Spectroscopic Identification of Bacteria Resistance to Antibiotics by Means of Absorption of Specific Biochemical Groups and Special Machine Learning Algorithm.

FTIR (Fourier transform infrared spectroscopy) is one analytical technique of the absorption of infrared radiation. FTIR can also be used as a tool to characterize profiles of biomolecules in bacterial cells, which can be useful in differentiating different bacteria. Considering that different bacterial species have different molecular compositions, it will then result in unique FTIR spectra for each species and even bacterial strains. Having this important tool, here, we have developed a methodology aimed at refining the analysis and classification of the FTIR absorption spectra obtained from samples of Staphylococcus aureus, with the implementation of machine learning algorithms. In the first stage, the system conforming to four specified species groups, Control, Amoxicillin induced (AMO), Gentamicin induced (GEN), and Erythromycin induced (ERY), was analyzed. Then, in the second stage, five hidden samples were identified and correctly classified as with/without resistance to induced antibiotics. The total analyses were performed in three windows, Carbohydrates, Fatty Acids, and Proteins, of five hundred spectra. The protocol for acquiring the spectral data from the antibiotic-resistant bacteria via FTIR spectroscopy developed by Soares et al. was implemented here due to demonstrating high accuracy and sensitivity. The present study focuses on the prediction of antibiotic-induced samples through the implementation of the hierarchical cluster analysis (HCA), principal component analysis (PCA) algorithm, and calculation of confusion matrices (CMs) applied to the FTIR absorption spectra data. The data analysis process developed here has the main objective of obtaining knowledge about the intrinsic behavior of S. aureus samples within the analysis regions of the FTIR absorption spectra. The results yielded values with 0.7 to 1 accuracy and high values of sensitivity and specificity for the species identification in the CM calculations. Such results provide important information on antibiotic resistance in samples of S. aureus bacteria for potential application in the detection of antibiotic resistance in clinical use.

Recovering the susceptibility of antibiotic-resistant bacteria using photooxidative damage.

Multidrug-resistant bacteria are one of the most serious threats to infection control. Few new antibiotics have been developed; however, the lack of an effective new mechanism of their action has worsened the situation. Photodynamic inactivation (PDI) can break antimicrobial resistance, since it potentiates the effect of antibiotics, and induces oxidative stress in microorganisms through the interaction of light with a photosensitizer. This paper addresses the application of PDI for increasing bacterial susceptibility to antibiotics and helping in bacterial persistence and virulence. The effect of photodynamic action on resistant bacteria collected from patients and bacteria cells with induced resistance in the laboratory was investigated. Staphylococcus aureus resistance breakdown levels for each antibiotic (amoxicillin, erythromycin, and gentamicin) from the photodynamic effect (10 µM curcumin, 10 J/cm2) and its maintenance in descendant microorganisms were demonstrated within five cycles after PDI application. PDI showed an innovative feature for modifying the degree of bacterial sensitivity to antibiotics according to dosages, thus reducing resistance and persistence of microorganisms from standard and clinical strains. We hypothesize a reduction in the degree of antimicrobial resistance through photooxidative action combats antibiotic failures.

Physicochemical mechanisms of bacterial response in the photodynamic potentiation of antibiotic effects.

Antibiotic failures in treatments of bacterial infections from resistant strains have been a global health concern, mainly due to the proportions they can reach in the coming years. Making microorganisms susceptible to existing antibiotics is an alternative to solve this problem. This study applies a physicochemical method to the standard treatment for modulating the synergistic response towards circumventing the mechanisms of bacterial resistance. Photodynamic inactivation protocols (curcumina 10 µM, 10 J/cm2) and their cellular behavior in the presence of amoxicillin, erythromycin, and gentamicin antibiotics were analyzed from the dynamics of bacterial interaction of a molecule that produces only toxic effects after the absorption of a specific wavelength of light. In addition to bacterial viability, the interaction of curcumin, antibiotics and bacteria were imaged and chemically analyzed using confocal fluorescence microscopy and Fourier-transform infrared spectroscopy (FTIR). The interaction between therapies depended on the sequential order of application, metabolic activity, and binding of bacterial cell surface biomolecules. The results demonstrated a potentiating effect of the antibiotic with up to to 32-fold reduction in minimum inhibitory concentrations and mean reductions of 7 log CFU/ml by physicochemical action at bacterial level after the photodynamic treatment. The changes observed as a result of bacteria-antibiotic interactions, such as membrane permeabilization and increase in susceptibility, may be a possibility for solving the problem of microbial multidrug resistance.

