Latino-Hispanic Unsheltered Homelessness Before and After COVID-19.

Objectives. To identify sociodemographic shifts among unsheltered Latino people experiencing homelessness (PEH) between 2020-2022. Methods. We examined differences in characteristics reported in demographic surveys for Latino PEH older than 25 years from 2020 (n = 1215) and 2022 (n = 1395) in Los Angeles County, California, using weighted bivariate χ2 tests. Results. From 2020 to 2022, there was a 25% increase in the number of unsheltered Latino individuals. The share of Latino PEH who were unemployed increased (57% to 67%). The increase in homelessness occurred largely among individuals living in vehicles (14% to 33%), rather than in tents or on sidewalks. Latino PEH were significantly less likely to report mental illness (24% vs 18%) and had higher rates of first entry into homelessness in the past 2 years than non-Latino respondents. Conclusions. Our results are consistent with the effects of increasing socioeconomic vulnerability, likely related to COVID-19, in driving the increase in Latino PEH. Policy Implications. The rise in homelessness among economically vulnerable yet healthy Latinos suggests a need to bolster social safety nets and increase homelessness prevention programs. (Am J Public Health. 2024;114(S6):S510-S514. https://doi.org/10.2105/AJPH.2024.307717) [Formula: see text].

Steering the Titanic: One tertiary care children's hospital's experience navigating safe sleep for hospitalized infants.

BACKGROUND: Sudden Unexpected Infant Death (SUID) is the leading cause of death in infants 1 month to 1 year of age in the United States. Despite extensive efforts in research and public education, rates of sleep-related infant death have plateaued since the late-1990s, largely due to unsafe sleep practices and environments. LOCAL PROBLEM: A multidisciplinary team assessed our institution's compliance with its own infant safe sleep policy. Data was collected on infant sleep practices, nurses' knowledge and training on the hospital policy, and teaching practices for parents and caregivers of hospitalized infants. Zero crib environments from our baseline observation met all the American Academy of Pediatrics recommendations for infant safe sleep. METHODS: A comprehensive safe sleep program was implemented in a large pediatric hospital system. The purpose of this quality improvement project was to improve compliance with safe sleep practice from 0% to 80%, documentation of infant sleep position and environment every shift from 0% to 90%, and documentation of caregiver education from 12% to 90% within 24 months. INTERVENTIONS: Interventions included revision of hospital policy, staff education, family education, environmental modifications, creation of a safe sleep taskforce, and electronic health record modifications. RESULTS: Documented compliance with infant safe sleep interventions at the bedside improved from 0% to 88%, while documentation of family safe sleep education improved from 12% to 97% during the study period. CONCLUSIONS: A multifaceted, multidisciplinary approach can lead to significant improvements in infant safe sleep practices and education in a large tertiary care children's hospital system.

Exploring nurse beliefs and perceived readiness for system wide integration of evidence based practice in a large pediatric health care system.

PURPOSE: Evidence-based practice (EBP) within healthcare leads to improved patient outcomes, high-quality care, job satisfaction, reduced turnover, professional autonomy, and validates nursing practice. Although a plethora of research focuses on implementing EBP, there has been little attention on assessing organizational readiness for integration. The primary aims of this study were to explore nursing beliefs and attitudes about EBP and explore the culture and readiness among pediatric nurses for system-wide integration of EBP. DESIGN AND METHODS: This study was a quantitative, cross-sectional survey-based study conducted at a large pediatric health system. RESULTS: Overall pediatric nurses had a mean score of 61.78 ± 9.32 on the EBPB (n = 396). Results of the EBPB Scale and OCRSIEP showed no statistical difference between nursing roles EBPB scores; however, nursing leaders had higher scores than any other nursing role. The OCRSIEP had a mean score of 84.98 ± 19.53 (n = 388). CONCLUSIONS: Findings suggest that pediatric nurses believe that EBP results in the best clinical care for patients and can improve clinical care, but they lack the skills and time necessary to engage in the process. This study found that increasing awareness of EBP resources and developing EBP competencies may assist pediatric nurse leaders with EBP integration into daily practice. PRACTICE IMPLICATIONS: Increasing visibility and competencies of EBP may positively impact organizational readiness by increasing confidence needed to remove identified barriers and engrain EBP in the organization's culture.

