Understanding Patient Utilization Patterns of Cochlear Implant Processors.

OBJECTIVE: To evaluate the extent of benefit the second processor provides and to better understand utilization patterns regarding cochlear implant (CI) sound processors. BACKGROUND: Institutional contracts determine the external CI sound processor hardware that a patient is eligible for. Despite the high prevalence of CI worldwide, there is a paucity in the literature regarding patient preferences and how patients utilize provided external hardware. METHODS: A close-ended, multiple-choice survey was mailed to all patients over the age of 18 years who underwent CI between 2016 to 2020 at a tertiary academic medical center. Patients who received their CI hardware prior to 2018 were provided 2 processors, whereas those who received their hardware in 2018 or later were provided 1 processor. RESULTS: A total of 100/263 surveys were returned for a response rate of 38.0%. Of the cohort with 1 processor, 31.3% experienced a period without a functioning processor and access to sound compared to 5.6% of the cohort with 2 processors (P = -.003). Of the cohort with 2 processors, 24.3% noted that they often or always utilize their second processor. When asked how important having a second processor was, 62.9% of the 2-processor group responded that it was very important (P = .001). The most common reason for utilizing the second processor was a damaged primary processor. Patients who received 2 processors had a significantly lower number of postoperative audiology clinic visits for device troubleshooting (P < .001). CONCLUSION: Patients who have 2 CI external processors identify this as being very important to them and experience significantly less time without access to sound due to lack of a functioning processor. As institutional contracts often dictate whether a patient will receive 1 or 2 sound processors with their CI hardware, it is important to understand patient preferences and utilization patterns in order to guide patient-centric policies.

Body image and depression in endometriosis: Examining self-esteem and rumination as mediators.

Endometriosis is a chronic systemic disease affecting 1 in 10 people assigned female at birth, that can result in appearance-based and functional bodily changes which can negatively impact body image. Empirical evidence supports the body dissatisfaction-driven hypothesis that negative body image leads to greater depressive symptoms; but potential underlying mechanisms are under-researched. This prospective study investigated the mediating role of two theoretically-derived intervening factors, self-esteem and rumination, in individuals living with endometriosis who typically report high rates of body image concerns and depressive symptoms. Initially, 996 participants completed the first online survey (T0) assessing demographic, medical and psychological factors. Of these, 451 completed surveys at 1-month (T1) and 2-months (T2) follow-up assessing self-esteem, rumination and depression. Bootstrapped analyses with full-information maximum likelihood estimation indicated that poor body image (T0) predicted greater depressive symptoms over time (T2). Self-esteem (T1), but not rumination (T1), mediated the body image-depression relationship. These results provide support for the body dissatisfaction-driven hypothesis and further identify that self-esteem is a key meditating factor. This highlights the importance of addressing self-esteem in body image focused interventions.

Symptoms of Survivors of Pediatric Hematopoietic Stem Cell Transplant by Age, Sex, and Transplant Type.

Purpose: The purpose of this study was to describe symptoms experienced by survivors of pediatric hematopoietic stem cell transplant (HSCT), and demographic and treatment-factors associated with ongoing symptomology. Methods: Fifty pediatric survivors completed a cross-sectional pilot study. Questionnaires were administered online via REDCap to assess symptoms experienced in the last week. Survivors also consented to a medical record chart review. Results: Survivors were on average 5.4 years post-HSCT (range 1.1 to 9 years), male (58%), and Caucasian (80%) who received an allogeneic HSCT (92%). The most commonly reported symptoms were difficulty concentrating (42.5%), pain (38%), worry (38%), nervousness (37.5%), and lack of energy/fatigue (34%). Survivors reported up to 14 symptoms, with 90% of the sample experiencing at least one symptom in the previous week. Average number of symptoms varied by age group between 2.1 (8-9 years) and 6.8 (18 and older). Age and female gender were associated with higher levels of fatigue. Conclusions: The majority of survivors experienced at least one symptom in the previous week. Neuropsychological symptoms and pain endure well into survivorship that can influence outcomes such as function and health-related quality of life (HRQOL). Research is needed on biological mechanisms of ongoing symptomology, effective interventions to prevent or mitigate symptoms, and the impact of symptoms on patient outcomes including daily functioning and HRQOL. Implications Survivors of pediatric HSCT continued to experience symptoms for up to nine years. Survivors should be frequently screened for symptoms, as symptoms may affect function, learning/employment outcomes, and HRQOL.

