Now showing items 21-40 of 17427

    • Multi-site observational maternal and infant COVID-19 vaccine study (MOMI-vax): a study protocol.

      Munoz, Flor M; Beigi, Richard H; Posavad, Christine M; Richardson, Barbra A; Chu, Helen Y; Bok, Karin; Campbell, James; Cardemil, Cristina; DeFranco, Emily; Frenck, Robert W; et al. (Springer Nature, 2022-05-12)
      Background: Pregnant women were excluded from investigational trials of COVID-19 vaccines. Limited data are available to inform pregnant and postpartum women on their decisions to receive a COVID-19 vaccine. Methods: The goal of this observational, prospective cohort study is to evaluate the immunogenicity and safety of various Emergency Use Authorization (EUA) or licensed COVID-19 vaccines administered to pregnant or lactating women and describe the transplacental antibody transfer and kinetics of antibodies in mothers and infants. The study is adaptive, allowing additional groups to be added as new vaccines or vaccine regimens are authorized. Up to 20 clinical research institutions in the United States (U.S.) will be included. Approximately 200 pregnant women and 65 postpartum women will be enrolled per EUA or licensed COVID-19 vaccine formulation in the U.S. This study will include pregnant and postpartum women of all ages with and without chronic medical conditions. Their infants will be enrolled and followed beginning at birth in the pregnant cohort and beginning at the earliest possible time point in the postpartum cohort. Blood samples will be collected for immunogenicity outcomes and pregnancy and birth outcomes assessed among women and infants. Primary analyses will be descriptive and done by vaccine type and/or platform. Discussion: Given the long-standing and legitimate challenges of enrolling pregnant individuals into clinical trials early in the vaccine development pipeline, this study protocol describes our current study and provides a template to inform the collection of data for pregnant individuals receiving COVID-19 or other vaccines. Trial registration: NCT05031468 .
    • Best-worst scaling methodology to evaluate constructs of the Consolidated Framework for Implementation Research: application to the implementation of pharmacogenetic testing for antidepressant therapy.

      Salloum, Ramzi G; Bishop, Jeffrey R; Elchynski, Amanda L; Smith, D Max; Rowe, Elizabeth; Blake, Kathryn V; Limdi, Nita A; Aquilante, Christina L; Bates, Jill; Beitelshees, Amber L; et al. (2022-05-14)
      Background: Despite the increased demand for pharmacogenetic (PGx) testing to guide antidepressant use, little is known about how to implement testing in clinical practice. Best-worst scaling (BWS) is a stated preferences technique for determining the relative importance of alternative scenarios and is increasingly being used as a healthcare assessment tool, with potential applications in implementation research. We conducted a BWS experiment to evaluate the relative importance of implementation factors for PGx testing to guide antidepressant use. Methods: We surveyed 17 healthcare organizations that either had implemented or were in the process of implementing PGx testing for antidepressants. The survey included a BWS experiment to evaluate the relative importance of Consolidated Framework for Implementation Research (CFIR) constructs from the perspective of implementing sites. Results: Participating sites varied on their PGx testing platform and methods for returning recommendations to providers and patients, but they were consistent in ranking several CFIR constructs as most important for implementation: patient needs/resources, leadership engagement, intervention knowledge/beliefs, evidence strength and quality, and identification of champions. Conclusions: This study demonstrates the feasibility of using choice experiments to systematically evaluate the relative importance of implementation determinants from the perspective of implementing organizations. BWS findings can inform other organizations interested in implementing PGx testing for mental health. Further, this study demonstrates the application of BWS to PGx, the findings of which may be used by other organizations to inform implementation of PGx testing for mental health disorders.
    • Telemedicine Improves Access to Care for Spine Patients With Low Socioeconomic Status