Breaking down antibiotic resistance in methicillin-resistant Staphylococcus aureus: Combining antimicrobial photodynamic and antibiotic treatments.

The widespread use of antibiotics drives the evolution of antimicrobial-resistant bacteria (ARB), threatening patients and healthcare professionals. Therefore, the development of novel strategies to combat resistance is recognized as a global healthcare priority. The two methods to combat ARB are development of new antibiotics or reduction in existing resistances. Development of novel antibiotics is a laborious and slow-progressing task that is no longer a safe reserve against looming risks. In this research, we suggest a method for reducing resistance to extend the efficacious lifetime of current antibiotics. Antimicrobial photodynamic therapy (aPDT) is used to generate reactive oxygen species (ROS) via the photoactivation of a photosensitizer. ROS then nonspecifically damage cellular components, leading to general impairment and cell death. Here, we test the hypothesis that concurrent treatment of bacteria with antibiotics and aPDT achieves an additive effect in the elimination of ARB. Performing aPDT with the photosensitizer methylene blue in combination with antibiotics chloramphenicol and tetracycline results in significant reductions in resistance for two methicillin-resistant Staphylococcus aureus (MRSA) strains, USA300 and RN4220. Additional resistant S. aureus strain and antibiotic combinations reveal similar results. Taken together, these results suggest that concurrent aPDT consistently decreases S. aureus resistance by improving susceptibility to antibiotic treatment. In turn, this development exhibits an alternative to overcome some of the growing MRSA challenge.

Synergic dual phototherapy: Cationic imidazolyl photosensitizers and ciprofloxacin for eradication of in vitro and in vivo E. coli infections.

The emergence of new microorganisms with resistance to current antimicrobials is one of the key issues of modern healthcare that must be urgently addressed with the development of new molecules and therapies. Photodynamic inactivation (PDI) in combination with antibiotics has been recently regarded as a promising wide-spectrum therapy for the treatment of localized topical infections. However, further studies are required regarding the selection of the best photosensitizer structures and protocol optimization, in order to maximize the efficiency of this synergic interaction. In this paper, we present results that demonstrate the influence of the structure of cationic imidazolyl-substituted photosensitizers and light on the enhancement of ciprofloxacin (CIP) activity, for the inactivation of Escherichia coli. Structure-activity studies have highlighted the tetra cationic imidazolyl porphyrin IP-H-Me4+ at sub-bactericide concentrations (4-16 nM) as the most promising photosensitizer for combination with sub-inhibitory CIP concentration (<0.25 mg/L). An optimized dual phototherapy protocol using this photosensitizer was translated to in vivo studies in mice wounds infected with E. coli. This synergic combination reduced the amount of photosensitizer and ciprofloxacin required for full E. coli inactivation and, in both in vitro and in vivo studies, the combination therapy was clearly superior to each monotherapy (PDI or ciprofloxacin alone). Overall, these findings highlight the potential of cationic imidazolyl porphyrins in boosting the activity of antibiotics and lowering the probability of resistance development, which is essential for a sustainable long-term treatment of infectious diseases.

Photodynamic viral inactivation: Recent advances and potential applications.

