A diagnostic stewardship approach to prevent unnecessary testing of an enteric bacterial molecular panel.

IMPORTANCE: Testing for enteric bacterial pathogens in patients hospitalized for more than 3 days is almost always inappropriate. Our study validates the utility of the 3-day rule and the use of clinical decision support tools to decrease unnecessary testing of enteropathogenic bacteria other than C. difficile. Overriding the restriction was very low yield. Our study highlights the importance of diagnostic stewardship and further refines the criteria for allowing providers to override the restriction while monitoring the impact of the interventions.

Implementation of a novel team-based model of care using expert intensive care unit physiotherapists to supplement critical care surge demand.

Within Victoria, Australia, the emergence of the Delta variant resulted in a significant and rapid increase in case numbers and high demand for intensive care beds statewide. While prior pandemic planning had been undertaken at a state level, the Delta variant necessitated a need for further rapid expansion of intensive care unit (ICU) beds. Our hospital subsequently implemented a Department of Health-designed team-based model of care to support this rapid ICU expansion-where tasks were allocated according to skill and not discipline. Here we report our local experiences as critical care physiotherapists participating in this novel model of care for physiotherapists to support the functioning of the ICU under peak pandemic surge conditions. Our core skill set as ICU-trained physiotherapists, including depth knowledge of the assessment and treatment of critical care patients, and ICU functioning, enabled us to play a contributing role in team-based care. We discuss our reflections and lessons learnt including future directions for clinicians, educators, managers, policymakers, and researchers to refine implementation of this novel model of care and how these lessons could be leveraged in future scenarios where healthcare systems might be significantly strained by future pandemics.

Are Republicans and Conservatives More Likely to Believe Conspiracy Theories?

A sizable literature tracing back to Richard Hofstadter's The Paranoid Style (1964) argues that Republicans and conservatives are more likely to believe conspiracy theories than Democrats and liberals. However, the evidence for this proposition is mixed. Since conspiracy theory beliefs are associated with dangerous orientations and behaviors, it is imperative that social scientists better understand the connection between conspiracy theories and political orientations. Employing 20 surveys of Americans from 2012 to 2021 (total n = 37,776), as well as surveys of 20 additional countries spanning six continents (total n = 26,416), we undertake an expansive investigation of the asymmetry thesis. First, we examine the relationship between beliefs in 52 conspiracy theories and both partisanship and ideology in the U.S.; this analysis is buttressed by an examination of beliefs in 11 conspiracy theories across 20 more countries. In our second test, we hold constant the content of the conspiracy theories investigated-manipulating only the partisanship of the theorized villains-to decipher whether those on the left or right are more likely to accuse political out-groups of conspiring. Finally, we inspect correlations between political orientations and the general predisposition to believe in conspiracy theories over the span of a decade. In no instance do we observe systematic evidence of a political asymmetry. Instead, the strength and direction of the relationship between political orientations and conspiricism is dependent on the characteristics of the specific conspiracy beliefs employed by researchers and the socio-political context in which those ideas are considered. Supplementary Information: The online version contains supplementary material available at 10.1007/s11109-022-09812-3.

Resolving the polygenic aetiology of a late onset combined immune deficiency caused by NFKB1 haploinsufficiency and modified by PIK3R1 and TNFRSF13B variants.

Genetic variants in PIK3CD, PIK3R1 and NFKB1 cause the primary immune deficiencies, activated PI3Kδ syndrome (APDS) 1, APDS2 and NFκB1 haploinsufficiency, respectively. We have identified a family with known or potentially pathogenic variants NFKB1, TNFRSF13B and PIK3R1. The study's aim was to describe their associated immune and cellular phenotypes and compare with individuals with monogenic disease. NFκB1 pathway function was measured by immunoblotting and PI3Kδ pathway activity by phospho-flow cytometry. p105/p50 expression was absent in two individuals but elevated pS6 only in the index case. Transfection of primary T cells demonstrated increased basal pS6 signalling due to mutant PIK3R1, but not mutant NFKB1 or their wildtype forms. We report on the presence of pathogenic variant NFKB1, with likely modifying variants in TNFRSF13B and PIK3R1 in a family. We describe immune features of both NFκB1 haploinsufficiency and APDS2, and the inhibition of excessive PI3K signalling by rapamycin in vitro.

From Sorcery to Laboratory: Pandemics and Yanyuwa Experiences of Viral Vulnerability.

