Nutritional, environmental and economic implications of children plate waste at school: a comparison between two Italian case studies.

OBJECTIVE: This study aims at comparing two Italian case studies in relation to schoolchildren's plate waste and its implications, in terms of nutritional loss, economic cost and carbon footprint. DESIGN: Plate waste was collected through an aggregate selective weighting method for 39 d. SETTING: Children from the first to the fifth grade from four primary schools, two in each case study (Parma and Lucca), were involved. RESULTS: With respect to the served food, in Parma, the plate waste percentage was lower than in Lucca (P < 0·001). Fruit and side dishes were highly wasted, mostly in Lucca (>50 %). The energy loss of the lunch meals accounted for 26 % (Parma) and 36 % (Lucca). Among nutrients, dietary fibre, folate and vitamin C, Ca and K were lost at most (26-45 %). Overall, after adjusting for plate waste data, most of the lunch menus fell below the national recommendations for energy (50 %, Parma; 79 %, Lucca) and nutrients, particularly for fat (85 %, Parma; 89 %, Lucca). Plate waste was responsible for 19 % (Parma) and 28 % (Lucca) of the carbon footprint associated with the food supplied by the catering service, with starchy food being the most important contributor (52 %, Parma; 47 %, Lucca). Overall, the average cost of plate waste was 1·8 €/kg (Parma) and 2·7 €/kg (Lucca), accounting respectively for 4 % and 10 % of the meal full price. CONCLUSION: A re-planning of the school meals service organisation and priorities is needed to decrease the inefficiency of the current system and reduce food waste and its negative consequences.

Defining wound bed conformability: a new testing methodology to assess the relative swelling rise of foam dressings.

OBJECTIVE: Using a dressing that expands and conforms to the wound bed upon exudate absorption is one of the best ways to promote wound healing. While many products claim wound bed conformability, no externally replicated or verified test methodology had been developed to quantify a wound dressing's ability to conform to the wound bed. The Relative Swelling Rise (RSR) test methodology was developed to measure the relative swelling rise of foam dressings upon fluid absorption, and offers a quantifiable and easily replicated method to measure wound bed conformability. METHOD: The RSR test method was developed, validated and reliability tested by Coloplast A/S, Denmark. External replication was provided by ALS Odense, Denmark (previously DB Lab). Circular fences provide a fixed diameter to apply and contain the fluid and prevent horizontal spreading in the test set-up. The swelling height is quantified relative to the fence's inner diameter, i.e., the ratio alpha (α), and allows evaluation of a material's ability to conform to the wound bed. RESULTS: Biatain Silicone foam products (n=3, Coloplast A/S, Denmark) were tested, all afforded an average α-ratio from 0.30 to 0.60. The relative standard deviations were between 1-3%, demonstrating the strength of the test. Robustness of the methodology was demonstrated through the internal validation study, the reliability study, and both an internal and external replication study, as well as a systematic literature review and expert review of the construct, content, criterion and generalisability of the method. CONCLUSION: Having a validated, effective and easily replicable testing method to quantify wound bed conformability of foam dressings is an important step towards achieving better healing outcomes.

Movement is muscle in hospitalized adults.

Physical inactivity is a major public health concern, but for hospitalized adults, the results of immobility are even more alarming. The "trauma of hospitalization" is a syndrome that refers to the collective impact of immobility, sleep deficits, and malnutrition associated with hospitalization and contributes to functional deficits. Functional decline is a modifiable and preventable risk factor. Nursing, at the center of patient care, is poised to coordinate the patient's mobility activities. Multiple steps to stave off functional decline to improve health outcomes for older adults are in the control of nurses and nursing practice and reflect the goals of the NICHE practice model.

Reducing lower extremity hospital-acquired pressure injuries: a multidisciplinary clinical team approach.

OBJECTIVE: Optimal methods of reducing incidence of hospital-acquired pressure injuries (HAPIs) remain to be determined. We assessed changes in yearly incidence of lower extremity HAPIs before and after an intervention aimed at reducing these wounds. METHOD: In 2012, we implemented a three-pronged intervention to reduce the incidence of HAPIs. The intervention included: a multidisciplinary surgical team; enhanced nursing education; and improved quality data reporting. Yearly incidence of lower extremity HAPIs was tracked. RESULTS: Pre-intervention, incidence of HAPIs was 0.746%, 0.751% and 0.742% in 2009, 2010 and 2011, respectively. Post-intervention, incidence of HAPIs was 0.002%, 0.051%, 0.038%, 0.000% and 0.006% in 2013, 2014, 2015, 2016 and 2017, respectively. Mean incidence of HAPIs was reduced from 0.746% before the intervention to 0.022% after the intervention (p<0.001). CONCLUSION: An intervention by a multidisciplinary surgical team enhanced nursing education, and improved quality data reporting reduced the incidence of lower extremity HAPIs.