Antibiotic-resistant bacteria, which are growing at a frightening rate worldwide, has put the world on a long-standing alert. The COVID-19 health crisis reinforced the pressing need to address a fast-developing pandemic. To mitigate these health emergencies and prevent economic collapse, cheap, practical, and easily applicable infection control techniques are essential worldwide. Application of light in the form of photodynamic action on microorganisms and viruses has been growing and is now successfully applied in several areas. The efficacy of this approach has been demonstrated in the fight against viruses, prompting additional efforts to advance the technique, including safety use protocols. In particular, its application to suppress respiratory tract infections and to provide decontamination of fluids, such as blood plasma and others, can become an inexpensive alternative strategy in the fight against viral and bacterial infections. Diverse early treatment methods based on photodynamic action enable an accelerated response to emerging threats prior to the availability of preventative drugs. In this review, we evaluate a vast number of photodynamic demonstrations and first-principle proofs carried out on viral control, revealing its potential and encouraging its rapid development toward safe clinical practice. This review highlights the main research trends and, as a futuristic exercise, anticipates potential situations where photodynamic treatment can provide a readily available solution.

Sentimentos e emoções de mães de prematuros de uma unidade de terapia intensiva neonatal / Sentimientos y emociones de madres de hijos prematuros de una unidad de cuidados intensivos neonatales / Feelings and emotions of mothers of preterm babies at a neonatal intensive care unit

Objetivo: Desvelar os sentimentos e emoções das mães que se deparam com filho prematuro internado na Unidade de Terapia Intensiva Neonatal, para compreender o sentido dessa vivência. Método: Estudo qualitativo sob a perspectiva fenomenológica fundamentada em Heidegger. Os sujeitos do estudo foram sete mães que experenciaram o ser mãe de uma criança hospitalizada, em Unidade de Terapia Intensiva Neonatal. Resultados: Os discursos foram analisados, por meio de três categorias analíticas: sonho de ser mãe em risco e o sentimento de frustração e culpa, sentimentos ambivalentes no pós-parto e a vivência de sofrimento pela condição de fragilidade do filho e a ressignificação da experiência e o sentimento de esperança e fé. Conclusão: Houve ambivalência afetiva de sentimentos e emoções das mães. O vivido das mães foram marcados por experiências, cujo sentido se expressaram pelo sonho de ser mãe em risco até à ressignificação desse sofrimento construído pelas expectativas em torno da recuperação(AU)

Purpose: To unveil the feelings and emotions of mothers of a premature child admitted to the Neonatal Intensive Care Unit to understand the meaning of this experience. Method: A qualitative study under Heidegger's phenomenological perspective. The study subjects were seven women who experienced being a mother of a child hospitalized in a Neonatal Intensive Care Unit. Results: Their speeches were analyzed through three analytical categories: dream of being a mother at risk and the feeling of frustration and guilt; ambivalent feelings in the postpartum period and the experience of suffering due to the fragile condition of the child; and the redefinition of the experience and the feeling of hope and faith. Conclusion: There was an affective ambivalence of mothers' feelings and emotions. The mothers' experiences were marked by the dream of being a mother at risk as well as the re-signification of this suffering built by expectations around recovery(AU)

Objetivo: Revelar los sentimientos y emociones de las madres que se enfrentan a un niño prematuro ingresado en la Unidad de Cuidados Intensivos Neonatales para comprender el significado de esta experiencia. Método: Estudio cualitativo bajo la perspectiva fenomenológica basado en Heidegger. Los sujetos del estudio fueron siete madres que vivieron la experiencia de ser madres de un niño hospitalizado en una Unidad de Cuidados Intensivos Neonatales. Resultados: Los discursos se analizaron a través de tres categorías analíticas: el sueño de ser madre en riesgo y el sentimiento de frustración y culpa, los sentimientos ambivalentes en el posparto y la vivencia del sufrimiento por la frágil condición del niño y la redefinición de la experiencia y el sentimiento de esperanza y fe. Conclusión: Hubo ambivalencia afectiva de los sentimientos y emociones de las madres. La vida de las madres estuvo marcada por experiencias cuyo significado fue expresado por el sueño de ser madre en riesgo hasta la resignificación de este sufrimiento construido por expectativas en torno a la recuperación(AU)

