Contaminant Organism Growth in Febrile Infants at Low Risk for Invasive Bacterial Infection.

In this multicenter, cross-sectional, secondary analysis of 4042 low-risk febrile infants, nearly 10% had a contaminated culture obtained during their evaluation (4.9% of blood cultures, 5.0% of urine cultures, and 1.8% of cerebrospinal fluid cultures). Our findings have important implications for improving sterile technique and reducing unnecessary cultures.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants.

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Drug Utilization Review: Our Patients Deserve Our Very Best.

In 1990, the Omnibus Budget Reconciliation Act included requirements for Medicaid patients in an effort to save the federal government money. The requirements included a prospective drug utilization review, patient counseling, and maintenance of patient records. Subsequently, in 1993, when the pharmacy practice requirements went into effect, this federal regulation became the standard of care for pharmacists and part of their professional duty. This article suggests that the pharmacy should review all active pharmaceutical ingredients and excipients that are dispensed at the pharmacy and list all interactions or potential side effects in the review, so that a proper drug utilization review can be performed.

The Effects of a Community-Based, Multicomponent, Depression Prevention Intervention in Mothers At-Risk.

The purpose of this study was to develop a 12-week multicomponent, depression prevention pilot intervention and evaluate its feasibility and preliminary effects on improving levels and correlates of depressive symptoms, including anger, self-esteem perceived stress, social support, and racism. A quasi-experimental, mixed-methods design and a community-based participatory research (CBPR) approach was employed. University faculty, students and community residents collaborated at a low-income housing complex in a low-resourced, urban community. Fifteen low-income, ethnic minority mothers ages 23-46 years completed the intervention and evaluation surveys. Eight mothers participated in a focus group. The intervention included social group-dance, health education, and socialization. t-Tests, sign-tests, and thematic analysis was employed. Mothers identified barriers and facilitators of program engagement. Depressive symptoms were significantly reduced (t(14) = 2.41, p = .030). Self-esteem (t(14) = 2.28, p = .039) and social support levels (M = 4.5, p = .035) were significantly increased. This multicomponent intervention is feasible. Preliminary efficacy evidence was mixed.

Using Mindfulness-Informed Photovoice to Explore Stress and Coping in Women Residing in Public Housing in a Low-Resourced Community.

The setting of the current study was an urban city where the majority of public housing residents are single females living in poverty. An adapted women's mindfulness program, including a Photovoice exercise, was offered to this vulnerable population. Stress contributes to poor mental/physical health. A Photovoice research method was used to elucidate the stressors and coping facilitators used by participants. Eleven participants took a digital photography workshop and then photographed stressors and coping facilitators. All 275 photographic submissions were analyzed thematically. Coping themes were: Aesthetics: Man-Made and Natural; Relationships: Pets and People; Self-Esteem and Cultural Identity; and Inspiration Through Religion and Social Media Messaging. Stress themes were: Urban Disarray and Existential Threat/Danger. Results showed that social connectedness, spirituality, improving neighborhood aesthetics, use of social media, and access to nature could support coping. [Journal of Psychosocial Nursing and Mental Health Services, 60(7), 23-31.].

Deep sequencing shows that HBV basal core promoter and precore variants reduce the likelihood of HBsAg loss following tenofovir disoproxil fumarate therapy in HBeAg-positive chronic hepatitis B.

OBJECTIVE: Hepatitis B e antigen (HBeAg) seroconversion and hepatitis B surface antigen (HBsAg) loss are important clinical outcomes for patients with chronic hepatitis B (CHB) treated with antiviral therapy. To date, there have been few studies that have evaluated viral sequence markers predicting serological response to nucleos(t)ide analogue (NA) treatment. DESIGN: We used next-generation sequencing (NGS) and quantitative HBV serology (HBeAg and HBsAg) to identify viral sequence markers associated with serological response to long-term tenofovir disoproxil fumarate therapy among HBeAg-positive patients. In the GS-US-174-0103 study, approximately half the patients seroconverted to anti-HBe by week 192 and 11% of patients exhibited HBsAg loss, the closest outcome to functional cure. The frequency of HBV variants that have previously been associated with HBV clinical outcomes was evaluated. HBV viral diversity in baseline sequences generated by NGS was calculated using Shannon entropy. RESULTS: NGS analysis of HBV sequences from 157 patients infected with genotypes A to D showed the frequency of variants in the basal core promoter (BCP) and precore (PC) regions varied by genotype and that these mutations were associated with the absence of HBsAg loss. This was the case even when mutations were present at frequencies below the threshold of detection by population sequencing. Increased viral diversity across the HBV genome as determined by NGS was also associated with reduced likelihood of HBsAg loss. CONCLUSION: Patients with detectable BCP and/or PC variants and higher viral diversity have a lower probability of HBsAg loss during long-term NA therapy. Strategies to achieve functional cure of HBV infection through combination therapy should consider using NGS to stratify patients according to BCP/PC sequence. Consideration should also be given to earlier initiation of therapy prior to the emergence of BCP/PC variants. TRIAL REGISTRATION NUMBER: NCT00116805; Post result.