      Ye, Ivan B.; Thomson, Alexandra E.; Chowdhury, Navid; Oster, Brittany; Miseo, Vincent S.; Jauregui, Julio J.; Cavanaugh, Daniel; Koh, Eugene; Gelb, Daniel; Ludwig, Steven (SAGE Publications Inc., 2022-01-01)
      Study Design: Retrospective cohort study. Objectives: The objective of this study is to compare the likelihood of missing a scheduled telemedicine and in-person appointments for spine patients. The secondary objective is to assess the impact of socioeconomic status on missed telemedicine and in-person appointments. Methods: Patients with scheduled outpatient appointments with orthopedic spine faculty between 2019 and 2021 were divided by appointment type: telemedicine (N = 4,387) and in-person (N = 3810). Socioeconomic status was assessed using Area Deprivation Index (ADI) stratified based on percentile: low (<25), medium (25–75), and high (>75) levels of socioeconomic disadvantage. The primary outcome measure was missed clinic appointments, which was defined as having at least one appointment that was cancelled or labeled “no show.” Results: Patients with in-person appointments missed appointments more often than patients with telemedicine visits (51.3% vs 24.7%, P <.001). Patients with high ADI missed their in-person appointments more often than patients with medium and low ADI (59.5% vs 52.2% and 47.5%, P <.001). There was no difference in missed telemedicine visits between patients with high, medium, and low ADI (27.6% vs 24.8% vs 23.8%, P =.294). Patients that missed an appointment were 41.9% more likely to be high ADI (OR 1.42, 95% CI 1.20–1.68, P <.001) and 13.4% more likely to be medium ADI (OR 1.13, 95% CI 1.03–1.26, P =.015) compared with low ADI patients. Conclusions: Telemedicine may serve a role in reducing disparity in appointment attendance. While further studies are needed to validate these findings, spine surgeons should consider offering telemedicine as an option to patients. © The Author(s) 2022.
    • Transcriptome profiling reveals that VNPP433-3β, the lead next-generation galeterone analog inhibits prostate cancer stem cells by downregulating epithelial–mesenchymal transition and stem cell markers

      Thomas, Elizabeth; Thankan, Retheesh S.; Purushottamachar, Puranik; Huang, Weiliang; Kane, Maureen A.; Zhang, Yuji; Ambulos, Nicholas; Weber, David J.; Njar, Vincent C.O. (Wiley-Blackwell, 2022-01-01)
      Cancer stem cells (CSCs) virtually present in all tumors albeit in small numbers are primarily responsible for driving cancer progression, metastasis, drug resistance, and recurrence. Prostate cancer (PCa) is the second most frequent cancer in men worldwide, and castration resistant prostate cancer (CRPC) remains a major challenge despite the tremendous advancements in medicine. Currently, none of the available treatment options are effective in treating CRPC. We earlier reported that VNPP433-3β, the lead next-generation galeterone analog is effective in treating preclinical in vivo models of CRPC. In this study using RNA-seq, cytological, and biochemical methods, we report that VNPP433-3β inhibits prostate CSCs by targeting key pathways critical to stemness and epithelial–mesenchymal transition. VNPP433-3β inhibits CSCs in PCa, presumably by degrading the androgen receptor (AR) thereby decreasing the AR-mediated transcription of several stem cell markers including BMI1 and KLF4. Transcriptome analyses by RNA-seq, Ingenuity Pathway Analysis, and Gene Set Enrichment Analysis demonstrate that VNPP433-3β inhibits transcription of several genes and functional pathways critical to the prostate CSCs thereby inhibiting CSCs in PCa besides targeting the bulk of the tumor. © 2022 The Authors. Molecular Carcinogenesis published by Wiley Periodicals LLC.
    • Brain responses to painful electrical stimuli and cognitive tasks interact in the precuneus, posterior cingulate cortex, and inferior parietal cortex and do not vary across the menstrual cycle