Prevalence and risk factors for internet gaming disorder

Objectives: To estimate the prevalence of internet gaming disorder (IGD) and associated risk factors in a sample of secondary and postsecondary students from a public federal institution of higher education (Instituto Federal de Educação, Ciência e Tecnologia) in Southern Brazil. Methods: The study included a sociodemographic questionnaire, the Beck Depression Inventory (BDI), Self-Report Questionnaire (SRQ-20), Pittsburgh Sleep Quality Index (PSQI-BR), the Mini-Social Phobia Inventory (Mini-SPIN), and the Game Addiction Scale (GAS). Finally, IGD was measured with the Brazilian version of the Internet Gaming Disorder Scale-Short-Form (IGDS9-SF), which has been psychometrically validated in this population. Results: Overall, 38.2% (n=212) of the sample exhibited IGD symptoms, with 18.2% (n=101) being classed as at-risk gamers. Regression analysis found IGD to be associated with male gender, severe depressive symptoms, poor sleep quality, increased time spent gaming, and total free time spent gaming (p < 0.001). Conclusions: The prevalence of IGD in this sample was relatively high, and associated risk factors found were similar to those previously reported in the literature. Further studies investigating the epidemiology of IGD in Brazilian samples are warranted to better understand treatment needs and inform preventive measures in this population.

Prevalence and risk factors for internet gaming disorder.

OBJECTIVES: To estimate the prevalence of internet gaming disorder (IGD) and associated risk factors in a sample of secondary and postsecondary students from a public federal institution of higher education (Instituto Federal de Educação, Ciência e Tecnologia) in Southern Brazil. METHODS: The study included a sociodemographic questionnaire, the Beck Depression Inventory (BDI), Self-Report Questionnaire (SRQ-20), Pittsburgh Sleep Quality Index (PSQI-BR), the Mini-Social Phobia Inventory (Mini-SPIN), and the Game Addiction Scale (GAS). Finally, IGD was measured with the Brazilian version of the Internet Gaming Disorder Scale-Short-Form (IGDS9-SF), which has been psychometrically validated in this population. RESULTS: Overall, 38.2% (n=212) of the sample exhibited IGD symptoms, with 18.2% (n=101) being classed as at-risk gamers. Regression analysis found IGD to be associated with male gender, severe depressive symptoms, poor sleep quality, increased time spent gaming, and total free time spent gaming (p < 0.001). CONCLUSIONS: The prevalence of IGD in this sample was relatively high, and associated risk factors found were similar to those previously reported in the literature. Further studies investigating the epidemiology of IGD in Brazilian samples are warranted to better understand treatment needs and inform preventive measures in this population.

Evolution of surviving Streptoccocus pyogenes from pharyngotonsillitis patients submit to multiple cycles of antimicrobial photodynamic therapy.

It is estimated over 600 million pharyngotonsillitis (PT) cases worldwide per year and 30% of this total are caused by Streptococcus pyogenes with standard antibiotic treatment. Antimicrobial Photodynamic Therapy (aPDT) has been studied for the clinical research in infectious diseases. The study aim was to analyze the evolution of aPDT on inactivation of clinical strains of multiple cycles. S. pyogenes and clinical strains isolated from patients with PT were incubated with curcumin in formulation (2.25 mg/ml) and irradiated at 450 nm in Light fluence rates. A mortality was a measure of the counting colony forming units per milliliter (CFU/ml) surviving. Parameters of bacterial biofilm formation, uptake of photosensitizer (PS) and efficacy of antibiotics on survival of bacteria of each cycle were tested. The bacteria profile remains unchanged between 10 aPDT cycles was observed. The bacterial colony survival presented a reduction in capacity to form biofilm due adhesion of strains and PS uptake rate. The antibiotic remained efficient after aPDT cycles. Our in vitro results suggested a low-level of development of PDT resistance, however a decrease of photosensitizer uptake was observed. Furthermore, there is no cross effect on aPDT cycles and the first application of antibiotics.