SARS-CoV-2 transmission and control in a hospital setting: an individual-based modelling study.

Development of strategies for mitigating the severity of COVID-19 is now a top public health priority. We sought to assess strategies for mitigating the COVID-19 outbreak in a hospital setting via the use of non-pharmaceutical interventions. We developed an individual-based model for COVID-19 transmission in a hospital setting. We calibrated the model using data of a COVID-19 outbreak in a hospital unit in Wuhan. The calibrated model was used to simulate different intervention scenarios and estimate the impact of different interventions on outbreak size and workday loss. The use of high-efficacy facial masks was shown to be able to reduce infection cases and workday loss by 80% (90% credible interval (CrI): 73.1-85.7%) and 87% (CrI: 80.0-92.5%), respectively. The use of social distancing alone, through reduced contacts between healthcare workers, had a marginal impact on the outbreak. Our results also indicated that a quarantine policy should be coupled with other interventions to achieve its effect. The effectiveness of all these interventions was shown to increase with their early implementation. Our analysis shows that a COVID-19 outbreak in a hospital's non-COVID-19 unit can be controlled or mitigated by the use of existing non-pharmaceutical measures.

"This Is How Hard It Is". Family Experience of Hospital-to-Home Transition with a Tracheostomy.

Rationale: Expansion of chronic ventilation options and shared decision-making have contributed to an increasing population of technology-dependent children. One particularly vulnerable group is children with tracheostomy who depend on technology for basic respiratory functions. Chronic critical care is now provided in the homecare setting with implications for family caregivers.Objectives: This study explores the experience of family caregivers of children and young adults with a tracheostomy during the transition from hospital to home care. We sought to identify the specific unmet needs of families to direct future interventions.Methods: We recruited a convenience sample of families from an established home ventilation program to participate in semistructured interviews. Sessions were conducted in person or via teleconference. A grounded-theory qualitative analysis was performed.Results: Between March 2017 and October 2018, we interviewed 13 individuals representing 12 families of children and/or young adults with tracheostomy. Patients ranged in age from 9 months to 28 years, had a tracheostomy for 8 months to 18 years, and represented a variety of underlying diagnoses. Five key themes emerged: 1) navigating home nursing; 2) care coordination and durable medical equipment (DME) impediments; 3) learning as a process; 4) managing emergencies; and 5) setting expectations.Conclusions: Our findings support the need for family-centered discharge processes including coordination of care and teaching focused on emergency preparedness.

Risk factors of SARS-CoV-2 infection in healthcare workers: a retrospective study of a nosocomial outbreak.

BACKGROUND: Healthcare workers (HCWs) are at the forefront of fighting against the COVID-19 pandemic. However, they are at high risk of acquiring the pathogen from infected patients and transmitting to other HCWs. We aimed to investigate risk factors for nosocomial COVID-19 infection among HCWs in a non-COVID-19 hospital yard. METHODS: Retrospective data collection on demographics, lifestyles, contact status with infected subjects for 118 HCWs (including 12 COVID-19 HCWs) at Union Hospital of Wuhan, China. Sleep quality and working pressure were evaluated by the Pittsburgh Sleep Quality Index (PSQI) and The Nurse Stress Index (NSI), respectively. The follow-up duration was from Dec 25, 2019, to Feb 15, 2020. RESULTS: A high proportion of COVID-19 HCWs had engaged in night shift-work (75.0% vs. 40.6%) and felt working under pressure (66.7% vs. 32.1%) than uninfected HCWs. SARS-CoV-2 infected HCWs had significantly higher scores of PSQI and NSI than uninfected HCWs (P < 0.001). Specifically, scores of 5 factors (sleep quality, sleep time, sleep efficiency, sleep disorder, and daytime dysfunction) in PSQI were higher among infected HCWs. For NSI, its 5 subscales (nursing profession and work, workload and time allocation, working environment and resources, patient care, management and interpersonal relations) were all higher in infected than uninfected nurse. Furthermore, total scores of PSQI (HR = 2.97, 95%CI = 1.86-4.76; P <0.001) and NSI (HR = 4.67, 95%CI = 1.42-15.45; P = 0.011) were both positively associated with the risk of SARS-CoV-2 infection. CONCLUSION: Our analysis shows that poor sleep quality and higher working pressure may increase the risk of nosocomial SARS-CoV-2 infection among HCWs.