The COVID-19 pandemic has prompted renewed attention among health professionals, Aboriginal community leaders, and social scientists to the need for culturally responsive preventative health measures and strategies. This article, a collaborative effort, involving Yanyuwa families from the remote community of Borroloola and two anthropologists with whom Yanyuwa have long associations, tracks the story of pandemics from the perspective of Aboriginal people in the Gulf region of northern Australia. It specifically orients the discussion of the current predicament of 'viral vulnerability' in the wake of COVID-19, relative to other pandemics, including the Hong Kong flu in 1969 and the Spanish flu decades earlier in 1919. This discussion highlights that culturally nuanced and prescribed responses to illness and threat of illness have a long history for Yanyuwa. Yanyuwa cultural repertoires have assisted in the process of making sense of massive change, in the form of past pandemics and the onset of sickness, the threat of illness with COVID-19 and the attribution of 'viral vulnerability' to this remote Aboriginal community. The aim is to centralise Yanyuwa voices in this story, as an important step in growing understandings of Aboriginal knowledge of pandemics and culturally relevant and controlled health responses and strategies for communal well-being.

The first reported cases of meat allergy following tick bites in the UK.

Allergic reactions frequently involve the production of immunoglobulin E (IgE) antibodies to proteins. However, reactions directed against carbohydrate moieties are increasingly being recognised. Tick bites can contribute to the development of immunoglobulin E to the galactose-1,3-galactose (alpha-gal) moiety on tick salivary proteins. These IgE molecules can cross-react with alpha-gal found in red meats, causing Type I IgE-mediated hypersensitivity reactions to these foods. We present three cases of delayed reactions to beef, pork and lamb in patients with prior tick bites and in the presence of a positive-specific IgE to alpha-gal. Patients were advised to avoid red meat consumption and to carry emergency treatment in the form of anti-histamines with or without adrenaline autoinjector devices. This is the first published report of red meat allergy caused by tick bites suffered in the UK.

Candidate name order effects in New Hampshire: Evidence from primaries and from general elections with party column ballots.

Research in a few U.S. states has shown that candidates listed first on ballots gain extra votes as a result. This study explored name order effects for the first time in New Hampshire, where such effects might be weak or entirely absent because of high political engagement and the use of party column ballots. In general elections (in 2012 and 2016) for federal offices and the governorship and in primaries (in 2000, 2002, and 2004), evidence of primacy effects appeared in 86% of the 84 tests, including the 2016 presidential race, when Donald Trump gained 1.7 percentage points from first listing, and Hillary Clinton gained 1.5 percentage points. Consistent with theoretical predictions, primacy effects were larger in primaries and for major-party candidates in general elections than for non-major-party candidates in general elections, more pronounced in less publicized contests, and stronger in contests without an incumbent running. All of this constitutes evidence of the reliability and generalizability of evidence on candidate name order effects and their moderators.

Comparison of the analytical sensitivity of seven commonly used commercial SARS-CoV-2 automated molecular assays.

The SARS-CoV-2 pandemic has challenged molecular microbiology laboratories to quickly implement and validate diagnostic assays and to expand testing capacity in a short timeframe. Multiple molecular diagnostic methods received FDA emergency use authorization (EUA) and were promptly validated for use nationwide. Several studies reported the analytical and/ or clinical evaluation of these molecular assays, however differences in the viral materials used for these evaluations complicated direct comparison of their analytical performance. In this study, we compared the analytical sensitivity (lower limit of detection, LOD) of seven commonly used qualitative SARS-CoV-2 molecular assays: the Abbott Molecular RealTime SARS-CoV-2 assay, the NeuMoDx™ SARS-CoV-2 assay, the Roche Cobas®SARS-CoV-2 assay, the BD SARS-CoV-2 reagents for BD MAX™ system, the Hologic Aptima® SARS-CoV-2 assay, the Xpert Xpress SARS-CoV-2 test, and the GenMark ePlex SARS-CoV-2 test. The comparison was performed utilizing a single positive clinical specimen that was serially diluted in viral transport media and quantified by the EUA approved SARS-CoV-2 droplet digital PCR (ddPCR) assay. Replicate samples were prepared and evaluated for reproducibility across different molecular assays with multiple replicates per assay. Our data demonstrated that the seven assays could detect 100 % of replicates at a nucleocapsid gene concentration of (N1 = 1,267 and N2 = 1,392) copies/mL. At a one log less concentration, the Abbott, the Roche, and the Xpert Xpress assays detected 100 % of the tested replicates.

CE: Acute Care for Patients with Dementia.

Among adults ages 65 and older, dementia doubles the risk of hospitalization. Roughly one in four hospitalized patients has dementia, and the prevalence of dementia in the United States is rising rapidly. Patients with dementia have significantly higher rates of hospital-acquired complications, including urinary tract infections, pressure injuries, pneumonia, and delirium, which when unrecognized and untreated can accelerate physical and cognitive decline, precipitating nursing home placement and death. The authors discuss the unique needs of patients with dementia who require acute care, highlighting evidence-based strategies for nurses to incorporate into practice.