      Veldhuijzen, Dieuwke S.; Meeker, Timothy J.; Bauer, Deborah; Keaser, Michael L.; Gullapalli, Rao P.; Greenspan, Joel D. (Wiley-Blackwell, 2022-01-01)
      Introduction: Bidirectional effects between cognition and pain have been extensively reported. Although brain regions involved in cognitive and pain processing seem to partly overlap, it is unknown what specific brain regions are involved in the interaction between pain and cognition. Furthermore, the role of gonadal hormones on these interacting effects has not been examined. This study investigated brain activation patterns of the interaction between pain and cognition over different phases of the naturally occurring menstrual cycle. Methods: Fifteen healthy normally cycling females were examined over the course of 4 different cycle phases. Sensory stimulation was applied using electrical pulses and cognitive performance was assessed using the Multi-Source Interference Task. Brain imaging consisted of functional magnetic resonance imaging using a repeated measures ANOVA group analysis approach. Results: Sensory stimulation was found to interact with task performance in the left precuneus, left posterior cingulate cortex and right inferior parietal lobule. No effects of cycle phase were observed to interact with main effects of stimulation, task or interaction effects between task performance and sensory stimulation. Conclusion: Potential neural correlates of shared resources between pain and cognition were demonstrated providing further insights into the potential mechanisms behind cognitive performance difficulties in pain patients and opening avenues for new treatment options including targeting specific cognitive factors in pain treatment such as cognitive interference. © 2022 The Authors. Brain and Behavior published by Wiley Periodicals LLC.
    • Clinical Practice Issues for Liver Transplantation in COVID-19 Recovered Recipients.

      Shetty, Kirti; Lominadze, Zurabi; Saharia, Kapil; Challa, Suryanarayana Reddy; Montenegro, Maria; Meier, Raphael P H; Malik, Saad; Alvarez-Casas, Josue; Sakiani, Sasan; Jakhete, Neha; et al. (SAGE Publications Inc., 2022-04-12)
      The ongoing burden of COVID-19 in persons with end stage liver failure necessitates the development of sound and rational policies for organ transplantation in this population. Following our initial experience with two COVID-19 recovered recipients who died shortly after transplant, we adjusted our center policies, re-evaluated outcomes, and retrospectively analyzed the clinical course of the subsequent seven COVID-19 recovered recipients. There were two early deaths and 5 successful outcomes. Both deceased patients shared common characteristics in that they had positive SARS-CoV2 PCR tests proximal to transplant (7-17 days), had acute on chronic liver failure, and suffered thromboembolic phenomena. After a careful review of clinical and virological outcome predictors, we instituted policy changes to avoid transplantation in these circumstances. We believe that our series offers useful insights into the unique challenges that confront transplant centers in the COVID-19 era and could guide future discussions regarding this important area. © 2022, NATCO. All rights reserved.
    • Comprehensive analysis of GEO-KOMPSAT-2A and FengYun satellite-based precipitation estimates across Northeast Asia

      Yin, Gaohong; Baik, Jongjin; Park, Jongmin (Taylor and Francis Inc., 2022-01-01)
      Geostationary meteorological satellites provide precipitation estimates with a high spatio-temporal resolution, which is important for near real-time precipitation monitoring. This study systematically evaluated geostationary orbit (GEO) satellite-based quantitative precipitation estimates (QPEs) from Chinese Fengyun-2 G (FY-2 G), Fengyun-4A (FY-4A), and South Korean Geo-KOMPSAT-2A (GK-2A) across Northeast Asia in 2020. Compared against ground-based rainfall gauges at a 6-hourly scale, FY-2 G provided the highest accuracy in the China region with a high correlation coefficient (R = 0.53) and a low bias (−0.26 mm) due to the ground calibration process in FY-2 G. Conversely, GK-2A provided more accurate precipitation estimates for South Korea and Japan stations. FY-4A QPE generally showed a large positive bias throughout different seasons, although it provided satisfactory R and categorical statistics. FY-based QPEs slightly overestimated summer precipitation, especially over South Korea and Japan region, while GK-2A tended to underestimate summer precipitation. All examined QPEs showed poor accuracy during the winter season due to the frozen particles and ice clouds. Intensity analysis revealed that FY-based QPEs tended to overestimate the occurrence of no rain and heavy rain cases, whereas GK-2A underestimated no rain and heavy rain cases and overestimated light rain occurrence. It is also found that all examined QPEs captured the temporal variation of precipitation during storm events, while FY-based products overestimated heavy precipitation peaks and GK-2A underestimated peak precipitation. The findings in the study provided valuable information to further improve current infrared precipitation retrieval algorithms. © 2022 The Author(s).
    • Starvation after infection restricts enterovirus D68 replication.