Modeling the effect of antibiotic exposure on the transmission of methicillin-resistant Staphylococcus aureus in hospitals with environmental contamination.

In this paper both deterministic and stochastic models are developed to explore the roles that antibiotic exposure and environmental contamination play in the spread of antibiotic-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA), in hospitals. Uncolonized patients without or with antibiotic exposure, colonized patients without or with antibiotic exposure, uncontaminated or contaminated healthcare workers, and free-living bacteria are included in the models. Under the assumption that there is no admission of the colonized patients, the basic reproduction number R0 is calculated. It is shown that when R0 < 1, the infection-free equilibrium is globally asymptotically stable; when R0 > 1, the infection is uniformly persistent. Numerical simulations and sensitivity analysis show that environmental cleaning is a critical intervention, and hospitals should use antibiotics properly and as little as possible. The rapid and efficient treatment of colonized patients, especially those with antibiotic exposure, is key in controlling MRSA infections. Screening and isolating colonized patients at admission, and improving compliance with hand hygiene are also important control strategies.

A role for the medial temporal lobe subsystem in guiding prosociality: the effect of episodic processes on willingness to help others.

Why are we willing to help others? Recent behavioral work on episodic processes (i.e. the ability to represent an event that is specific in time and place) suggests that imagining and remembering scenes of helping a person in need increases intentions to help. Here, we provide insight into the cognitive and neural mechanisms that enhance prosocial intentions via episodic simulation and memory. In Experiment 1, we scanned participants using functional neuroimaging as they imagined and remembered helping episodes, and completed non-episodic control conditions accounting for exposure to the story of need and conceptual priming of helping. Analyses revealed that activity in the medial temporal lobe (MTL) subsystem, as well as the right temporoparietal junction (RTPJ) predicted the effect of conditions on the strength of prosocial intentions. In Experiment 2, we used transcranial magnetic stimulation to disrupt activity in the RTPJ, and better isolate the contribution of MTL subsystem to prosocial intentions. The effect of conditions on willingness to help remained even when activity in the RTPJ was disrupted, suggesting that activity in the MTL subsystem may primarily support this prosocial effect. It seems our willingness to help may be guided, in part, by how easily we can construct imagined and remembered helping episodes.

A cluster of carbapenemase-producing Enterobacter cloacae complex ST171 at a tertiary care center demonstrating an ongoing regional threat.

BACKGROUND: In Minnesota and North Dakota, a clonal strain of blaKPC-3-producing Enterobacter cloacae complex has been reported with increasing frequency. METHODS: Between July 2015 and February 2016, 13 carbapenem-resistant E. cloacae complex isolates were identified at our institution. Five blaKPC-positive isolates were identified by polymerase chain reaction and underwent pulsed-field gel electrophoresis and whole genome sequencing. Medical records of these patients were reviewed. RESULTS: All 5 case-isolates belonged to sequence type 171 and were blaKPC-3-positive. Three pulsed-field gel electrophoresis patterns with >90% similarity were identified in the 5 case-isolates. We identified overlaps in time and location between case patients. Plasmid types and resistance genes were nearly identical between the isolates. Whole genome sequencing showed isolates A, B, and D to be closely related with <10 core single-nucleotide polymorphisms differences. Isolates C and E were also closely related to each other, but more distantly to A, B, and D; all belonged to the clonal lineage of the major circulating E. cloacae complex strain in Minnesota and North Dakota. Despite having overlapping hospital stays, isolates for patients C and D were not identical. CONCLUSIONS: Isolates A and D were nearly identical, indicating possible transmission during hospitalization. Transmission of the other isolates may have occurred elsewhere. This report highlights the importance of using both epidemiologic and molecular data to track the spread of carbapenemase-producers.