Framing the Opioid Crisis: Do Racial Frames Shape Beliefs of Whites Losing Ground?

CONTEXT: Although research has begun to examine perceptions of being on the losing side of politics, it has been confined to electoral politics. The context of health disparities, and particularly the opioid crisis, offers a case to explore whether frames that emphasize racial disadvantage activate loser perceptions and the political consequences of such beliefs. METHODS: White survey participants (N = 1,549) were randomized into three groups: a control which saw no news article, or one of two treatment groups which saw a news article about the opioid crisis framed to emphasize either the absolute rates of opioid mortality among whites or the comparative rates of opioid mortality among whites compared to blacks. FINDINGS: Among control group participants, perceiving oneself a political loser was unrelated to attitudes about addressing opioids, whereas those who perceived whites to be on the losing side of public health had a less empathetic response to the opioid crisis. The comparative frame led to greater beliefs that whites are on the losing side of public health, whereas the absolute frame led to more empathetic policy opinions. CONCLUSIONS: Perceptions that one's racial group has lost ground in the public health context could have political consequences that future research should explore.

Improving satisfaction with postoperative pain management for patients with persistent pain: a preoperative pain medicine consultation intervention.

PURPOSE: Preoperative pain medicine consultations with opioid-tolerant patients allow for an accurate medication history, patient involvement in the postoperative plan, and realistic goal setting. The purpose of this quality improvement project was to increase attendance at preoperative pain consultations, thereby increasing patient satisfaction. METHODS: Retrospective chart reviews identified patients who had a preoperative pain consultation ordered from May through July 2016. Patient interviews determined reasons for not attending appointments, involvement in goal setting, engagement in pain management planning, and satisfaction with postoperative pain management. RESULTS: Retrospective chart reviews and interviews were conducted after the intervention (May-July 2017). Scheduling changes increased attendance at preoperative pain consultations by 14 percentage points (50% vs 64%). Those who attended consultations were more involved in goal setting and decisions and were more satisfied. CONCLUSIONS: Preoperative pain consultations with opioid-tolerant patients can increase satisfaction through realistic goal setting and involvement in the pain management plan.

An innovative course to prepare advanced practice registered nurses to spearhead quality and safety initiatives for older adults.

ABSTRACT: Current trends dictate that advanced practice registered nurses (APRNs) must be competent to address quality/safety issues specific to older adults. A gap analysis and review of key competencies in an adult-gerontology APRN-Doctorate of Nursing Practice (DNP) curriculum prompted the design and evaluation of an innovative online course, Quality and Safety for the Aging Adult. Course objectives align with key competencies, including graduate-level Quality and Safety Education for Nurses (QSEN) and the DNP Essentials. The course purpose was to prepare adult-gerontology APRN-DNP students as leaders to promote quality/safety outcomes for aging adults. The six-step Knowledge-to-Action Framework guided course development and evaluation. Select graduate-level QSEN competencies were used to construct a 20-item Quality and Safety Survey (4-point Likert scale) (Cronbach's alpha, 0.916). This survey was used during week 1 (pre) and week 15 (post) of the semester to evaluate students' preparation and confidence to perform key QSEN competencies. Significant improvements (p < .000) between pre/post scores on the Quality and Safety Survey were found across five classes. Students felt more prepared and confident to apply selected QSEN competencies on course completion. Moreover, nearly 60% (primary care) and nearly 35% (acute care) adult-gerontology APRN students selected the older adult population for their DNP projects. The Quality and Safety for the Aging Adult course positively influenced five classes of adult-gerontology APRN-DNP students. Integrating QSEN competencies with gerontology and quality/safety content is an effective strategy to prepare APRNs to lead quality/safety initiatives in aging adults. This innovative online course offers a successful model for innovative DNP education of adult-gerontology APRNs.

Promoting Older Adult Physical Activity Throughout Care Transitions Using an Interprofessional Approach.

The nurse practitioner plays a key role in monitoring and improving physical activity and function of older adults. Physical activity is an essential component of care management for all older adults, even those who are frail with multimorbidities. All physical activity, no matter how small, has the potential to impact functional independence and quality of life. Partnering with the older adult and caregivers along with interprofessional providers, such as a physical therapist or occupational therapist and community-based resources, facilitates the development of successful goals and plans and the implementation of activities to promote physical activity across the continuum of care.

Comprehensive Unit-based Safety Program (CUSP) to Improve Patient Experience: How a Hospital Enhanced Care Transitions and Discharge Processes.