Quality Improvement to Promote Sepsis Reassessment: The Sepsis Reassessment Protocol Improvement Project (SRPIP).

BACKGROUND: Implementation of the Surviving Sepsis Campaign (SSC) guidelines into practice has demonstrated improved outcomes. LOCAL PROBLEM: Compliance with a sepsis protocol, based on the SSC guidelines, in an urban teaching hospital was below the national average. METHODS: A pre- and posttest intervention design was used to improve clinician knowledge, confidence, and compliance with the protocol. INTERVENTIONS: Educational modules were developed on the SSC guidelines and reminder system alerts (RSA) for timely revaluation of patients with sepsis and lactate monitoring were implemented. RESULTS: A total of 33 (48%) clinicians participated. There was an increase in knowledge, documentation of sepsis reassessment, and serum lactate monitoring. There was an improvement in clinician perceptions following the initiative. CONCLUSIONS: The results demonstrate that education, combined with RSAs, can improve protocol knowledge and compliance.

Real world treatment of juvenile-onset systemic lupus erythematosus: Data from the UK JSLE cohort study.

BACKGROUND: In the absence of clinical trials evidence, Juvenile-onset Systemic Lupus Erythematosus (JSLE) treatment plans vary. AIM: To explore 'real world' treatment utilising longitudinal UK JSLE Cohort Study data. METHODS: Data collected between 07/2009-05/2020 was used to explore the choice/sequence of immunomodulating drugs from diagnosis. Multivariate logistic regression determined how organ-domain involvement (pBILAG-2004) impacted treatment choice. RESULT: 349 patients met inclusion criteria, median follow-up 4-years (IQR:2,6). Mycophenolate mofetil (MMF) was most commonly used for the majority of organ-domains, and significantly associated with renal involvement (OR:1.99, 95% CI:1.65-2.41, pc < 0.01). Analyses assessing the sequence of immunomodulators focused on 197/349 patients (meeting relevant inclusion/exclusion criteria). 10/197 (5%) solely recieved hydroxychloroquine/prednisolone, 62/197 (31%) received a single-immunomodulator, 69/197 (36%) received two, and 36/197 patients (28%) received ≥three immunomodulators. The most common first and second line immunomodulator was MMF. Rituximab was the most common third-line immunomodulator. CONCLUSIONS: Most UK JSLE patients required ≥two immunomodulators, with MMF used most commonly.

Attainment of low disease activity and remission targets reduces the risk of severe flare and new damage in childhood lupus.

OBJECTIVES: To assess the achievability and effect of attaining low disease activity (LDA) or remission in childhood-onset SLE (cSLE). METHODS: Attainment of three adult-SLE derived definitions of LDA (LLDAS, LA, Toronto-LDA), and four definitions of remission (clinical-SLEDAI-defined remission on/off treatment, pBILAG-defined remission on/off treatment) was assessed in UK JSLE Cohort Study patients longitudinally. Prentice-Williams-Petersen gap recurrent event models assessed the impact of LDA/remission attainment on severe flare/new damage. RESULTS: LLDAS, LA and Toronto-LDA targets were reached in 67%, 73% and 32% of patients, after a median of 18, 15 or 17 months, respectively. Cumulatively, LLDAS, LA and Toronto-LDA was attained for a median of 23%, 31% and 19% of total follow-up-time, respectively. Remission on-treatment was more common (61% cSLEDAI-defined, 42% pBILAG-defined) than remission off-treatment (31% cSLEDAI-defined, 21% pBILAG-defined). Attainment of all target states, and disease duration (>1 year), significantly reduced the hazard of severe flare (P < 0.001). As cumulative time in each target increased, hazard of severe flare progressively reduced. LLDAS attainment reduced the hazard of severe flare more than LA or Toronto-LDA (P < 0.001). Attainment of LLDAS and all remission definitions led to a statistically comparable reduction in the hazards of severe flare (P > 0.05). Attainment of all targets reduced the hazards of new damage (P < 0.05). CONCLUSIONS: This is the first study demonstrating that adult-SLE-derived definitions of LDA/remission are achievable in cSLE, significantly reducing risk of severe flare/new damage. Of the LDA definitions, LLDAS performed best, leading to a statistically comparable reduction in the hazards of severe flare to attainment of clinical remission.