Effect of stimulant medication use by children with ADHD on heart rate and perceived exertion.

The effect of stimulant medication use by children with attention deficit/hyperactivity disorder (ADHD) on the rating of perceived exertion (RPE)-heart rate (HR) relationship was examined. Children with ADHD (n=20; 11.3±1.8 yrs) and children without ADHD (n=25; 11.2±2.1 yrs) were studied. Children with ADHD were examined while on their usual dose of medication on the day of study. HR and RPE, using the OMNI RPE scale, were assessed during a graded exercise to peak voluntary effort. The RPE-HR relationship was determined individually and the intercept and slope responses were compared between groups. The intercept was 132.4±19.5 bpm for children with ADHD and 120.6±15.7 bpm for children without ADHD. The slope was 7.3±1.9 bpm/RPE for the children with ADHD and 8.1±1.6 bpm/ RPE for the children without ADHD. For the group with ADHD the intercept and slope values fell outside of the 95% CI observed in the control group. The altered relationship between RPE and HR with stimulant medication use in children with ADHD has practical implications with respect to the use of HR and RPE to monitor exercise intensity.

Efficacy of infection control interventions in reducing the spread of multidrug-resistant organisms in the hospital setting.

Multidrug-resistant organisms (MDRO) continue to spread in hospitals globally, but the population-level impact of recommended preventive strategies and the relative benefit of individual strategies targeting all MDRO in the hospital setting are unclear. To explore the dynamics of MDRO transmission in the hospital, we develop a model extending data from clinical individual-level studies to quantify the impact of hand hygiene, contact precautions, reducing antimicrobial exposure and screening surveillance cultures in decreasing the prevalence of MDRO colonization and infection. The effect of an ongoing increase in the influx of patients colonized with MDRO into the hospital setting is also quantified. We find that most recommended strategies have substantial effect in decreasing the prevalence of MDRO over time. However, screening for asymptomatic MDRO colonization among patients who are not receiving antimicrobials is of minimal value in reducing the spread of MDRO.

Efficacy of concurrent application of chlorhexidine gluconate and povidone iodine against six nosocomial pathogens.

BACKGROUND: Chlorhexidine gluconate (CHG) and povidone iodine (PI) are rarely used concurrently despite a lack of evidence regarding functional incompatibility of these agents. METHODS: CHG and PI, alone and combined, were evaluated against Staphylococcus aureus (methicillin-susceptible S aureus [MSSA] and methicillin-resistant S aureus [MRSA]), Staphylococcus epidermidis (MRSE), Acinetobacter baumannii, Pseudomonas aeruginosa, and Escherichia coli using checkerboard microbroth dilution techniques. Minimum bactericidal concentration (MBC) was the concentration (percent wt/vol) that reduced bacterial burden ≥ 5-log(10) colony-forming units/mL at 2 hours when compared with bacterial densities in growth controls. Fractional bactericidal concentration indexes (FBCIs) were calculated to determine CHG and PI compatibility. Additionally, tissue plugs from freshly excised porcine vaginal mucosa were infected with S aureus (MSSA), treated for 2 hours with CHG 3%, PI 5%, or CHG 3% and PI 5% combined and then viable bacteria on the tissue plugs enumerated. RESULTS: In broth, CHG demonstrated dose-dependent bactericidal activity, whereas PI activity was all-or-none. All isolates studied were similarly susceptible to CHG (MBCs: 0.0078% ± 0.0019%, 0.0069% ± 0.0026%, 0.0024% ± 0.0005%, 0.0024% ± 0.0005%, 0.0059% ± 0.0%, and 0.0029% ± 0.0%, respectively). The MBCs of PI were identical (0.625%) for all isolates. Overall, FBCI calculations showed indifference. Treatment of MSSA-infected porcine tissue for 2 hours demonstrated that the CHG-PI combination was superior to either antiseptic alone. CONCLUSION: FBCIs, determined in broth culture, indicate that combining CHG and PI had no negative impact on antisepsis. Moreover, data from an ex vivo porcine mucosal infection model suggest a potential benefit when combining the 2 antiseptic agents.