The Trach Safe Initiative: A Quality Improvement Initiative to Reduce Mortality among Pediatric Tracheostomy Patients.

OBJECTIVE: To describe the Trach Safe Initiative and assess its impact on unanticipated tracheostomy-related mortality in outpatient tracheostomy-dependent children (TDC). METHODS: An interdisciplinary team including parents and providers designed the initiative with quality improvement methods. Three practice changes were prioritized: (1) surveillance airway endoscopy prior to hospital discharge from tracheostomy placement, (2) education for community-based nurses on TDC-focused emergency airway management, and (3) routine assessment of airway events for TDC in clinic. The primary outcome was annual unanticipated mortality after hospital discharge from tracheostomy placement before and after the initiative. RESULTS: In the 5 years before and after the initiative, 131 children and 155 children underwent tracheostomy placement, respectively. At the end of the study period, the institution sustained Trach Safe practices: (1) surveillance bronchoscopies increased from 104 to 429 bronchoscopies, (2) the course trained 209 community-based nurses, and (3) the survey was used in 488 home ventilator clinic visits to identify near-miss airway events. Prior to the initiative, 9 deaths were unanticipated. After Trach Safe implementation, 1 death was unanticipated. Control chart analysis demonstrates significant special-cause variation in reduced unanticipated mortality. DISCUSSION: We describe a system shift in reduced unanticipated mortality for TDC through 3 major practice changes of the Trach Safe Initiative. IMPLICATION FOR PRACTICE: Death in a child with a tracheostomy tube at home may represent modifiable tracheostomy-related airway events. Using Trach Safe practices, we address multiple facets to improve safety of TDC out of the hospital.

Respiratory infections and chronic cough due to triple A (Allgrove) syndrome.

Cough and respiratory infections are common in pediatrics. Our case report illustrates the need for pediatricians to consider rare diagnoses such as genetic syndromes and primary gastrointestinal motility disorders in patients with unremitting respiratory and gastrointestinal symptoms. Early identification provides early intervention and reduces long-term morbidity for pediatric patients.

Optimization for microbial incorporation and efficiency of photodynamic therapy using variation on curcumin formulation.

INTRODUCTION: A mixture of curcuminoids: curcumin, desmethoxycurcumin (DMC), and bisdemethoxycurcumin (BDMC) are named natural curcumin. It is a lipophilic photosensitizer (PS) highly soluble in an organic solvent such as dimethyl sulfoxide (DMSO). Curcumin is a PS used for microbial inactivation using photodynamic action. However, this solvent has high cytotoxicity and is unavailable in formulations for clinical use. This study aimed to investigate the interactions of curcuminoids syrup with Streptococcus sp., a gram-positive coccus and one of the major pharyngeal pathogens, responsible for diseases such as pharyngitis. METHODS: Bacteria were incubated with curcuminoids (natural curcumin, synthetic, DMC, BDMC) at 37 °C in formulations: 1) syrup (water + sucrose) 2) solution alcohol + DMSO. Was centrifuged, and the supernatant collected for absorbance analysis. The results obtained correlating the absorbance with the supernatant to the absorbance of the default concentration. A study of microbial metabolism by growth curve was carried out to justify the result. RESULTS: The incorporation of curcumin in syrup is superior to alcohol/DMSO solution by microorganisms. Curcumin incorporation by S. mutans, S. pyogenes, isolated bacteria was 24, 26, 27 % in syrup and 10, 13, 5 % in alcohol/DMSO, respectively. Also, the presence of carbohydrate in a solution can activate the bacterial metabolism, getting better uptake results and photodynamic inactivation to natural curcumin and DMC. Such finds care optimizes the use of curcumin without complications generated by the solvent.

Surveillance endoscopy after tracheostomy placement in children: Findings and interventions.