Limited sensitivity and specificity of the ACR/EULAR-2019 classification criteria for SLE in JSLE?-observations from the UK JSLE Cohort Study.

OBJECTIVES: This study aimed to test the performance of the new ACR and EULAR criteria, that include ANA positivity as entry criterion, in JSLE. METHODS: Performance of the ACR/EULAR-2019 criteria were compared with Systemic Lupus International Collaborating Clinics (SLICC-2012), using data from children and young people (CYP) in the UK JSLE Cohort Study (n = 482), with the ACR-1997 criteria used as reference standard. An unselected cohort of CYP positive for ANA (n = 129) was used to calculate positive/negative predictive values of the criteria. RESULTS: At both first and last visits, the number of patients fulfilling the different classification criteria varied significantly (P < 0.001). The sensitivity of the SLICC-2012 criteria was higher when compared with that of the ACR/EULAR-2019 criteria at first and last visits (98% vs 94% for first visit, and 98% vs 96% for last visit; P < 0.001), when all available CYP were considered. The ACR/EULAR-2019 criteria were more specific when compared with the SLICC-2012 criteria (77% vs 67% for first visit, and 81% vs 71% for last visit; P < 0.001). Significant differences between the classification criteria were mainly caused by the variation in ANA positivity across ages. In the unselected cohort of ANA-positive CYP, the ACR/EULAR-2019 criteria produced the highest false-positive classification (6/129, 5%). CONCLUSION: In CYP, the ACR/EULAR-2019 criteria are not superior to those of the SLICC-2012 or ACR-1997 criteria. If classification criteria are designed to include CYP and adult populations, paediatric rheumatologists should be included in the consensus and evaluation process, as seemingly minor changes can significantly affect outcomes.

Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries.

GENERAL PURPOSE: To synthesize the literature regarding skin injuries that are found in patients at the end of life and to clarify the terms used to describe these conditions. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be better able to:1. Define the terms used to describe pressure injuries and skin changes at the end of life.2. Discuss the concept of skin failure as applied to end-of-life skin injuries and implications for practice. ABSTRACT: This article synthesizes the literature regarding the concepts of "terminal" skin injuries that are found in patients at the end of life, including Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, and skin failure. Also included is a discussion of avoidable and unavoidable pressure injuries as defined and differentiated by the Centers for Medicare & Medicaid Services and the National Pressure Ulcer Advisory Panel. To help clarify the controversy among these terms, a unifying concept of "skin failure" that may occur with an acute illness, chronic illness, or as part of the dying process is proposed. This proposed concept of skin failure is etiologically different than a pressure injury, although pressure injury and skin failure can occur concomitantly. These proposed concepts require further research and validated diagnostic criteria. Consensus around appropriate terminology is essential to reduce confusion among stakeholders and ensure appropriate patient care.

Early Treatment Response Predicts Outcome in Paediatric Ulcerative Colitis: GASTROENTEROLOGY: INFLAMMATORY BOWEL DISEASE.

The disease course of children with ulcerative colitis (UC) varies substantially. Published data on predictors of disease outcomes in children remain scarce. We validate clinical predictors of outcomes in 93 children with UC in a single centre (age range: 2-18 years, minimum follow-up: 18 months). We stratified children into 3 groups according to their disease course, that is, 1 = mild (38/93, 40.9%), 2 = moderate (38/93, 40.9%), 3 = severe (17, 18.2%). Comparison of clinical and biochemical parameters was performed between groups using Chi-square, Mann-Whitney, and log-rank tests. Predictors of a severe disease course included pancolitis (P 0.01), low albumin (P 0.005), low haemoglobin at diagnosis (P 0.04), paediatric ulcerative colitis activity index (PUCAI) at 3 months, and nonresponse to steroids at 3 months (P 0.0001). In our cohort, failure to achieve remission at 3 months implied an 80% likelihood to require biologics or major surgery within 18 months. A specific 3-month review point is recommended to guide future management.