      Jassey, Alagie; Wagner, Michael A; Galitska, Ganna; Paudel, Bimal; Miller, Katelyn; Jackson, William T (Taylor and Francis Inc., 2022-04-21)
      Enterovirus D68 (EV-D68) is a respiratory pathogen associated with acute flaccid myelitis, a childhood paralysis disease. No approved vaccine or antiviral treatment exists against EV-D68. Infection with this virus induces the formation of autophagosomes to enhance its replication but blocks the downstream autophagosome- lysosome fusion steps. Here, we examined the impact of autophagy induction through starvation, either before (starvation before infection, SBI) or after (starvation after infection, SAI) EV-D68 infection. We showed that SAI, but not SBI, attenuated EV-D68 replication in multiple cell lines and abrogated the viral-mediated cleavage of host autophagic flux-related proteins. Furthermore, SAI induced autophagic flux during EV-D68 replication and prevented production of virus-induced membranes, which are required for picornavirus replication. Pharmacological inhibition of autophagic flux during SAI did not rescue EV-D68 titers. SAI had the same effect in multiple cell types, and restricted the replication of several medically relevant picornaviruses. Our results highlight the significance of autophagosomes for picornavirus replication and identify SAI as an attractive broad-spectrum anti-picornavirus strategy.Abbreviations: BAF: bafilomycin A1; CCCP: carbonyl cyanide m-chlorophenylhydrazone; CQ: chloroquine; CVB3: coxsackievirus B3; EV-D68: enterovirus D68; hpi: hour post-infection; MAP1LC3/LC3: microtubule associated protein 1 light chain 3; MOI: multiplicity of infection; NSP2B: nonstructural protein 2B; PV: poliovirus; RES: resveratrol; RV14: rhinovirus 14; SAI: starvation after infection; SBI: starvation before infection; SNAP29: synaptosome associated protein 29; SQSTM1/p62: sequestosome 1; TFEB: transcription factor EB.
    • Assessment of Adherence to the Use of the World Health Organization Surgical Safety Checklist among Medical Staff in Ain Shams University Hospital, Egypt

      Fahmy, K. M.D.; Nagy, Mostafa; El-Setouy, Maged; Hirshon, Jon Mark; El-Shinawi, Mohamed (Celsius Publishing House, 2022-03-01)
      Introduction: Surgical services are considered one of the main and most important, fundamental health-care services provided in any health-care system. Annually, approximately 310 million operations are performed worldwide. The World Health Organization checklist is aimed at detecting potential safety hazards, improving communication among surgical staff, and decreasing the incidence of drug and surgical site errors. We aim to assess the degree of adherence of medical staff to the safety checklist and to study the effect of supervision on adherence. Methods: This study was conducted in the Department of Surgery, Ain shams University Hospital, between January 2017 and December 2018, and included all the patients who underwent either elective or emergency general surgical operations in the selected unit at Ain Shams University Hospital. The baseline pre-intervention phase of the study was conducted then the checklist was implemented for 4 months without supervision followed by another 4 months with supervision. Results: We observed that the incidence of postoperative morbidities (21.40%) before implementation significantly decreased after implementation without (11.2%) and with supervision (4.7%). A significant improvement in adherence was observed in the three groups in terms of the number of patients with missed items in the checklist (10.9%) after implementation without (5.2%) and with supervision (7 patients, 1.6%). Conclusion: Our results indicated that the implementation of the surgical safety checklist was associated with improved postoperative results and decreased postoperative morbidities linked to the surgery. Further research with a larger sample is needed to investigate the association between the checklist implementation and its effect on patient mortality and survival. Copyright © Celsius Publishing House
    • EBF2 contributes to pancreatic cancer progenitor cell differentiation and tumor suppression