OBJECTIVE: To determine whether Comprehensive Unit-based Safety Program (CUSP) teams could be used to enhance patient experience by improving care transitions and discharge processes in a 318-bed community hospital. METHODS: In 2015, CUSP teams produced feasible solutions by participating in a design-thinking initiative, coupled with performance improvement tools involving data analytics and peer-learning communities. Teams completed a 90-day sprint challenge, involving weekly meetings, monthly department leader meetings, and progress trackers. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was used, and the percent top (best) scores were reported for overall hospital ratings, discharge information, and care transitions. RESULTS: The percentage of patients choosing the top score increased from 61.0% preintervention to 68.0% postintervention for overall hospital rating and from 71.4% to 80.7% for recommending the hospital. The top scores increased from 76.0% preintervention to 84.5% postintervention for the discharge information domain and from 49.2% to 53.6% for the care transitions domain. CONCLUSION: CUSP teams improved patient experience. The teams could expand their scope to be the unit-level resource focused not only on safety but also on external quality measures to which patient experience is a broad category for HCAHPS scores, and potentially on value in future work.

Prognosis of Good syndrome: mortality and morbidity of thymoma associated immunodeficiency in perspective.

Good syndrome (GS) or thymoma-associated immunodeficiency, is a rare condition that has only been studied in retrospective case series. General consensus was that GS has a worse prognosis than other humoral immunodeficiencies. In this study, physicians of GS patients completed two questionnaires with a two year interval with data on 47 patients, 499 patient years in total. Results on epidemiology, disease characteristics, and outcome are presented. Mean age at diagnosis was 60years and median follow-up from onset of symptoms was 9years. There was a high frequency of respiratory tract infections due to encapsulated bacteria. Median survival was 14years. Survival was reduced compared to age-matched population controls (5-year survival: 82% versus 95%, p=0.008). In this cohort survival was not associated with gender (HR 0.9, 95% CI 0.3-3.0), autoimmune diseases (HR 2.9, 95% CI 0.8-10.1) or immunosuppressive use (HR 0.3, 95% CI: 0.1-1.2).

Multicenter Evaluation of BioFire FilmArray Meningitis/Encephalitis Panel for Detection of Bacteria, Viruses, and Yeast in Cerebrospinal Fluid Specimens.

Rapid diagnosis and treatment of infectious meningitis and encephalitis are critical to minimize morbidity and mortality. Comprehensive testing of cerebrospinal fluid (CSF) often includes Gram stain, culture, antigen detection, and molecular methods, paired with chemical and cellular analyses. These methods may lack sensitivity or specificity, can take several days, and require significant volume for complete analysis. The FilmArray Meningitis/Encephalitis (ME) Panel is a multiplexed in vitro diagnostic test for the simultaneous, rapid (∼1-h) detection of 14 pathogens directly from CSF specimens: Escherichia coli K1, Haemophilus influenzae, Listeria monocytogenes, Neisseria meningitidis, Streptococcus pneumoniae, Streptococcus agalactiae, cytomegalovirus, enterovirus, herpes simplex virus 1 and 2, human herpesvirus 6, human parechovirus, varicella-zoster virus, and Cryptococcus neoformans/Cryptococcus gattii We describe a multicenter evaluation of 1,560 prospectively collected CSF specimens with performance compared to culture (bacterial analytes) and PCR (all other analytes). The FilmArray ME Panel demonstrated a sensitivity or positive percentage of agreement of 100% for 9 of 14 analytes. Enterovirus and human herpesvirus type 6 had agreements of 95.7% and 85.7%, and L. monocytogenes and N. meningitidis were not observed in the study. For S. agalactiae, there was a single false-positive and false-negative result each, for a sensitivity and specificity of 0 and 99.9%, respectively. The specificity or negative percentage of agreement was 99.2% or greater for all other analytes. The FilmArray ME Panel is a sensitive and specific test to aid in diagnosis of ME. With use of this comprehensive and rapid test, improved patient outcomes and antimicrobial stewardship are anticipated.

Impact of APN Home Visits in Reducing Healthcare Costs and Improving Function in Homebound Heart Failure.

By providing quality primary care in the home setting, nurse practitioners can treat homebound patients effectively and decrease the number of hospitalizations, 30-day readmissions, and emergency department visits. Forty patients with a diagnosis of Class III or IV heart failure who were homebound were chosen for this project. The project manager, an Adult-Gerontological nurse practitioner, made home visits to these patients on a monthly and as-needed basis throughout the 3-month project. The rate of hospital admissions, emergency department visits, and 30-day readmissions was reduced by 64%, 85%, and 95%, respectively. Patients were assessed using the Kansas City Cardiomyopathy Questionnaire (Green et al., 2000) at the initial visit and at 3 months. The scoring for physical functionality, symptom frequency, and quality of life were improved by 44%, 40%, and 54%, respectively.