Clinical Evaluation of a Skin Protectant for the Management of Incontinence-Associated Dermatitis: An Open-Label, Nonrandomized, Prospective Study.

PURPOSE: The purpose of this study was to evaluate the efficacy of an investigational skin protectant product at managing severe skin breakdown associated with incontinence. DESIGN: Open-label, nonrandomized, prospective study. SUBJECTS AND SETTING: The sample comprised 16 patients; inclusion criteria were: patients older than 18 years, cared for in the intensive care unit of a level I trauma center hospital or in long-term care facilities in the northeast region of the United States, and had incontinence-associated dermatitis (IAD). Twelve of the patients had epidermal skin loss and 4 had severe redness. METHODS: The investigational product is a formulation based on acrylate chemistry. The skin protectant application schedule was twice weekly for up to 3 weeks for a maximum of 6 applications during the study period. The skin was evaluated via a skin assessment instrument specifically designed for use in this study; this instrument has not undergone validation studies. The main outcome measure was changes in the instrument score over time. In addition, complete reepithelialization was recorded when observed, and pain scores (associated with IAD) were noted in participants who were able to report pain. RESULTS: The IAD score improved in 13 of 16 patients, remained unchanged in 1 patient, and deteriorated in 2 patients. The median percent improvement in the skin assessment instrument was 96% (P = .013). Four of the patients with epidermal skin loss had complete reepithelialization of the skin surface with 4 to 6 applications of the skin protectant, and 5 had substantial improvement. The 4 patients with severe red skin returned to healthy normal skin with 2 to 4 skin protectant applications. Substantial pain reduction was reported by all 9 patients who reported pain at enrollment. No adverse events associated with the skin protectant application were reported during data collection. CONCLUSION: Results of this study suggest that an acrylate-based product, evaluated here for the first time in patients, may be effective as a protective barrier in the presence of continued incontinence. Additional research is needed to confirm these findings.

Ex Vivo Application of Secreted Metabolites Produced by Soil-Inhabiting Bacillus spp. Efficiently Controls Foliar Diseases Caused by Alternaria spp.

Bacterial biological control agents (BCAs) are largely used as live products to control plant pathogens. However, due to variable environmental and ecological factors, live BCAs usually fail to produce desirable results against foliar pathogens. In this study, we investigated the potential of cell-free culture filtrates of 12 different bacterial BCAs isolated from flower beds for controlling foliar diseases caused by Alternaria spp. In vitro studies showed that culture filtrates from two isolates belonging to Bacillus subtilis and Bacillus amyloliquefaciens displayed strong efficacy and potencies against Alternaria spp. The antimicrobial activity of the culture filtrate of these two biological control agents was effective over a wider range of pH (3.0 to 9.0) and was not affected by autoclaving or proteolysis. Comparative liquid chromatography-mass spectrometry (LC-MS) analyses showed that a complex mixture of cyclic lipopeptides, primarily of the fengycin A and fengycin B families, was significantly higher in these two BCAs than inactive Bacillus spp. Interaction studies with mixtures of culture filtrates of these two species revealed additive activity, suggesting that they produce similar products, which was confirmed by LC-tandem MS analyses. In in planta pre- and postinoculation trials, foliar application of culture filtrates of B. subtilis reduced lesion sizes and lesion frequencies caused by Alternaria alternata by 68 to 81%. Taken together, our studies suggest that instead of live bacteria, culture filtrates of B. subtilis and B. amyloliquefaciens can be applied either individually or in combination for controlling foliar diseases caused by Alternaria species.

Disaster Preparedness in Philippine Nurses.

