Implementation of a Colorectal Surgical Site Infection Prevention Bundle and Checklist: A Quality Improvement Project.

After noting an elevated surgical site infection rate in 2019 associated with colorectal surgeries, leaders at two Central Virginia health system hospitals convened an interdisciplinary team to audit current practices and research infection prevention strategies. After identifying a lack of standardization in care processes for colorectal surgery patients and reviewing the literature on colorectal bundles, the team created a bundle focusing on the use of antibiotics, chlorhexidine gluconate wipes or baths, separate closing instrument trays, nasal decolonization, bowel preparation, and maintaining patient normothermia. After synthesis and stakeholder input, the team implemented the colorectal bundle along with a checklist for all users to complete to ensure compliance and standardization of practice and for auditing purposes. Implementation results were positive: the total number of colorectal infections decreased from nine in 2020 to three in 2021. Education was critical to securing staff member engagement for successful implementation of and compliance with the bundle.

Photovoltaics at multi-terawatt scale: Waiting is not an option.

25% annual PV growth is possible over the next decade.

Hierarchical approach to evaluating storage requirements for renewable-energy-driven grids.

Energy storage can accelerate the decarbonization of the electrical grid. As useful energy storage technologies are developed, investors and manufacturers want to determine the needs for storage in a wide range of scenarios. In this study, we introduce a strategy for identifying the types of storage that will be most valuable to the grid given specific generation and load profiles. This method estimates the annual minimum number of cycles for each storage, how long each holds the charge, and charging and discharging rates for an idealized system, giving insight into tomorrow's complex systems. We demonstrate the proposed hierarchical approach and quantify how many fewer times wind-driven grids cycle the storage at night compared with solar-driven grids, as well as how winter-dominant wind generation and latitude-tilt solar may reduce the need for seasonal storage. Also, we quantify how higher discharging rates are required for energy storage products that cycle most frequently.

Seasonal challenges for a California renewable- energy-driven grid.

Currently, the most difficult time of year for California to supply the demanded electricity is around sunset on very hot summer days. As California uses more renewable electricity, that challenge may shift to any time of the year depending on the supply of electricity more than on the demand. We study various scenarios for applying a 100% renewable energy grid using six years (2015-2020) of historical demand and scaled-up solar and wind generation to investigate the main function of the storage in affording adequate electricity supply at all times of the year. We identify the times of year that may be most challenging. We detect that, for a solar dominant generation profile, the ultimate challenge shifts from summer to winter. Furthermore, the critical time of the year may be shifted by one or two months depending on the amount and the mix of the renewable generation that will be built.

Influence of Spatial Planting Arrangement of Winter Rye Cover Crop on Corn Seedling Disease and Corn Productivity.

Despite numerous environmental benefits associated with cover crop (CC) use, some farmers are reluctant to include CCs in their production systems because of reported yield declines in corn. There are numerous potential reasons for this yield decline, including seedling disease. A winter rye CC can serve as a "green bridge" for corn seedling pathogens. We hypothesized that proximity of corn seedling roots to decaying rye CC roots contributes to corn seeding disease. An experimental field plot and an on-farm study were conducted over 2 years to evaluate growth, development, and disease severity of corn seedlings planted at various distances from decaying winter rye CC plants. The experimental field plot study was conducted in a no-till corn-soybean rotation with five replications of a winter rye CC treatment seeded as (i) no-CC control, (ii) broadcast, (iii) 19-cm drilled rows, and (iv) 76-cm drilled rows. The on-farm study was no-till corn-soybean rotation with four replications of a winter rye CC seeded as 38-cm drilled rows, 76-cm drilled rows, and no-CC control. The corn was planted on 76-cm rows shortly after rye was terminated. With multiple seeding arrangements of winter rye, corn was planted at different distances from winter rye. Corn radicle root rot severity and incidence, shoot height, shoot dry weight, corn height and chlorophyll at VT (tasseling), ear parameters, and yield were collected. Soil samples were taken in the corn row and the interrow at winter rye termination, corn planting, and corn growth stage V3 (three leaves with fully developed collars) to estimate the abundance of Pythium clade B members present in soil samples. Our results showed that increased distance between winter rye residue and corn reduced seedling disease and Pythium clade B populations in the radicles and soil and increased shoot dry weight, leaf chlorophyll, plant height, and yield. This suggests that physically distancing the corn crop from the winter rye CC is one way to reduce the negative effects of a winter rye CC on corn.

Seedling Disease of Corn Caused by Pythium Increases With Proximity of Rye.