Modeling species-specific diacylglycerol dynamics in the RAW 264.7 macrophage.

A mathematical model of the G protein signaling pathway in RAW 264.7 macrophages downstream of P2Y(6) receptors activated by the ubiquitous signaling nucleotide uridine 5'-diphosphate is developed. The model, which is based on time-course measurements of inositol trisphosphate, cytosolic calcium, and diacylglycerol, focuses particularly on differential dynamics of multiple chemical species of diacylglycerol. When using the canonical pathway representation, the model predicted that key interactions were missing from the current network structure. Indeed, the model suggested that accurate depiction of experimental observations required an additional branch to the signaling pathway. An intracellular pool of diacylglycerol is immediately phosphorylated upon stimulation of an extracellular receptor for uridine 5'-diphosphate and subsequently used to aid replenishment of phosphatidylinositol. As a result of sensitivity analysis of the model parameters, key predictions can be made regarding which of these parameters are the most sensitive to perturbations and are therefore most responsible for output uncertainty.

Competition of hospital-acquired and community-acquired methicillin-resistant Staphylococcus aureus strains in hospitals.

Recently, we [E.M.C. D'Agata, G.F. Webb, M.A. Horn, R.C. Moellering Jr., and S. Ruan, Modellingthe invasion of community-acquired methicillin-resistant Staphylococcus aureus into the hospital setting, Clin. Infect. Dis. 48 (2009), pp. 274­284] proposed a deterministic mathematical model to characterize the factors contributing to the replacement of hospital-acquired methicillin-resistant Staphylococcus aureus(HA-MRSA) with the community-acquired MRSA (CA-MRSA) and to quantify the effectiveness of interventionsaimed at limiting the spread of CA-MRSA in the hospital setting. Numerical simulations of the model strongly suggest that CA-MRSA will become the dominant MRSA strain in the hospital setting. In this companion paper, we provide steady-state analysis and more numerical simulations of the model. It is shown that when no colonized or infected patients enter the hospital, competitive exclusion of HA-MRSA by CA-MRSA will occur with increased severity of CA-MRSA infections resulting in longer hospitalizations and a larger in-hospital reservoir of CA-MRSA. Improving compliance with hand hygiene and decolonization of CA-MRSA carriers are effective control strategies.

Mathematical modelling and analysis of cellular signalling in macrophages.

Cell signalling pathways play a crucial role in proper cell development and behaviour, with implications to survival, chemotaxis, proliferation, and even programmed cell death known as apoptosis. In this article, we outline a mathematical model of the G-protein signalling pathway in a particular cell line of macrophages, focusing on activation of a particular G-protein-coupled receptor, P2Y(6). The model is based on the kinetics of P2Y(6) surface receptors, inositol trisphosphate, cytosolic calcium, and differential dynamics of multiple species of diacylglycerol. Insight into the dynamics of the system is given through recently available experimental results and incorporated into the model. Mathematical analysis of the model, including establishment of global existence, uniqueness, positivity, and boundedness of solutions, and global stability of a unique steady-state solution is discussed.

Modeling the invasion of community-acquired methicillin-resistant Staphylococcus aureus into hospitals.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) has traditionally been associated with infections in hospitals. Recently, a new strain of MRSA has emerged and rapidly spread in the community, causing serious infections among young, healthy individuals. Preliminary reports imply that a particular clone (USA300) of a community-acquired MRSA (CA-MRSA) strain is infiltrating hospitals and replacing the traditional hospital-acquired MRSA strains. If true, this event would have serious consequences, because CA-MRSA infections in hospitals would occur among a more debilitated, older patient population. METHODS: A deterministic mathematical model was developed to characterize the factors contributing to the replacement of hospital-acquired MRSA with CA-MRSA and to quantify the effectiveness of interventions aimed at limiting the spread of CA-MRSA in health care settings. RESULTS: The model strongly suggests that CA-MRSA will become the dominant MRSA strain in hospitals and health care facilities. This reversal of dominant strain will occur as a result of the documented expanding community reservoir and increasing influx into the hospital of individuals who harbor CA-MRSA. Competitive exclusion of hospital-acquired MRSA by CA-MRSA will occur, with increased severity of CA-MRSA infections resulting in longer hospitalizations and a larger in-hospital reservoir of CA-MRSA. CONCLUSIONS: Improving compliance with hand hygiene and screening for and decolonization of CA-MRSA carriers are effective strategies. However, hand hygiene has the greatest return of benefits and, if compliance is optimized, other strategies may have minimal added benefit.