Purposeful Hourly Rounding to Decrease Peripheral Intravenous Infiltrations and Extravasations in Pediatrics.

PURPOSE: Pediatric patients are at high risk for peripheral intravenous infiltrations and extravasations (PIVIE) resulting in patient harm. Structured hourly rounding has demonstrated to improve quality outcomes. The purpose of this quality improvement project was to implement structured hourly rounding to decrease the median rate of moderate PIVIE rates from 3.13 to 2.58 per thousand patient days over a 6-month time period in pediatric patients with infusing continuous IV fluids. DESIGN AND METHODS: A pilot was conducted to hardwire hourly assessments for peripheral intravenous lines (PIV) in pediatric patients with continuous fluids utilizing a structured hourly rounding process. Bedside nurses utilized the P.A.T.H. model to assess pain management (P), assess PIVs for early PIVIE recognition (A), address things patient and family may need (T), and reduce the occurrence in hospital acquired conditions (H). Data was collected on unit nurse sensitive indicators and compliance to hourly rounding. RESULTS: Structured hourly rounding using the P.A.T.H. model successfully hardwired hourly PIV assessments. The unit reduced their median moderate PIVIE rate to 1.83 per thousand patient days, an 41% improvement. The pilot also had positive unintended consequences of improved pain reassessment from 67% to 100%, increased patient satisfaction scores of 67% to 97% and reduced patient falls by 29%. CONCLUSIONS: Structured hourly rounding using the P.A.T.H. model can positively hardwire hourly PIV assessments in pediatric patients. PRACTICE IMPLICATIONS: Sustainability of hourly rounding requires leadership support and nursing commitment to impact quality metrics. Organizations should consider implementing focused hourly rounding to address PIVIEs.

HIV-1 causes CD4 cell death through DNA-dependent protein kinase during viral integration.

Human immunodeficiency virus-1 (HIV-1) has infected more than 60 million people and caused nearly 30 million deaths worldwide, ultimately the consequence of cytolytic infection of CD4(+) T cells. In humans and in macaque models, most of these cells contain viral DNA and are rapidly eliminated at the peak of viraemia, yet the mechanism by which HIV-1 induces helper T-cell death has not been defined. Here we show that virus-induced cell killing is triggered by viral integration. Infection by wild-type HIV-1, but not an integrase-deficient mutant, induced the death of activated primary CD4 lymphocytes. Similarly, raltegravir, a pharmacologic integrase inhibitor, abolished HIV-1-induced cell killing both in cell culture and in CD4(+) T cells from acutely infected subjects. The mechanism of killing during viral integration involved the activation of DNA-dependent protein kinase (DNA-PK), a central integrator of the DNA damage response, which caused phosphorylation of p53 and histone H2AX. Pharmacological inhibition of DNA-PK abolished cell death during HIV-1 infection in vitro, suggesting that processes which reduce DNA-PK activation in CD4 cells could facilitate the formation of latently infected cells that give rise to reservoirs in vivo. We propose that activation of DNA-PK during viral integration has a central role in CD4(+) T-cell depletion, raising the possibility that integrase inhibitors and interventions directed towards DNA-PK may improve T-cell survival and immune function in infected individuals.

Calibration of the global physical activity questionnaire to Accelerometry measured physical activity and sedentary behavior.

BACKGROUND: Self-report questionnaires are a valuable method of physical activity measurement in public health research; however, accuracy is often lacking. The purpose of this study is to improve the validity of the Global Physical Activity Questionnaire by calibrating it to 7 days of accelerometer measured physical activity and sedentary behavior. METHODS: Participants (n = 108) wore an ActiGraph GT9X Link on their non-dominant wrist for 7 days. Following the accelerometer wear period, participants completed a telephone Global Physical Activity Questionnaire with a research assistant. Data were split into training and testing samples, and multivariable linear regression models built using functions of the GPAQ self-report data to predict ActiGraph measured physical activity and sedentary behavior. Models were evaluated with the testing sample and an independent validation sample (n = 120) using Mean Squared Prediction Errors. RESULTS: The prediction models utilized sedentary behavior, and moderate- and vigorous-intensity physical activity self-reported scores from the questionnaire, and participant age. Transformations of each variable, as well as break point analysis were considered. Prediction errors were reduced by 77.7-80.6% for sedentary behavior and 61.3-98.6% for physical activity by using the multivariable linear regression models over raw questionnaire scores. CONCLUSIONS: This research demonstrates the utility of calibrating self-report questionnaire data to objective measures to improve estimates of physical activity and sedentary behavior. It provides an understanding of the divide between objective and subjective measures, and provides a means to utilize the two methods as a unified measure.