OBJECTIVES/HYPOTHESIS: The Seattle Children's Hospital implemented the Trach Safe Initiative to improve airway safety in tracheostomy-dependent children (TDC). A key tenet of this initiative is surveillance endoscopy. The objectives of this study were to describe the prevalence of abnormal airway changes in TDC, identify risk factors for these changes, and describe the frequency of airway interventions. STUDY DESIGN: Retrospective case series. METHODS: This is a review of children 0 to 21 years old who underwent tracheostomy and surveillance endoscopy from February 1, 2014 to January 1, 2019. Descriptive statistics were used to report the prevalence of abnormal airway changes and interventions following tracheostomy. Pearson χ2 tests and logistic regression were used to identify risk factors for the development of abnormal changes. RESULTS: There were 127 children identified. The median time from tracheostomy to initial surveillance endoscopy was 1.6 months (interquartile range = 1.3-2.4 months). At initial endoscopy, 86.6% of patients had at least one abnormal airway finding. The most common findings were subglottic edema/stenosis (57.3%), glottic edema (37.3%), and suprastomal granulation tissue (31.8%). Prematurity and a history of failed extubations were significantly associated with abnormal findings on endoscopy (odds ratio [OR] = 7.2, P = .01 and OR = 4.1, P = .03, respectively). Of those with abnormal findings, 32.7% underwent an intervention to improve airway patency and safety. The most common interventions performed were suprastomal granuloma excision (44.4%), steroid injection (22.2%), and balloon dilation of the glottis or subglottis (19.4%). CONCLUSIONS: The prevalence of early abnormal airway changes in TDC is high, particularly in young children with a history of prematurity and failed extubation. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1327-1332, 2020.

Photodynamic inactivation for in vitro decontamination of Staphylococcus aureus in whole blood.

BACKGROUND: Blood can be the target of microbial cells in the human body. Erythrocytes, platelets, and plasma concentrates in blood bags used in hemotherapy for blood transfusion are contamination targets, which can trigger serious diseases in blood. These infections can cause septicemia that can lead to death if not recognized rapidly and treated adequately. The aim of this study was to evaluate the photodynamic inactivation in the in vitro decontamination of Staphylococcus aureus in whole blood, erythrocytes and platelet-rich plasma. METHODS: Photodynamic inactivation using light doses of 10, 15 and 30 J/cm2 at 630 nm and an hematoporphyrin-derivative photosensitizer (Photogem®) solutions at 25 and 50 µg/mL were evaluated. Toxicity of treatment was determined by hemolysis and cell viability assays. RESULTS: The S. aureus reduction in phosphate buffered saline (PBS), whole blood, erythrocytes and platelet-rich plasma at 15 J/cm2 and 50 µg/mL were 7.2, 1.0, 1.3 and 0.4 log CFU/mL, respectively. Quantitative and qualitative analyses were performed in whole blood samples, and Photogem® showed a low risk of hemolysis (10.7%) in whole blood. However, 100% of erythrocytes suffered hemolysis in the absence of plasma. The cell viability assay showed 13.9% of apoptosis in erythrocytes, but normal platelet viability. CONCLUSION: S. aureus inactivation of whole blood samples using 50 µg/mL Photogem® and 15 J/cm2 resulted in better outcomes, providing promising indications for treatment of bacterial contamination of blood, and in this work, alternative possibilities to apply the technique for blood decontamination are discussed.

Relationship Between Esophageal Abnormalities on Fluoroscopic Esophagram and Pulmonary Function Testing in Juvenile Systemic Sclerosis.