Root Cause Analysis, Part 2: STERILE COMPOUNDING.

When an adverse event or near miss occurs in a pharmacy, eliminating the root cause to prevent recurrence is critically important. Addressing the root cause of the problem reduces the recurrence of putting patients and the pharmacy at risk. This article proposes a method for performing Root Cause Analysis applicable to sterile compounding.

Root Cause Analysis, Part 1: Nonsterile Compounding.

When an adverse event or near miss occurs in a pharmacy, eliminating the root cause to prevent recurrence is critically important. We occasionally see pharmacies address deviations in a manner that only superficially addresses the adverse event, but does not address the root cause of the problem, thereby putting patients and the pharmacy at risk of a recurrence. This article proposes a method for performing Root Cause Analysis.

Evaluation of optical coherence tomography to discriminate lesions of the upper aerodigestive tract.

BACKGROUND: This study evaluated the capability of optical coherence tomography (OCT) to differentiate premalignant and early malignant lesions of the upper aerodigestive tract (UADT). METHODS: An OCT screening was performed in 52 healthy volunteers. Epithelial thicknesses on 38 OCT images and histopathological slides were correlated. One hundred primary lesions were rated via OCT concerning invasiveness by an "unblinded" investigator, then biopsied, and the results correlated. All OCT images were evaluated by 3 "blinded" investigators. Forty-eight images underwent retrospective image analysis. RESULTS: Screening showed large differences concerning epithelial thicknesses, but good correlation (κ = 0.63) between OCT and histopathological slides. In the unblinded evaluation, noninvasive and invasive lesions could be distinguished with a sensitivity of 88.9% and specificity of 89.0% whereas the blinded evaluations led to sensitivities of 100%, 66.7%, and 77.8% and specificities of 75.8%, 71.4%, and 70.3%. The difference of mean intraepithelial intensity reductions in dysplasias (38.7%) and hyperplasias (18.9%) was statistically significant. CONCLUSION: OCT complements visual inspection for differentiating UADT-lesions.

The construct validity of the health utilities index mark 3 in assessing health status in lung transplantation.

PURPOSE: To assess the cross-sectional construct validity of the Health Utilities Index Mark 3 (HUI3) in lung transplantation. METHODS: Two hundred and thirteen patients (103 pre-transplant and 110 post-transplant) with mean age 53 years old (SD 13) were recruited during a randomized controlled clinical trial at the out-patient clinic in a tertiary institution. At baseline, patients self-completed measures that included the HUI3, EuroQol EQ-5D, Hospital Anxiety and Depression Scale (HADS) and socio-demographic questionnaire. Six-minute walk test scores and forced expiratory volume in 1 second data were collected from patient's medical records. A priori hypotheses were formulated by members of the transplant team about the expected degree of association between the measures. Correlation coefficients of < 0.1 were considered as negligible, 0.1 to < 0.3 as small, 0.3 to < 0.5 as medium, and ≥ 0.5 as large. RESULTS: Of the ninety predictions made, forty three were correct but in 31 the correlation was slightly lower than predicted and in 7 the correlations were much higher than predicted. In 48% of the cases, predicted and observed associations were in agreement. Predictions of associations were off by one category in 42% of the cases; in 10% of the cases the predictions were off by two categories. CONCLUSIONS: This is the first study providing evidence of cross-sectional construct validity of HUI3 in lung transplantation. Results indicate that the HUI3 was able to capture the burden of lung disease before transplantation and that post-transplant patients enjoyed higher health-related quality of life than pre-transplant patients.

Lung and heart lung transplantation at the University of Alberta 1986-2010.

The lung transplantation program at the University of Alberta has been in existence for 25 years. The current volume is 35-40 new lung transplants per year. We offer single-lung, bilateral lung, heart/lung and bilateral living lobar transplantation as options. Experience has allowed for widening of the indications and acceptance of patients with more risk. Donor evaluation and management has allowed for extended donors to be included in the donor pool. Results will likely continue to improve with increased understanding of the mechanisms and management of bronchiolitis obliterans syndrome. Our research interests have been in the areas of risk analysis, outcome assessment, and quality of life changes from transplantation.