      Mathew, Hannah; Barb, Jennifer J.; Bentzen, Soren; Varghese, Sheelu (AME Publishing Company, 2022-04-01)
      Background: Cancer stem cells (CSCs) and poorly differentiated progenitor cells in pancreatic ductal adenocarcinoma (PDAC) exacerbate hierarchical tissue organization contributing to cell hyperproliferation and therapy resistance. Although studies have identified unique transcription factors in the selection of normal pancreatic lineages, the cells of origin and molecular mechanisms arbitrating PDAC growth are poorly defined. Here we show that cell differentiation suppresses tumor formation. Methods: We isolated CSCs from low passage PDAC cell lines derived from human tumors and commercially available cell lines. Cells were transfected with the early B-cell factor-2 (EBF2) to activate progenitor cell differentiation and gauged the tumorigenic potentials of the derived cell subsets. We studied tumor cell signaling in the cell subsets to understand the tumor-inhibitory potentials of EBF2. Results: Here we show that the brown adipose differentiation gene, EBF2, activates differentiation-associated signals in the cancer progenitor cells in culture and CSC transplantation models. Mechanistically, EBF2 uniformly activates Pparγ-expression in pancreatic cancer cells and limits cell proliferation, whereas oncogenic drivers are expressed differentially in the progenitor cell subsets. Expression of EBF2 in the PDX1 and E-cadherin-expressing and organoid forming pancreatic epithelial CSCs indeed induced ductal and acinar-like structural differentiation in vivo in tumors resulting in tumor suppression. Likewise, EBF2 prompted cell differentiation in cultured mesenchymal-type PDAC cells; adipose-like lineage is associated with preferential expression of PI3K-p110α. In contrast, Akt-phosphorylation, β-catenin, and c-Myc are repressed in the cells, presumably inhibiting tumor growth. Conversely, endothelial-like subsets grew tumors in mice upon cell transplantation; however, the tumor growth rate was significantly reduced. The tumor-promoting signals such as Akt-phosphorylation, β-catenin, and c-Myc were upregulated in the cells compared to the controls. Conclusions: This study reveals a previously unrecognized function of EBF2 in regulating PDAC progenitor cell differentiation and tumor suppression. © 2022 AME Publishing Company. All Rights Reserved.
    • Differential Incidence of Malaria in Neighboring Villages in a High-Transmission Setting of Southern Mali.

      Fofana, Bakary; Takala-Harrison, Shannon; Ouattara, Amed; Sagara, Issaka; Togo, Amadou H; Diakité, Hamadoun; Keita, Mohamed; Sanogo, Kassim; Touré, Sekou; Doumbo, Ogobara K; et al. (American Society of Tropical Medicine and Hygiene, 2022-02-28)
      Throughout a phase IIIb/IV efficacy study of repeated treatment with four artemisinin-based combination therapies, significant heterogeneity was found in the number of clinical episodes experienced by individuals during the 2-year follow-up. Several factors, including host, parasite, and environmental factors, may contribute to the differential malaria incidence. We aimed to identify risk factors of malaria incidence in the context of a longitudinal study of the efficacy of different artemisinin-based combination therapy regimens in Bougoula-Hameau, a high-transmission setting in Mali. Risk factors including age, residence, and treatment regimen were compared among individuals experiencing eight or more clinical episodes of malaria (“high-incidence group”) and individuals experiencing up to three clinical episodes (“low-incidence group”). Consistent with the known association between age and malaria risk in high-transmission settings, individuals in the high incidence group were significantly younger than individuals in the low-risk group (mean age, 7.0 years versus 10.6 years, respectively; t-test, P, 0.0001). Compared with individuals receiving artemether-lumefantrine, those receiving artesunate-amodiaquine had greater odds of being in the high-incidence group (odds ratio [OR], 2.24; 95% CI, 1.03 – 4.83, P 5 0.041), while individuals receiving dihydroartemisinin-piperaquine had a lower odds of being in high incidence group (OR: 0.30, 95% CI, 0.11–0.85; P 5 0.024). Individuals residing in the forested areas of Sokourani and Karamogobougou had significantly greater odds of being in the high-incidence group compared with individuals residing in the semi-urban area of Bougoula-Hameau 1 (Karamogobougou: OR, 3.68; 95% CI, 1.46–9.31; P 5 0.0059; Sokourani: OR, 11.46; 95% CI, 4.49–29.2; P, 0.0001). This study highlights the importance of fine-mapping malaria risks even at sub-district levels for targeted and customized interventions. Copyright © 2022 by The American Society of Tropical Medicine and Hygiene
    • Predictors of Self-repackaging of Antiretroviral Therapy in Northern Tanzania.