Exosome-mediated microenvironment dysregulation in leukemia.

The hematopoietic stem cell (HSC) niche is composed of a complex set of stromal support cells that maintain HSCs and promote normal hematopoiesis. We now know that molecular changes within the hematopoietic niche contribute to leukemia development. Leukemia cells often reorganize the hematopoietic niche to promote and support their own survival and growth. Here we will summarize recent works that decipher the normal hematopoietic niche cellular components and describe how the leukemia-transformed niche contributes to hematological malignances. Finally, we will discuss recent publications that highlight a possible role for exosomes in the leukemia-induced niche reorganization. This article is part of a Special Issue entitled: Tumor Microenvironment Regulation of Cancer Cell Survival, Metastasis, Inflammation, and Immune Surveillance edited by Peter Ruvolo and Gregg L. Semenza.

Using Network Sampling and Recruitment Data to Understand Social Structures Related to Community Health in a Population of People Who Inject Drugs in Rural Puerto Rico.

OBJECTIVE: This research examined the social network and recruitment patterns of a sample of people who inject drugs (PWIDs) in rural Puerto Rico, in an attempt to uncover systematic clustering and between-group social boundaries that potentially influence disease spread. METHODS: Respondent driven sampling was utilized to obtain a sample of PWID in rural Puerto Rico. Through eight initial "seeds", 317 injection drug users were recruited. Using recruitment patterns of this sample, estimates of homophily and affiliation were calculated using RDSAT. RESULTS: Analyses showed clustering within the social network of PWID in rural Puerto Rico. In particular, females showed a very high tendency to recruit male PWID, which suggests low social cohesion among female PWID. Results for (believed) HCV status at the time of interview indicate that HCV+ individuals were less likely to interact with HCV- individuals or those who were unaware of their status, and may be acting as "gatekeepers" to prevent disease spread. Individuals who participated in a substance use program were more likely to affiliate with one another. The use of speedballs was related to clustering within the network, in which individuals who injected this mixture were more likely to affiliate with other speedball users. CONCLUSION: Social clustering based on several characteristics and behaviors were found within the IDU population in rural Puerto Rico. RDS was effective in not only garnering a sample of PWID in rural Puerto Rico, but also in uncovering social clustering that can potentially influence disease spread among this population.

Size-dependent regulation of dorsal-ventral patterning in the early Drosophila embryo.

How natural variation in embryo size affects patterning of the Drosophila embryo dorsal-ventral (DV) axis is not known. Here we examined quantitatively the relationship between nuclear distribution of the Dorsal transcription factor, boundary positions for several target genes, and DV axis length. Data were obtained from embryos of a wild-type background as well as from mutant lines inbred to size select embryos of smaller or larger sizes. Our data show that the width of the nuclear Dorsal gradient correlates with DV axis length. In turn, for some genes expressed along the DV axis, the boundary positions correlate closely with nuclear Dorsal levels and with DV axis length; while the expression pattern of others is relatively constant and independent of the width of the Dorsal gradient. In particular, the patterns of snail (sna) and ventral nervous system defective (vnd) correlate with nuclear Dorsal levels and exhibit scaling to DV length; while the pattern of intermediate neuroblasts defective (ind) remains relatively constant with respect to changes in Dorsal and DV length. However, in mutants that exhibit an abnormal expansion of the Dorsal gradient which fails to scale to DV length, only sna follows the Dorsal distribution and exhibits overexpansion; in contrast, vnd and ind do not overexpand suggesting some additional mechanism acts to refine the dorsal boundaries of these two genes. Thus, our results argue against the idea that the Dorsal gradient works as a global system of relative coordinates along the DV axis and suggest that individual targets respond to changes in embryo size in a gene-specific manner.

Conduct and reporting of multivariate network meta-analyses: a scoping review.