Yield loss of corn following a winter rye cover crop (CC) has been associated with increases in seedling disease caused by Pythium spp. We hypothesized that physical separation between the CC and corn could reduce the risk of seedling disease, and benefit corn growth and development. In a growth chamber experiment, corn seedlings were planted at 0 cm and 8 to 10 cm from terminated winter rye plants. Root rot severity was assessed at crop development stage V2, and quantitative PCR was used to estimate the abundance of Pythium clade B and clade F members present in corn roots. Radicle and seminal root rot severity was numerically greater when seedlings were planted 0 cm from terminated rye plants compared with seedlings planted 8 to 10 cm away. Moreover, a greater abundance of Pythium clade B was detected in corn grown within the terminated winter rye compared with corn planted further away (P = 0.0003). No effect of distance between corn and winter rye was detected for Pythium clade F. These data contribute to our understanding of the effect of a winter rye cover crop on corn and will inform field trial management practices for farmers to reduce occasional yield loss of corn following a winter rye cover crop.

A preliminary study of the effects of individual patient-level feedback in outpatient substance abuse treatment programs.

The purpose of this study was to examine the effects of feedback provided to counselors on the outcomes of patients treated at community-based substance abuse treatment programs. A version of the Outcome Questionnaire (OQ-45), adapted to include drug and alcohol use, was administered to patients (N = 304) in 3 substance abuse treatment clinics. Phase I of the study consisted only of administration of the assessment instruments. Phase II consisted of providing feedback reports to counselors based on the adapted OQ-45 at every treatment session up to Session 12. Patients who were found to not be progressing at an expectable rate (i.e., "offtrack") were administered a questionnaire that was used as a second feedback report for counselors. For offtrack patients, feedback compared with no feedback led to significant linear reductions in alcohol use throughout treatment and also in OQ-45 total scores and drug use from the point of the second feedback instrument to Session 12. The effect for improving mental health functioning was evident at only 1 of the 3 clinics. These results suggest that a feedback system adapted to the treatment of substance use problems is a promising approach that should be tested in a larger randomized trial.

Combined medication and cognitive therapy for generalized anxiety disorder.

The current study assessed efficacy of combined cognitive behavioral therapy (CBT) and venlafaxine XR compared to venlafaxine XR alone in the treatment of generalized anxiety disorder (GAD) within settings where medication is typically offered as the treatment for this disorder. Patients with DSM-IV-diagnosed GAD who were recently enrolled in a long-term venlafaxine XR study were randomly offered (n=77), or not offered (n=40), the option of adding 12 sessions of CBT. Of those offered CBT, 33% (n=26) accepted and attended at least one treatment session. There were no differences between the combined treatment group and the medication only group on primary or secondary efficacy measures in any of the sample comparisons. Many patients who present in medical/psychopharmacology settings seeking treatment for GAD decline the opportunity to receive adjunctive treatment. Of those that receive CBT, there appears to be no additional benefit of combined treatment compared to venlafaxine XR alone.

The dependability of alliance assessments: the alliance-outcome correlation is larger than you might think.

OBJECTIVE: To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance-outcome relationship. METHOD: We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used. RESULTS: At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3-9 explained 14.7% of outcome variance. CONCLUSION: Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance-outcome relationship.

A generalizability theory analysis of group process ratings in the treatment of cocaine dependence.

Videotaped group drug counseling sessions were rated for alliance, self-disclosure, positive and negative feedback, group cohesion, and degree of participation of each group member. Interrater reliability was good to excellent for most measures. However, generalizability coefficients based on statistical models that included terms for patient, counselor, session, group, and rater revealed that some measures had inadequate dependability at the patient level if only two raters and two sessions were used to create patient-level scores. In contrast, good generalizability coefficients based on two raters and two sessions were obtained for alliance, non-positive learning statements received from counselor, participation variables, and self-disclosures about the past. The implications of the findings for the design of process-outcome studies are discussed.

Program, counselor, and patient variability in the alliance: a multilevel study of the alliance in relation to substance use outcomes.

We explored patient, therapist, and program variability in the alliance in relation to drug and alcohol use during treatment, and whether alliance mediates the relation of program characteristics to drug/alcohol use. Data (N = 1,613 patients) were drawn from a randomized clinical trial investigating the efficacy of an intervention that provided alliance and outcome feedback to 112 counselors across 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Program characteristics were measured using the Organization Readiness for Change scale. Using multilevel modeling, we found that alliance was related to both drug and alcohol use during the past week at the patient and program levels of analysis, but not the counselor level. Several program characteristics were related to average drug and alcohol use. The alliance was not a mediator of these relationships. Program variability in the alliance is important to the alliance-outcome relationship in the treatment of substance abuse. Better outcomes can be achieved by improving both organizational functioning and the patient-counselor alliance.

Multijunction solar cells for conversion of concentrated sunlight to electricity.