The use of patient-reported outcomes becomes standard practice in the routine clinical care of lung-heart transplant patients.

OBJECTIVE: To assess the use of patient-reported outcome (PROs) measures in the routine clinical care of lung-heart transplant patients. We assessed whether the addition of PROs in routine clinical care affected the duration of the consultation and patient's and clinician's views. METHOD: Consecutive lung-heart transplant patients visiting the outpatient clinic, University of Alberta Hospital, completed the Chronic Respiratory Questionnaire (CRQ) and the Health Utilities Index (HUI) on touchscreen computers. Information on the patient's responses was made available to the members of the transplant team prior to the encounter with the patient. The duration of clinical encounters was noted. At the end of every visit, clinicians completed a questionnaire on the usefulness of having PRO information available. After 6 months patients completed a survey of their experiences. RESULTS: The final patient sample consisted of 172 patients with a mean (SD) age of 52 (13.3) years old; 47% were female; 68% were organ recipients and 32% candidates. The transplant team, comprising four pulmunologists, two nurses, and one pharmacist had an average of 9 years of practical experience in pulmunology. The mean duration of patient-clinician encounters in minutes was 15.15 (4.52). Ninety-eight percent of patients indicated that they would be happy to complete the CRQ and HUI at every clinic visit. Ninety-one percent of the assessments completed by clinicians showed complete satisfaction with the use of PROs in routine practice. Further, the clinicians developed guidelines for the use of PRO information in clinical practice. CONCLUSIONS: The incorporation of PRO measures in the routine clinical care of lung-heart transplant patients resulted in a reduction of the duration of patient-clinician encounters. The experience was well accepted by patients and clinicians. We conclude that the routine use of PROs in lung-heart transplant patients has become standard practice.

Full steam ahead on the SS "external regulator"? Mandatory reporting, professional independence, self-regulation and patient harm.

Mandatory reporting by medical practitioners of their colleagues who demonstrate poor clinical performance, are intoxicated while working or have sexual relations with patients, has been recently legislated for in New South Wales, and is likely to become law in Queensland. Somewhat similar legislation was introduced in New Zealand in relation to most health practitioners, but resistance, particularly from the New Zealand Medical Association, resulted in discretionary, as opposed to mandatory, reporting. The National Registration and Accreditation Scheme for the Health Professions in Australia is also canvassing mandatory reporting for 10 major health profession registrants, as part of its processes for dealing with performance, health and conduct matters. Mandatory reporting is an important incursion on the self-regulation functions and privileges of the health professions. The medical profession, in particular, has resisted mandatory reporting provisions, but appears not to discern that its allegiance to a model of traditional rather than transparent self-regulation may be self-defeating.

Prospective monitoring of BK polyomavirus infection early posttransplantation in nonrenal solid organ transplant recipients.

BACKGROUND: BK virus-associated nephropathy is an important cause of renal dysfunction in renal transplant recipients. Renal dysfunction after nonrenal solid organ transplantation (NRSOT) is common; however, the impact of BK virus remains uncertain. METHODS: Sixty (7 heart, 25 liver, and 28 lung) NRSOT recipients were enrolled in this single center prospective longitudinal study. Urine and plasma were collected for detection of BK viral load using a real-time quantitative polymerase chain reaction assay at transplantation and at 3, 6, and 9 months posttransplantation. Demographic and clinical data including serum creatinine and immunosuppressive therapy were also collected. RESULTS: BK viruria was detected in 16 of 193 (8.3%) samples corresponding to 9 of 60 (15%) subjects. The median BK viral load was 1.12 x 10 (range, 1.1 x 10-2.66 x 10) copies per milliliter. No viremia was detected. In seven of nine, viruria occurred by 3 months posttransplantation. At 9 months of posttransplantation, the median Modification of Diet in Renal Disease-estimated glomerular filtration rate in those with BK viruria on at least one sample was similar to those without viruria (58.0 [IQR 43.1-60.7] mL/min/1.73 m vs. 61.4 [IQR 50.6-74.4] mL/min/1.73 m; P=0.39). CONCLUSIONS: Although BK infection was common in this NRSOT population, BK viremia was not observed and there was no association between BK viruria and renal dysfunction. Our data suggest that routine surveillance for BK virus early posttransplantation in NRSOT may not be warranted but should be further examined in a larger multicenter trial.