OBJECTIVES: Combining multivariate and network meta-analysis methods simultaneously in a multivariate network meta-analysis (MVNMA) provides the methodological framework to analyze the largest amount of evidence relevant to decision-makers (i.e., from indirect evidence and correlated outcomes). The objectives of this scoping review were to summarize the characteristics of MVNMAs published in the health sciences literature and map the methodological guidance available for MVNMA. STUDY DESIGN AND SETTING: We searched MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature from inception to 28 August 2023, along with citations of included studies, for quantitative evidence syntheses that applied MVNMA and articles addressing MVNMA methods. Pairs of reviewers independently screened potentially eligible studies. Collected data included bibliographic, methodological, and analytical characteristics of included studies. We reported results as total numbers, frequencies, and percentages for categorical variables and medians and interquartile ranges for continuous variables that were not normally distributed. RESULTS: After screening 1,075 titles and abstracts, and 112 full texts, we included 38 unique studies, of which, 10 were quantitative evidence syntheses that applied MVNMA and 28 were articles addressing MVNMA methods. Among the 10 MVNMAs, the first was published in 2013, four used studies identified from already published systematic reviews, and eight addressed pharmacological interventions, which were the most common interventions. They evaluated interventions for metastatic melanoma, colorectal cancer, prostate cancer, oral hygiene, disruptive behavior disorders, rheumatoid arthritis, narcolepsy, type 2 diabetes, and overactive bladder syndrome. Five MVNMAs analyzed two outcomes simultaneously, and four MVNMAs analyzed three outcomes simultaneously. Among the articles addressing MVNMA methods, the first was published in 2007 and the majority provided methodological frameworks for conducting MVNMAs (26/28, 93%). One study proposed criteria to standardize reporting of MVNMAs and two proposed items relevant to the quality assessment of MVNMAs. Study authors used data from 18 different illnesses to provide illustrative examples within their methodological guidance. CONCLUSIONS: The application of MVNMA in the health sciences literature is uncommon. Many methodological frameworks are published; however, standardization and specific criteria to guide reporting and quality assessment are lacking. This overview of the current landscape may help inform future conduct of MVNMAs and research on MVNMA methods.

Effect of post-harvest storage on the chemical and microstructural characteristics of the common bean (Phaseolus vulgaris L.).

Hard to cook is a textural defect that affects the nutritional quality of beans stored under adverse temperature and humidity conditions. This defect is related to intrinsic characteristics such as seed coat thickness, composition and microstructure. The aim of the present study was to evaluate the chemical and microstructural characteristics of common bean (Phaseolus vulgaris L.) during 270 days of post-harvest storage at 30 °C and 70% relative humidity. Microstructural analysis revealed alteration of the cotyledon cell wall and seed coat affecting seed viability and restricting seedling emergence. The seed coat thickness contraction from 105.79 µm to 97.35 µm (270 days). Changes are related with the protein bodies migration from cotyledons to seed coat. An increase in neutral detergent fiber and the presence of CaOx crystals were observed, which confer rigidity to the seed coat and affect water diffusion after 150 days causing permeability changes that contributed to seed hardening.

Effect of cooking on structural changes in the common black bean (Phaseolus vulgaris var. Jamapa).

The cooking process is fundamental for bean consumption and to increase the bioavailability of its nutritional components. The study aimed to determine the effect of cooking on bean seed coat through morphological analyses with different microscopy techniques and image analyses. The chemical composition and physical properties of raw black bean (RBB) and cooked black bean (CBB) seeds were determined. The surface and cross-sectional samples were studied by Optical microscopy (OM), environmental scanning electron microscopy (ESEM), atomic force microscopy (AFM) and confocal laser scanning microscopy (CLSM). The composition of samples showed significant differences after the cooking process. OM images and gray level co-occurrence matrix algorithm (GLCM) analysis indicated that cuticle-deposited minerals significantly influence texture parameters. Seed coat surface ESEM images showed cluster cracking. Texture fractal dimension and lacunarity parameters were effective in quantitatively assessing cracks on CBB. AFM results showed arithmetic average roughness (Ra) (121.67 nm) and quadratic average roughness (Rq) (149.94 nm). The cross-sectional ESEM images showed a decrease in seed coat thickness. The CLSM results showed an increased availability of lipids along the different multilayer tissues in CBB. The results generated from this research work offer a valuable potential to carry out a strict control of bean seed cooking at industrial level, since the structural changes and biochemical components (cell wall, lipids and protein bodies) that occur in the different tissues of the seed are able to migrate from the inside to the outside through the cracks generated in the multilayer structure that are evidenced by the microscopic techniques used.