Solar-cell efficiencies have exceeded 40% in recent years. The keys to achieving these high efficiencies include: 1) use of multiple materials that span the solar spectrum, 2) growth of these materials with near-perfect quality by using epitaxial growth on single-crystal substrates, and 3) use of concentration. Growth of near-perfect semiconductor materials is possible when the lattice constants of the materials are matched or nearly matched to that of a single-crystal substrate. Multiple material combinations have now demonstrated efficiencies exceeding 40%, motivating incorporation of these cells into concentrator systems for electricity generation. The use of concentration confers several key advantages.

Multijunction solar cells for conversion of concentrated sunlight to electricity.

Solar-cell efficiencies have exceeded 40% in recent years. The keys to achieving these high efficiencies include: 1) use of multiple materials that span the solar spectrum, 2) growth of these materials with near-perfect quality by using epitaxial growth on single-crystal substrates, and 3) use of concentration. Growth of near-perfect semiconductor materials is possible when the lattice constants of the materials are matched or nearly matched to that of a single-crystal substrate. Multiple material combinations have now demonstrated efficiencies exceeding 40%, motivating incorporation of these cells into concentrator systems for electricity generation. The use of concentration confers several key advantages.

A randomized controlled study of a web-based performance improvement system for substance abuse treatment providers.

We report here the results of a randomized, controlled trial evaluating the efficacy of a semiautomated performance improvement system ("patient feedback") that enables real-time monitoring of patient outcomes in outpatient substance abuse treatment clinics. The study involved 118 clinicians working at 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Ten clinics received 12 weeks of the patient feedback performance improvement intervention, and 10 clinics received no intervention during the 12 weeks. More than 1,500 patients provided anonymous ratings of therapeutic alliance, treatment satisfaction, and drug/alcohol use. There was no evidence of an intervention effect on the primary drug and alcohol use scales. There was also no evidence of an intervention effect on secondary measures of therapeutic alliance. Clinician-rated measures of organizational functioning and job satisfaction also showed no intervention effect. Possible insights from these findings and alternative methods of utilizing feedback reports to enhance clinical outcomes are proposed.

Unique and common mechanisms of change across cognitive and dynamic psychotherapies.

The goal of this article was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. A pooled study database collected at the University of Pennsylvania Center for Psychotherapy Research, which includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders, was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy.

A pilot study of community-friendly manual-guided drug counseling.

Therapist training manuals that are more "community friendly" are needed to facilitate effectiveness testing and dissemination of treatments to community based setting. The aim of the current project was to create revised versions of individual drug counseling (IDC) and group drug counseling (GDC) treatment manuals for cocaine dependence and to conduct a preliminary study of their effectiveness. After changing the format and context of existing drug counseling manuals to have greater ease of use in the community, draft manuals were given to 23 community-based counselors for their feedback. Final versions were then used in a pilot randomized clinical trial involving 41 cocaine-dependent patients who received 3 months of either IDC + GDC or GDC-alone treatment. Counselors implemented the new treatment manuals with acceptable levels of adherence and competence. Outcome results indicated that substantial change in drug use was evident, but the amount of abstinence obtained was limited.

Development and initial validation of a multi-domain self-report measure of work functioning.

The need for a self-report measure of work functioning that is flexible to involvement in work across 3 domains (employment, school, and home) led to the development of the Work History Inventory (WHI). The WHI was administered to 185 patients who participated in psychotherapy studies and to 110 community control respondents who were not in treatment. The WHI Total score and subscales (Performance and Interpersonal) demonstrated adequate to good reliability. WHI scores correlated moderately with symptom measures and strongly with another work functioning measure. Changes across treatment indicated that the WHI Total and Performance scores increased significantly across psychotherapy. The WHI seems to be a reliable and valid instrument for measuring treatment related changes in work functioning.

Dopamine transporter levels in cocaine dependent subjects.

Cocaine use is a significant problem in the US and it is well established that cocaine binds to the dopamine transporter (DAT) in the brain. This study was designed to determine if the DAT levels measured by 99mTc TRODAT SPECT (single photon emission computed tomography) brain scans are altered in cocaine dependent subjects and to explore clinical correlates of such alterations. SPECT brain scans were acquired on 21 cocaine dependent subjects and 21 healthy matched controls. There were significantly higher DAT levels in cocaine dependent subjects compared to controls for the anterior putamen (p=0.003; Cohen's d effect size=0.98), posterior putamen (p<0.001; effect size=1.32), and caudate (p=0.003; effect size=0.97). DAT levels in these regions were 10%, 17%, and 8% higher in the cocaine dependent subjects compared to controls. DAT levels were unrelated to craving, severity of cocaine use, or duration of cocaine use, but DAT levels in the caudate and anterior putamen were significantly (p<0.05) negatively correlated with days since last use of cocaine.