OBJECTIVE: Juvenile systemic sclerosis (SSc) is a disabling autoimmune condition that affects multiple organs in addition to skin, notably the gastrointestinal and pulmonary systems. The relationship between esophageal abnormalities and pulmonary disease in juvenile SSc is not well understood. We describe associations between radiologic esophageal abnormalities and pulmonary function. METHODS: Clinical and radiographic data of children ages >18 years who fulfilled the 2007 Pediatric Rheumatology Provisional Classification Criteria for juvenile SSc between 1994 and 2016 were reviewed. Fluoroscopic upper gastrointestinal (UGI) studies, high-resolution computed tomography (HRCT), and pulmonary function tests (PFTs) within 12 months of presentation to Seattle Children's Hospital were extracted. RESULTS: Twenty-one children with juvenile SSc (67% female, ages 8-17 years) were studied. Esophageal abnormalities, defined as abnormal esophageal peristalsis and/or bolus clearance, were found in 12 patients. Abnormal esophagus on UGI tests was not associated with gastrointestinal or pulmonary symptoms, disease duration, use of medications (proton pump inhibitor or immunosuppressant), or specific autoantibodies. Compared with patients with a normal esophagus on UGI tests, children with an abnormal esophagus had decreased PFTs: mean forced expiratory volume in 1 second 96% versus 78% (P = 0.03), forced vital capacity 94% versus 76% (P = 0.02), and vital capacity 95% versus 76% (P = 0.02). Children with an abnormal esophagus on UGI tests had a larger mean esophageal diameter on HRCT (14.6 mm compared to 8.5 mm; P < 0.01). CONCLUSION: There was an association between esophageal and pulmonary disease in children with juvenile SSc. Esophageal findings on UGI tests or HRCT, despite lack of symptoms, should raise concern for esophageal dysfunction and prompt heightened surveillance for concurrent lung disease.

A pilot study assessing clinic value in pediatric pharyngeal dysphagia: The OPPS/cost method.

OBJECTIVES/HYPOTHESIS: Given the costs of healthcare, capitation, and desires for quality improvement (QI), there is a need to better assess healthcare value. Time-driven activity-based costing and the Quadruple Aim have evaluated value by assessing health outcomes and provider experiences relative to costs. The proposed OPPS/Cost method expands on this to examine value for aerodigestive clinic treatment of pediatric persistent pharyngeal dysphagia: O + P1 + P2 + S/Cost (O = objective health [video-fluoroscopic swallow study results], P1 = patient/family experience [Consumer Assessment of Healthcare Providers and Systems], P2 = provider experience [Copenhagen Burnout Inventory {CBI}], S = subjective health [Feeding/Swallowing-Impact Survey], C = cost [time-driven activity-based costing]). STUDY DESIGN: Use of QI time data, surveys, and retrospective chart review for 56 patient encounters. METHODS: Staff interviews were used to develop process maps, and monetary values were assigned to activities. OPPS/Cost outcomes were normalized amongst variables, and composite values were calculated. Comparisons were made using a Student t test for pre- and postclinic relocation over a 14-month period. RESULTS: Time reductions were check-in (13 minutes/patient), rooming (21 minutes/patient), and providers (4 minutes/patient). Patient in-room wait time increased (4 minutes/patient). The CBI identified burnout as an area for improvement. OPPS/Cost composite values increased by 14%, with a 1.7% cost reduction, improvement in objective and subjective health outcomes of 47.4% (P < .05) and 7.3%, respectively, and stable patient/family experience. CONCLUSIONS: OPPS/Cost is feasible in an interdisciplinary clinic and helped evaluate value during a clinic relocation. The QI opportunities identified are indicative of the potential of OPPS/Cost. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1527-1532, 2019.

Impact of National Institutes of Health Gastrointestinal PROMIS Measures in Clinical Practice: Results of a Multicenter Controlled Trial.