      Semvua, Seleman Khamis; Kim, Christine Yaeree; Muiruri, Charles; Peter, Timothy Antipas; Mmbaga, Blandina T; Bartlett, John A; Zullig, Leah L; Jazowski, Shelley A; Knettel, Brandon A; Karia, Francis P; et al. (Ingenta, 2022-04)
      Objectives: In this study, we explored determinants of "researcher-observed" patient-initiated antiretroviral therapy (ART) repackaging practices among people living with HIV (PLHIV) in Northern Tanzania. Methods: We used a quasi-experimental design to describe the prevalence of ART self- repackaging; we conducted face-to-face surveys to determine factors associated with ART self- repackaging practices. Data collection sites included the Kilimanjaro Christian Medical Centre and the Mawenzi Referral Hospital. We used study-specific numerical identifiers assigned to ARTs packaging to determine self-repackaging behavior. Self-repackaging was defined as a binary variable where participants who discarded antiretroviral drugs packaging in at least 2 clinic visits were classified as self- repackagers. We used multivariable logistic regression to assess the determinants of patient-initiated repackaging practices. Results: Among 590 study participants, 57.6% self-repackaged based on researcher observation and 55.6% self-repackaged based on patient report. Researcher-observed self- repackaging was associated with gender (AOR = 1.590; 95% CI: 1.011, 2.502), employment status (AOR = 0.475: 95% CI; 0.239, 0.942), and study site (AOR = 0.218; 95% CI: 0.134, 0.355). Conclusions: A substantial proportion of patients self-repackage their ARTs for various reasons. Health system interventions should focus on addressing the attributes of repackaging among men and unemployed patients.
    • New Developments in the Pathogenesis, Therapeutic Targeting, and Treatment of Pediatric Medulloblastoma

      Fang, Francia Y.; Rosenblum, Jared S.; Ho, Winson S.; Heiss, John D. (MDPI AG, 2022-05-01)
      Pediatric medulloblastoma (MB) is the most common pediatric brain tumor with varying prognoses depending on the distinct molecular subtype. The four consensus subgroups are WNT, Sonic hedgehog (SHH), Group 3, and Group 4, which underpin the current 2021 WHO classification of MB. While the field of knowledge for treating this disease has significantly advanced over the past decade, a deeper understanding is still required to improve the clinical outcomes for pediatric patients, who are often vulnerable in ways that adult patients are not. Here, we discuss how recent insights into the pathogenesis of pediatric medulloblastoma have directed current and future research. This review highlights new developments in understanding the four molecular subtypes’ pathophysiology, epigenetics, and therapeutic targeting. In addition, we provide a focused discussion of recent developments in imaging, and in the surgery, chemotherapy, and radiotherapy of pediatric medulloblastoma. The article includes a brief explanation of healthcare costs associated with medulloblastoma treatment. © 2022 by the authors.
    • Thrombopoietin, Soluble CD40 Ligand, and Platelet Count During Veno-arterial Extracorporeal Membrane Oxygenation

