Adherence and Barriers to Inpatient Physical Therapy Among Adolescents and Young Adults with Hematologic Malignancies.

This study described inpatient physical therapy (PT) adherence and barriers to inpatient PT among adolescents and young adults (AYAs) with hematologic malignancies receiving care at a Midwestern children's hospital. Forty-seven AYAs receiving care over a 2-year period were included. PT contact was established in 93% of hospitalizations. AYAs declined an average of 34% of PT visits, resulting in PT visits on 27% of hospitalized days, 1 day less than the goal of 3 days a week. The most frequent reasons for decline included: AYA sleeping (22%), AYA undergoing medical procedure (18%), and AYA not feeling well (12%).

The Role of the Legal System in the Flint Water Crisis.

Policy Points A major factor explaining government actors' failure to mitigate or avert the Flint, Michigan, water crisis is the sheer complexity of the laws regulating how governmental agencies maintain and monitor safe drinking water. Coordination across agencies is essential in dealing with multiple legal arrangements. Public health legal authority and intervention mechanisms are not self-executing. Legal preparedness is essential to efficiently navigating complex legal frameworks to address public health threats. The Flint water crisis demonstrates the importance of democracy for protecting the public's health. Laws responding to municipal fiscal distress must be consistent with expected norms of democracy and require consideration of public health in decision making. Context The Flint, Michigan, water crisis resulted from a state-appointed emergency financial manager's cost-driven decision to switch Flint's water source to the Flint River. Ostensibly designed to address Flint's long-standing financial crisis, the switch instead created a public health emergency. A major factor explaining why the crisis unfolded as it did is the complex array of laws regulating how governmental agencies maintain and monitor safe drinking water. Methods We analyzed these legal arrangements to identify what legal authority state, local, and federal public health and environmental agencies could have used to avert or mitigate the crisis and recommend changes to relevant laws and their implementation. First, we mapped the legal authority and roles of federal, state, and local agencies responsible for safe drinking water and the public's health-that is, the existing legal environment. Then we examined how Michigan's emergency manager law altered the existing legal arrangements, leading to decisions that ignored the community's long-term health. Juxtaposed on those factors, we considered how federalism and the relationship between state and local governments influenced public officials during the crisis. Findings The complex legal arrangements governing public health and safe drinking water, combined with a lack of legal preparedness (the capacity to use law effectively) among governmental officials, impeded timely and effective actions to mitigate or avert the crisis. The emergency manager's virtually unfettered legal authority in Flint exacerbated the existing complexity and deprived residents of a democratically accountable local government. Conclusions Our analysis reveals flaws in both the legal structure and how the laws were implemented that simultaneously failed to stop and substantially exacerbated the crisis. Policymakers need to examine the legal framework in their jurisdictions and take appropriate steps to avoid similar disasters. Addressing the implementation failures, including legal preparedness, should likewise be a priority for preventing future similar crises.

Cross Sector Data Sharing: Necessity, Challenge, and Hope.

Existing data sources have tremendous potential to inform public health activities. However, a patchwork of data protection laws impede data sharing efforts. Nevertheless, a data-sharing initiative in Peoria, IL was able to overcome challenges to set up a cross-sectoral data system to coordinate mental health, law enforcement, and healthcare services.

A Simulation Study to Evaluate Improvements in Anesthesia Work Environment Contamination After Implementation of an Infection Prevention Bundle.