PURPOSE: This study examined the perceived level of disaster preparedness in Philippine nurses. DESIGN: A descriptive, cross-sectional research design was used in this study. METHODS: Two hundred nurses were invited to participate in the study, with 170 responses (105 hospital nurses and 65 community nurses) or an 85% response rate, during the months of April 2014 through July 2014. Data collection was based on interviews using a standardized instrument, the Disaster Preparedness Questionnaire. Descriptive statistics such as frequencies, means, percentages, and standard deviations were utilized to quantify the responses. RESULTS: Three fourths of the respondents (n = 136, 80%) indicated that they were not fully prepared to respond to disasters, while only 20% (n = 34) acknowledged that they felt they were adequately prepared. Respondents believed that they could function in the primary roles of educator (n = 107, 62.94%), caregiver (n = 104, 61.17%), and counselor (n = 82, 48.24%). More than half of the respondents (n = 98, 57.7%) were not aware of existing protocols of disaster management in the workplace. Courses taken in such areas as first aid (n = 79, 46.4%), field triage (n = 43, 25.29%), and basic cardiac life support (n = 57, 33.53%) were cited as important in preparing for disasters. CONCLUSIONS: Nurses in the study revealed that they were not sufficiently prepared for disasters nor were they aware of disaster management protocols in the workplace. CLINICAL RELEVANCE: Hospital administrators should consider the development and formulation of disaster management protocols and provide appropriate disaster nursing education and training. Nursing curricula should incorporate basic principles of disaster management into nursing courses as a framework for addressing this critical deficit.

Characterization of Phytophthora spp. Isolated from Ornamental Plants in Florida.

This report investigates population structure and genetic variability of Phytophthora spp. isolated from botanically diverse plants in Florida. Internal transcribed spacer-based molecular phylogenetic analyses indicate that Phytophthora isolates recovered from ornamental plants in Florida represent a genetically diverse population and that a majority of the isolates belong to Phytophthora nicotianae (73.2%), P. palmivora (18.7%), P. tropicalis (4.9%), P. katsurae (2.4%), and P. cinnamomi (0.8%). Mating type analyses revealed that most isolates were heterothallic, consisting of both mating type A1 (25.2%) and mating type A2 (39.0%), and suggesting that they could outcross. Fungicide sensitivity assays determined that several isolates were moderate to completely insensitive to mefenoxam. In addition, several isolates were also moderately insensitive to additional fungicides with different modes of action. However, correlation analyses did not reveal occurrence of fungicide cross-resistance. These studies suggest that a genetically diverse Phytophthora population infects ornamental crops and the occurrence of mefenoxam-insensitive Phytophthora populations raises concerns about disease management in ornamentals. Mitigating fungicide resistance will require prudent management strategies, including tank mixes and rotation of chemicals with different modes of actions.

The VCU Pressure Ulcer Summit: The Search for a Clearer Understanding and More Precise Clinical Definition of the Unavoidable Pressure Injury.

This article reports the findings of the Unavoidable Pressure Ulcer Committee (of the VCU Pressure Ulcer Summit) that was tasked with addressing key issues associated with pressure injuries that are unavoidable or unpreventable. Our goals were (1) to clarify nomenclature and descriptions surrounding "terminal ulceration," (2) to describe the medical complications and comorbid conditions that can lead to skin failure and/or terminal ulceration, (3) to describe the variable possible causes of unavoidable pressure injuries, and (4) to present clinical cases to exemplify pressure injuries considered to be unavoidable.

Inhibition of Phytophthora parasitica and P. capsici by Silver Nanoparticles Synthesized Using Aqueous Extract of Artemisia absinthium.

Application of nanoparticles for controlling plant pathogens is a rapidly emerging area in plant disease management, and nanoparticles synthesis methods that are economical and ecofriendly are extensively investigated. In this project, we investigated the potential of silver nanoparticles (AgNPs) synthesized with aqueous extract of Artemisia absinthium against several Phytophthora spp., which cause many economically important crop diseases. In in vitro dose-response tests conducted in microtiter plates, 10 µg ml⁻¹ of AgNPs inhibited mycelial growth of P. parasitica, P. infestans, P. palmivora, P. cinnamomi, P. tropicalis, P. capsici, and P. katsurae. Detailed in vitro dose-response analyses conducted with P. parasitica and P. capsici revealed that AgNPs synthesized with A. absinthium extract were highly potent (IC50: 2.1 to 8.3 µg ml⁻¹) and efficacious (100%) in inhibiting mycelial growth, zoospore germination, germ tube elongation, and zoospore production. Interestingly, AgNP treatment accelerated encystment of zoospores. Consistent with in vitro results, in planta experiments conducted in a greenhouse revealed that AgNP treatments prevented Phytophthora infection and improved plant survival. Moreover, AgNP in in planta experiments did not produce any adverse effects on plant growth. These investigations provide a simple and economical method for controlling Phytophthora with AgNP without affecting normal plant physiology.