OBJECTIVES: The National Institutes of Health (NIH) created the Patient Reported Outcomes Measurement Information System (PROMIS) to allow efficient, online measurement of patient-reported outcomes (PROs), but it remains untested whether PROMIS improves outcomes. Here, we aimed to compare the impact of gastrointestinal (GI) PROMIS measures vs. usual care on patient outcomes. METHODS: We performed a pragmatic clinical trial with an off-on study design alternating weekly between intervention (GI PROMIS) and control arms at one Veterans Affairs and three university-affiliated specialty clinics. Adults with GI symptoms were eligible. Intervention patients completed GI PROMIS symptom questionnaires on an e-portal 1 week before their visit; PROs were available for review by patients and their providers before and during the clinic visit. Usual care patients were managed according to customary practices. Our primary outcome was patient satisfaction as determined by the Consumer Assessment of Healthcare Providers and Systems questionnaire. Secondary outcomes included provider interpersonal skills (Doctors' Interpersonal Skills Questionnaire (DISQ)) and shared decision-making (9-item Shared Decision Making Questionnaire (SDM-Q-9)). RESULTS: There were 217 and 154 patients in the GI PROMIS and control arms, respectively. Patient satisfaction was similar between groups (P>0.05). Intervention patients had similar assessments of their providers' interpersonal skills (DISQ 89.4±11.7 vs. 89.8±16.0, P=0.79) and shared decision-making (SDM-Q-9 79.3±12.4 vs. 79.0±22.0, P=0.85) vs. CONCLUSIONS: This is the first controlled trial examining the impact of NIH PROMIS in clinical practice. One-time use of GI PROMIS did not improve patient satisfaction or assessment of provider interpersonal skills and shared decision-making. Future studies examining how to optimize PROs in clinical practice are encouraged before widespread adoption.

Six-session caregiver psychoeducation on bipolar disorder: Does it bring benefits to caregivers?

AIM: To evaluate the impact of psychoeducational intervention on the levels of burden, of self-esteem and quality of life in caregivers of patients diagnosed with Bipolar Disorders. METHOD: In this randomized clinical trial, changes in degree of burden, levels of self-esteem and quality of life were evaluated. Caregivers could participate in the group of psychoeducation (six sessions) or usual treatment (without psychoeducation following a manual). RESULTS: There were no significant differences regarding levels of objective burden between groups. Both groups presented improvement in subjective burden scores throughout the interventions. Objective burden scores showed significant reduction in the usual treatment group (p = .003) and a trend toward decrease in the psychoeducational intervention (p = .081). There are no differences regarding improvement in perceived self-esteem and quality of life when comparing means between the groups with and without intervention. CONCLUSION: A six-session caregiver psychoeducational intervention on bipolar disorder did not bring benefits to caregiver's health. A longer longitudinal follow-up study would be crucial to see whether there were differences in degree of burden, perceived self-esteem and quality of life over time in caregivers.

Computer versus physician identification of gastrointestinal alarm features.

OBJECTIVE: It is important for clinicians to inquire about "alarm features" as it may identify those at risk for organic disease and who require additional diagnostic workup. We developed a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS) that systematically collects patient gastrointestinal (GI) symptoms and alarm features, and then "translates" the information into a history of present illness (HPI). Our study's objective was to compare the number of alarms documented by physicians during usual care vs. that collected by AEGIS. METHODS: We performed a cross-sectional study with a paired sample design among patients visiting adult GI clinics. Participants first received usual care by their physicians and then completed AEGIS. Each individual thus contributed both a physician-documented and computer-generated HPI. Blinded physician reviewers enumerated the positive alarm features (hematochezia, melena, hematemesis, unintentional weight loss, decreased appetite, and fevers) mentioned in each HPI. We compared the number of documented alarms within patient using the Wilcoxon signed-rank test. RESULTS: Seventy-five patients had both physician and AEGIS HPIs. AEGIS identified more patients with positive alarm features compared to physicians (53% vs. 27%; p<.001). AEGIS also documented more positive alarms (median 1, interquartile range [IQR] 0-2) vs. physicians (median 0, IQR 0-1; p<.001). Moreover, clinicians documented only 30% of the positive alarms self-reported by patients through AEGIS. CONCLUSIONS: Physicians documented less than one-third of red flags reported by patients through a computer algorithm. These data indicate that physicians may under report alarm features and that computerized "checklists" could complement standard HPIs to bolster clinical care.