Simvastatin inhibits Staphylococcus aureus host cell invasion through modulation of isoprenoid intermediates.

Patients on a statin regimen have a decreased risk of death due to bacterial sepsis. We have found that protection by simvastatin includes the inhibition of host cell invasion by Staphylococcus aureus, the most common etiologic agent of sepsis. Inhibition was due in part to depletion of isoprenoid intermediates within the cholesterol biosynthesis pathway and led to the cytosolic accumulation of the small GTPases CDC42, Rac, and RhoB. Actin stress fiber disassembly required for host invasion was attenuated by simvastatin and by the inhibition of phosphoinositide 3-kinase (PI3K) activity. PI3K relies on coupling to prenylated proteins, such as this subset of small GTPases, for access to membrane-bound phosphoinositide to mediate stress fiber disassembly. Therefore, we examined whether simvastatin restricts PI3K cellular localization. In response to simvastatin, the PI3K isoform p85, coupled to these small-GTPases, was sequestered within the cytosol. From these findings, we propose a mechanism whereby simvastatin restricts p85 localization, inhibiting the actin dynamics required for bacterial endocytosis. This approach may provide the basis for protection at the level of the host in invasive infections by S. aureus.

Voluntary dehydration in runners despite favorable conditions for fluid intake.

This study investigated the relationship between runners' perceptions of fluid needs and drinking behavior under conditions of compensable heat stress (ambient temperature = 20.5 +/- 0.7 degrees C, 68.9 degrees F; relative humidity = 76.6%). Eighteen experienced runners (15 men, 40.5 +/- 2.5 y, and 3 women, 42 +/- 2.3 y) were given ad libitum access to a sports drink (6% carbohydrate-electrolyte solution) at Miles 2, 4, 6, and 8. After the run (75.5 +/- 8.0 min), subjects completed questionnaires that required them to estimate their individual fluid intake and sweat loss. Dehydration averaged 1.9% +/- 0.8% of initial body weight (a mean sweat loss of 21.6 +/- 5.1 mL.kg-1.h-1). Subjects replaced only 30.5% +/- 18.1% of sweat loss and underestimated their sweat loss by 42.5% +/- 36.6% (P

Smaller mandibular size in infants with a history of an apparent life-threatening event.

OBJECTIVES: To examine small mandibular size and preference for a hand-to-chin posture as salient characteristics in infants with a history of an apparent life-threatening event (ALTE). STUDY DESIGN: This was a prospective case-control study of term infants, from birth to 6 months of age, admitted post-ALTE and matched 1:2 with healthy control infants (age within 2 weeks and weight within 0.5 kg). Infants with confirmed gastroesophageal reflux and congenital anomalies, including severe micrognathia, were excluded. RESULTS: Infants with a history of an ALTE (n = 25) were matched to 47 healthy controls. Infants with a history of an ALTE had mandibular indices (larger index indicates a smaller mandible) that were 3.8 mm greater on the left side (95% CI: 2.0-5.6, P < .001) and 4.2 mm greater on the right side (95% CI: 2.7-5.6, P < .001) adjusting for length and non-white race. Controlling for matching and length, a 1-mm increase in the average mandibular index increased the odds of an ALTE by 62% (OR = 1.62, 95% CI: 1.22-2.44, P < .001). CONCLUSIONS: Smaller mandibular size was associated with ALTE, suggesting airway obstruction as a potential cause of ALTE. The association of this characteristic with ALTE also offers the potential for prospective quantification of ALTE risk.

The Methodist Hospital CCU: a Beacon unit of excellence.

This article features the Coronary Care Unit of The Methodist Hospital of Houston, Texas. This unit was one of the first Beacon Critical Care Units recognized by the American Association of Critical Care Nurses. This article focuses on how to achieve this award. The Coronary Care Unit nursing infrastructure is described, and specific unit examples are included.