HIV integration and T cell death: additional commentary.

Estaquier et al. provide commentary on our paper that elucidated the mechanism by which HIV-1 causes cell death in activated CD4 T lymphocytes. We showed that proviral DNA integration triggers DNA-PK dependent death signaling, leading to p53 phosphorylation and cell demise (Cooper A et al. Nature 498:376-379, 2013). They have raised several hypothetical points that we further clarify here.

Mycobacterium tuberculosis ß-lactamase variant reduces sensitivity to ampicillin/avibactam in a zebrafish-Mycobacterium marinum model of tuberculosis.

The ß-lactamase of Mycobacterium tuberculosis, BlaC, hydrolyzes ß-lactam antibiotics, hindering the use of these antibiotics for the treatment of tuberculosis. Inhibitors, such as avibactam, can reversibly inhibit the enzyme, allowing for the development of combination therapies using both antibiotic and inhibitor. However, laboratory evolution studies using Escherichia coli resulted in the discovery of single amino acid variants of BlaC that reduce the sensitivity for inhibitors or show higher catalytic efficiency against antibiotics. Here, we tested these BlaC variants under more physiological conditions using the M. marinum infection model of zebrafish, which recapitulates hallmark features of tuberculosis, including the intracellular persistence of mycobacteria in macrophages and the induction of granuloma formation. To this end, the M. tuberculosis blaC gene was integrated into the chromosome of a blaC frameshift mutant of M. marinum. Subsequently, the resulting strains were used to infect zebrafish embryos in order to test the combinatorial effect of ampicillin and avibactam. The results show that embryos infected with an M. marinum strain producing BlaC show lower infection levels after treatment than untreated embryos. Additionally, BlaC K234R showed higher infection levels after treatment than those infected with bacteria producing the wild-type enzyme, demonstrating that the zebrafish host is less sensitive to the combinatorial therapy of ß-lactam antibiotic and inhibitor. These findings are of interest for future development of combination therapies to treat tuberculosis.

Nanosuspensions as carriers of active ingredients: Chemical composition, development methods, and their biological activities.

Nanosuspensions (NSps) are colloidal dispersions of particles that have the potential to solve the delivery problems of active ingredients associated with their low solubility in water or instability due to environmental factors. It is essential to consider their chemical composition and preparation methods because they directly influence drug loading, size, morphology, solubility, and stability; these characteristics of nanosuspensions influence the delivery and bioavailability of active ingredients. NSps provides high loading of drugs, protection against degrading agents, rapid dissolution, high particle stability, and high bioavailability of active ingredients across biological membranes. In addition, they provide lower toxicity compared to other nanocarriers, such as liposomes or polymeric nanoparticles, and can modify the pharmacokinetic profiles, thus improving their safety and efficacy. The present review aims to address all aspects related to the composition of NSps, the different methods for their production, and the main factors affecting their stability. Moreover, recent studies are described as carriers of active ingredients and their biological activities.

Healing of a chronic ulcer of the lower limb of venous origin with fresh human amniochorionic membrane allograft / Curación de úlcera venosa crónica de la pierna con aloinjerto de membrana amniocoriónica humana fresca

In its fresh state, the amniochorionic membrane contains various multipotential cells, growth factors, and extracellular matrix proteins that contribute to the healing of chronic vascular ulcers. To demonstrate its effectiveness, a fresh human placental membrane allograft was applied to a chronic venous ulcer in the lower limb of an 89-year-old female patient with a 12 x 10 cm ulcerated lesion of 40 years of evolution in the malleolar area of her left lower limb. Sixty days after the graft, the ulcer was healed in 100% of its surface and a light pink scar on the edges indicated possible pigmentation. Fresh human amniochorionic membrane allograft is a therapeutic alternative for the healing of refractory chronic vascular ulcers of the lower extremities.

En su estado fresco, la membrana amniocoriónica contiene varias células multipotenciales, factores de crecimiento y proteínas de la matriz extracelular que contribuyen a la cicatrización de las úlceras vasculares crónicas. Para demostrar su efectividad, se recurrió a un aloinjerto de membrana placentaria humana fresca para tratar una úlcera venosa crónica, de 12 x 10 cm y con 40 años de evolución, en el zona maleolar interna e izquierda de una paciente de 89 años de edad. Transcurridos 60 días del injerto, la úlcera se encontraba cicatrizada en el 100 % de su superficie, observándose una cicatriz rosada clara en cuyos bordes se apreciaron intentos de pigmentación. El aloinjerto de membrana amniocoriónica humana fresca es una alternativa terapéutica para la curación de úlceras vasculares crónicas persistentes en las extremidades inferiores.