BACKGROUND: Microbiological contamination of the anesthesia work environment (AWE) is a potential source of health care-associated infections. Medication syringes, stopcocks, and many other areas are routinely contaminated during anesthetic care, and adherence to hand hygiene recommendations is poor. Using a simulation model, we investigated whether AWE contamination could be reduced by implementing an intervention bundle focused on infection prevention. METHODS: Twenty-five anesthesia providers were enrolled in this nonrandomized simulation scenario crossover design study. Subjects were asked to complete 2 general anesthesia scenarios in a mock operating room: a baseline scenario and an intervention scenario in which the bundle was implemented. The bundle included: double gloving before intubation, confining all airway equipment to 1 area, and performing hand hygiene before touching the anesthesia cart. Before each scenario, a manikin's oropharynx and face were marked with ultraviolet fluorescent tracers. After each scenario, the AWE was inspected with a ultraviolet light source to detect contaminant, and all sites were photographed. A blinded observer scored the images for the presence or absence of tracer at 20 sites. Videos of the scenarios were analyzed for duration and number of hand hygiene and glove removal events. Data were analyzed using a mixed effects model. Subjects completed a survey about their experience and the value of the scenarios. RESULTS: The intervention was associated with a decreased subject contamination score of 4.0 (95% confidence interval, 2.2-5.6; P < .001), a 27% reduction in score between baseline and intervention scenarios. Some sites were universally contaminated despite the intervention (eg, laryngoscope handles). The intervention had a statistically significant impact on reducing contamination on medication syringes and the anesthesia cart. There was no significant difference in time needed to complete baseline and intervention scenarios. The majority of subjects felt that the simulations had significant value and would affect their future clinical behavior. CONCLUSIONS: Our results support the concept of an infection prevention bundle in reducing AWE contamination. Anesthesia providers deliver care in a unique environment in which "clean" and "contaminated" tasks are performed rapidly and often in parallel. Linking hand hygiene to specific high-impact tasks such as administering medications, designating areas for contaminated equipment, and double gloving before airway management are simple steps that can be implemented rapidly and are compatible with timely patient care. Our study has improved awareness of infection prevention issues in our department, and has highlighted simple and achievable actions that have the potential to reduce health care-associated infections.

Transference-focused psychotherapy training during residency: an aide to learning psychodynamic psychotherapy.

Competency in psychodynamic psychotherapy is a requirement for residency training in psychiatry. However, for a variety of reasons, learning psychodynamic psychotherapy is difficult for residents. In this article, we share our experience in an elective in Transference-Focused Psychotherapy (TFP), a manualized treatment for severe personality disorders. Originally, this elective was conceptualized as an advanced component of training, offering specialized training in treating a subgroup of patients with severe personality disorders with a specific type of psychodynamic psychotherapy. However, contrary to the expectations of the residents and the training director, the elective in TFP strengthened understanding of core components of basic psychodynamic psychotherapy with all patients, not just those with severe personality disorders. We discuss various challenges in learning psychodynamic psychotherapy and how TFP served to address them. Two case vignettes illustrate several key points.

Ensuring public health's future in a national-scale learning health system.

Data and information are fundamental to every function of public health and crucial to public health agencies, from outbreak investigations to environmental surveillance. Information allows for timely, relevant, and high-quality decision making by public health agencies. Evidence-based practice is an important, grounding principle within public health practice, but resources to handle and analyze public health data in a meaningful way are limited. The Learning Health System is a platform that seeks to leverage health data to allow evidence-based real-time analysis of data for a broad range of uses, including primary care decision making, public health activities, consumer education, and academic research. The Learning Health System is an emerging endeavor that is gaining support throughout the health sector and presents an important opportunity for collaboration between primary care and public health. Public health should be a key stakeholder in the development of a national-scale Learning Health System because participation presents many potential benefits, including increased workforce capacity, enhanced resources, and greater opportunities to use health information for the improvement of the public's health. This article describes the framework and progression of a national-scale Learning Health System, considers the advantages of and challenges to public health involvement in the Learning Health System, including the public health workforce, gives examples of small-scale Learning Health System projects involving public health, and discusses how public health practitioners can better engage in the Learning Health Community.

Wellness as a worldwide phenomenon?

This article examines the concept of wellness through a comparative political economy and legal framework. It asks whether wellness, an increasingly defined term within US federal and state legislative instruments including, for example, the Patient Protection and Affordable Care Act, is primarily a US-centric phenomenon. Or is wellness, in its various different guises, a worldwide phenomenon? By focusing on three distinctly different jurisdictions - the United States, Germany, and Australia - this article examines wellness through the lens of employers, the health care system, employment and tort law, and the greater political economy. It notes that while improving employee health, well-being, and productivity is common across the three countries and their respective cultures, the focus on wellness as a distinct legal concept is unique to the United States.

Major trends in public health law and practice: a network national report.