      Mazzeffi, Michael; Henderson, Reney; Powell, Elizabeth; Strauss, Erik; Williams, Brittney; Tanaka, Kenichi; Yang, Stephen; Deatrick, Kristopher; Madathil, Ronson (Wolters Kluwer Health, 2022-05-01)
    • SRC Kinase-Mediated Tyrosine Phosphorylation of TUBB3 Regulates Its Stability and Mitotic Spindle Dynamics in Prostate Cancer Cells

      Alfano, Alan; Xu, Jin; Yang, Xi; Deshmukh, Dhanraj; Qiu, Yun (MDPI AG, 2022-05-01)
      Tubulin is an integral part of the cytoskeleton and plays a pivotal role in cellular signaling, maintenance, and division. β-tubulin is also the molecular target for taxane compounds such as docetaxel (DTX) and cabazitaxel (CTX), both first-line treatments for several solid cancers. Increased expression of Class III β-tubulin (TUBB3), a primarily neural isoform of β-tubulin, correlates with taxane resistance and poor prognosis. Although tyrosine kinase c-Src has been implicated to phosphorylate β-tubulins during both hematopoietic and neural differentiation, the mechanisms by which Src modulates tubulins functions are still poorly understood. Here, we report, for the first time, that TUBB3 is phosphorylated at Tyrosine 340 (Y340) by c-SRC in prostate cancer cells. We also showed that Y340 phosphorylation regulates TUBB3 protein stability and subcellular localization. Furthermore, we demonstrated that inhibition of SRC kinase activity compromises spindle stability in mitotic cells, at least partly due to the lack of TUBB3 Y340 phosphorylation. Given the importance of TUBB3 as a clinical biomarker of poor prognosis and drug resistance, characterization of TUBB3 posttranslational regulation could potentially serve as new biomarkers for disease recurrence and/or treatment failure.
    • Implementation of an Anesthesia Practice Change to Impact Postoperative Cognitive Dysfunction

      Greenberg, Rachel A.; Franquiz, Renee (2022-05)
      Problem: Approximately 25-40% of patients over the age of 60 who undergo anesthesia experience postoperative cognitive dysfunction (POCD) at hospital discharge, and 10% continue to suffer from this complication 3 months postoperatively. Devastating physical and financial outcomes occur including prolonged hospital stays, higher rates of readmission, financial stress and dependence, as well as increased mortality. Intraoperative administration of dexamethasone and dexmedetomidine are evidence-based effective strategies to reduce the incidence of POCD. Purpose: The purpose of this Quality Improvement (QI) project is to implement an anesthesia practice change to impact the incidence of POCD. The overall goal is to increase adherence to the administration of intraoperative dexamethasone and dexmedetomidine for patients who are identified preoperatively as high-risk for POCD through screening. Methods: Through collaboration with anesthesia leadership and other key stakeholders, a site-specific intraoperative checklist was developed to illustrate the anesthesia practice change. Anesthesia providers were prompted to evaluate results of the preoperative screening; patients with a positive screening result, indicating a higher risk of developing POCD, should be administered at least one of the evidence-based interventions listed on the intraoperative checklist. Administration of these interventions were documented on a paper checklist and collected for data analysis. Results: Preimplementation rates of dexamethasone and/or dexmedetomidine administration to patients aged 60 or older was compared to post-implementation rates of administration to high-risk individuals. Post-implementation findings demonstrate an overall adherence of 93.8% to the anesthesia practice change. Conclusions: Intraoperative administration of dexamethasone and/or dexmedetomidine is a safe, effective, and feasible strategy to reduce the risk of POCD in highrisk surgical patients.
    • Unintended Extubation Prevention Bundle in the Neonatal Intensive Care Unit

