old children when MUAC was measured by community agents in areas where an emergency had been declared. Evaluating the cut-offs used for identifying children suffering from acute malnutrition in Colombia today. Methodology Previously trained community agents and a nutritionist carried out a cross-sectional study for evaluating MUAC agreement, reproducibility and sensitivity in detecting acute malnutrition. Three hundred and six children were assessed in three municipalities where an emergency had been declared in the Cordoba department of Colombia. Results A Bland and Altman plot gave high agreement regarding measurements taken by the community agents and the nutritionist, 94 % of the measurements coming within the agreement limits. The intra-class correlation coefficient gave 0.87 reproducibility; however, validating the criterion for calculating the area below the ROC curve, sensitivity and the impact of the children's age on MUAC measurements highlighted problems in using 11.5 centimeters as the cut-off. Conclusions MUAC measurement was reliable, had good reproducibility and led to rapid diagnosis of nourishment status in 6-59 month-old children living in areas where an emergency had been declared. Validating the criterion, sensitivity, the impact of the children's age on MUAC measurement results and improved nourishment status concerning children aged less than 5 years old in Colombia highlighted the need for changing the current cut-off and using 14 centimeters instead.