Since its inception in September 2010, the Network for Public Health Law has responded to hundreds of public health legal technical assistance claims from around the country. Based on a review of these data, a series of major trends in public health practice and the law are analyzed, including issues concerning: the Affordable Care Act, tobacco control, emergency legal preparedness, health information privacy, food policy, vaccination, drug overdose prevention, sports injury law, public health accreditation, and maternal breastfeeding. These and other emerging themes in public health law demonstrate the essential role of law and practice in advancing the public's health.

Beyond public health emergency legal preparedness: rethinking best practices.

The concept of public health legal preparedness grew out of the public health emergency preparedness movement, but was conceptualized more broadly to be utilized to achieve full public health legal preparedness for all types of public health threats. This article analyzes the need to refocus public health legal preparedness to include all areas of public health law and presents a new model for the fourth core element that will aid in the development of legal benchmarks so public health systems can more effectively work towards attaining public health legal preparedness in all areas of public health practice.

A novel emergency department dysphagia screen for patients presenting with acute stroke.

OBJECTIVES: Dysphagia is a common complication for emergency department (ED) patients presenting with acute stroke (AS). Recent stroke recommendations have suggested that EDs screen patients with AS for dysphagia prior to administering anything by mouth. This study sought to develop and test a novel ED dysphagia screen to be used in this population. METHODS: A multidisciplinary approach was used to create a novel dysphagia screen performed by ED nurses during the initial evaluation of patients with suspected AS. The screen consists of five questions of which any single affirmative answer signified possible dysphagia. A prospective cohort study was conducted to evaluate the performance of this screen in detecting dysphagia after AS. Patients were followed for 30 days, and true dysphagia was determined if the patient had an abnormal modified barium swallow study (MBS), had placement of a feeding tube, or was placed on a dysphagia diet after assessment by a speech pathologist. The authors performed a substudy to determine agreement using a blinded kappa (κ) assessment with a convenience sample of 40 patients. RESULTS: Over a 21-month period, 283 patients met eligibility for analysis. The rate of cerebral infarction in this cohort was 245 (87%). The rates for true dysphagia, pneumonia, and death were 91 (32%), 26 (9%), and 18 (6%), respectively. The dysphagia screen had a sensitivity of 95% (95% confidence [CI] = 88% to 98%) and a negative likelihood ratio of 0.1 (95% CI = 0.04 to 0.2). The inter-rater agreement assessed by kappa was substantial (0.69, 95% CI = 0.55 to 0.83). CONCLUSIONS: These data suggest that this dysphagia screen may be a valuable tool for detecting dysphagia in ED patients presenting with AS. The simple screen can be performed by nursing personnel and appears to perform well with good agreement. Given the overall rate of dysphagia in one-third of AS patients, the use of an ED dysphagia screen appears warranted.

Cocaine in adolescent rats produces residual memory impairments that are reversible with time.

Rats received injections (subcutaneous) of either 10 or 20 mg/kg cocaine on postnatal days 26-33, while lab chow-fed and pair-fed controls received saline. Spatial memory in a Morris water maze was assessed on four different occasions commencing 10 days postcocaine and ending approximately 12 months later. To determine whether there existed long-term changes in cholinergic processes, maze performance was evaluated following 1 mg/kg scopolamine challenge 4 months postcocaine. Subjects survived under standard laboratory housing conditions until they died. Results from the first assessment indicated a working memory deficit in the low-dose cocaine group and a long-term memory impairment in the high-dose cocaine group. These decrements neither were permanent nor were exacerbated by age-related processes in that cocaine-treated subjects performed at control levels on subsequent assessments. An exception to this was the results derived from the third assessment indicating that animals previously treated with 20 mg/kg cocaine were impaired when challenged with scopolamine. Examination of mortality rates revealed that cocaine-treated rats died significantly sooner than lab chow-fed control subjects. Taken together, these data indicate that cocaine during adolescence causes residual, but not permanent, deleterious effects on memory that may be mediated by alterations in cholinergic neurochemistry. More provocatively, the results showed that cocaine during adolescence shortened the lifespan of rats. This latter finding suggests that cocaine during adolescence may produce residual physiological effects that last well into adulthood.