Intestinal Organoids: New Tools to Comprehend the Virulence of Bacterial Foodborne Pathogens.

Foodborne diseases cause high morbidity and mortality worldwide. Understanding the relationships between bacteria and epithelial cells throughout the infection process is essential to setting up preventive and therapeutic solutions. The extensive study of their pathophysiology has mostly been performed on transformed cell cultures that do not fully mirror the complex cell populations, the in vivo architectures, and the genetic profiles of native tissues. Following advances in primary cell culture techniques, organoids have been developed. Such technological breakthroughs have opened a new path in the study of microbial infectious diseases, and thus opened onto new strategies to control foodborne hazards. This review sheds new light on cellular messages from the host-foodborne pathogen crosstalk during in vitro organoid infection by the foodborne pathogenic bacteria with the highest health burden. Finally, future perspectives and current challenges are discussed to provide a better understanding of the potential applications of organoids in the investigation of foodborne infectious diseases.

Beyond demographics: Attitudinal barriers to the mental health service use of immigrants in the U.S.

Immigrants are at greater risk for mental health concerns but are less likely to use mental health services than their U.S.-born counterparts. Efforts to understand these disparities have focused on demographic characteristics while largely ignoring the role of immigrants' beliefs and values. This review synthesizes the research on the mental health-related beliefs and values associated with the mental health service underutilization of each major U.S. immigrant group. Results revealed two overarching attitudinal themes common to several immigrant groups and several attitudinal barriers unique to individual groups. They also elucidated several areas for additional research and highlighted the need to target these beliefs and values in public health efforts promoting MHS use among U.S. immigrants.

Phenolic compounds profile by UPLC-ESI-MS in black beans and its distribution in the seed coat during storage.

Hard to cook phenomenon results from inadequate post-harvest storage of the bean associated with the microstructure and changes in seed color and texture. The aim of this study was to evaluate the physical and chemical properties, identify the phenolic compounds and their relationship with the black bean seed coat microstructure during 270 days at 30 °C and 70% r. h. The water absorption capacity decrease to 12.19% that induced changes in seed texture observed by increasing the hardness from 5.42 to 19.96 N. A total of 37 compounds were identified by UPLC-ESI-MS and the changes in phenolic profile during storage period contribute to the seed coat color saturation. The identification of flavonoids, hydroxybenzoic and hydroxycinnamic acids, as well as distribution of condensed tannins in the seed coat, the changes in physical properties evidenced by seed darkening and hardening contribute to the seed coat impermeability.

Incorporating a Civility Program Into a Healthcare System: Journey or Expedition?

PURPOSE/OBJECTIVES: Incivility contributes to employee dissatisfaction, turnover, patient errors, and a disrespectful culture. Turnover rates and employee exit interviews alerted hospital leaders to uncivil behaviors exhibited by staff. A clinical nurse specialist (CNS) team captured this as an opportunity to create a civility program to develop team cohesiveness and improve patient safety. The purpose of this process improvement project was to identify uncivil behaviors in a pediatric hospital. DESCRIPTION OF THE PROJECT/PROGRAM: Using the Plan-Do-Study-Act model, an interprofessional team led by CNSs collaborated on a program to assess, intervene, and evaluate a program to improve civility. A preprogram survey, the Negative Acts Questionnaire-Revised, was used to assess staff perceptions of their work environment. Staff attended an education program on ways to recognize and intervene in situations involving less than standard civil behavior. Classes included communication application in uncivil situations using scenarios paired with evidence-based practice articles. Unit leaders reset behavioral expectations learned from a leader-specific class on managing unproductive behaviors. OUTCOME: Staff completed a postprogram Negative Acts Questionnaire-Revised survey 6 months after conclusion of classes. Survey results indicated the civility program effected a reduction in frequency of negative behaviors indicating an overall positive shift in workplace civility. CONCLUSION: The program provided staff with tools to recognize and intervene for improving civility, which impacted the overall work environment and patient safety.