      Gallant, Letitia A.; Connolly, Mary Ellen (2022-05)
      Problem: Endotracheal intubation is a common procedure in the Neonatal Intensive Care Unit. Unintended extubation is defined as the accidental dislodgement of the endotracheal tube from the trachea and is a common adverse event in NICUs. Unintended extubation is associated with a multitude of profound consequences in neonates including airway trauma, intraventricular hemorrhage, pneumothorax, cardiovascular collapse, and death. In 2020, a Level VI Neonatal Intensive Care Unit had an unintended extubation rate of 1.2 per 100 ventilator days, exceeding the unit goal of less than 1 per 100 ventilator days. Purpose: The purpose of the quality improvement project is to implement an initiative outlining an unintended extubation bundle with an emphasis on management of high-risk procedures to reduce unintended extubation in a Level IV Neonatal Intensive Care Unit. Methods: A multidisciplinary team evaluated current literature along with previous unintended extubation events and developed a unintended extubation bundle that emphasized the presence of two licensed providers for all “high risk” procedures and, in addition all intubated infants greater than 35 weeks’ gestation were required to have mittens placed on their hands. Adherence to the bundle was tracked via random observation audits with verbal feedback, and success was determined thorough evaluation of by weekly run charts, over a 15-week timeframe. Results: Results of this quality improvement project were mixed. The nursing education goal of 100% of nursing staff was achieved. The process goal of 100% compliance to the unintended extubation bundle was not met. The unit unintended extubation rate remained unchanged at 1.2 per 100 ventilator days. Conclusions: Preventing unintended extubation in Neonatal Intensive Care Units remains a challenging problem but with supportive stakeholders and a strong commitment to organizational change, along with a concrete framework for implementation, success can be achieved. Evaluation of the implementation over a longer period of time may produce different results.
    • Implementation of an Extubation Readiness Guideline for Preterm Infants

      Cobb, Emily B.; Fitzgerald, Jennifer (2022-05)
      Problem & Purpose: Intubated preterm infants ≤ 32 6/7 weeks gestation in a mid-Atlantic level IV Neonatal Intensive Care Unit (NICU) faced a high number of days on the ventilator. The literature supported that use of an extubation guideline will decrease ventilator days, and this NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility. In 2020 this NICU had 22.0% of very low birth weight (VLBW) infants on a ventilator for > 28 days, compared to a median of 15.7% infants (in this subgroup) in other similar NICUs throughout the United States (U.S.). Based on six weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants ≤ 32 6/7 weeks were intubated for > 28 days, with an average of 23 days on a ventilator. The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants ≤ 32 6/7 weeks gestation in a mid-Atlantic level IV NICU. Methods: This project occurred over a 17-week period in fall of 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, guideline dissemination, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre/post implementation data. Staff education completion, guideline use, guideline adherence, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked. Results: Post implementation data indicated decreased: average total ventilator days, need for intubation > 28 days, and days to first extubation attempt for preterm infants ≤ 32 6/7 weeks gestation. Conclusions: Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants ≤ 32 6/7 weeks gestation.
    • Implementation of Advance Care Planning Discussions and Completion of Advance Directives

      Trobiano, Thomas J.; Wilson, Tracey L. (2022-05)
      Problem: In the Heart Failure Clinic of a tertiary care, academic institution, the advanced directive (AD) completion rate is marginal and the documentation surrounding advance care planning (ACP) discussion is suboptimal. A retrospective chart review between September and November 2020 revealed a 15% AD completion rate with no documentation of ACP discussions. The impact of not having an AD on record potentiates misalignment of the patient’s future goals and wishes, in addition to unnecessary life-sustaining measures utilized, and prolonged hospitalizations. Purpose: The purpose of this quality improvement (QI) project was to implement and monitor the effectiveness of a multistage approach to documenting ACP discussions and completing ADs. Methods: This QI project took place in an ambulatory heart failure clinic from September 2021 - December 2021. The individuals involved in carrying out this QI project included a multidisciplinary team impacting nearly 200 patients during the implementation phase. The stakeholders instituted evidence-based structure and workflow changes to attain the goals of this project, including integration of an ACP discussion and end-of-life goals documented via the utilization of smart phrases within the electronic health record (EHR). An inpatient heart failure census was audited daily for patient enrollment. Smart phrase utilization reports were extracted weekly from the EHR while ADs were manually totaled on a weekly basis from the EHR. Results: This project yielded a 95% (177/187) consistent trend in documentation of ACP conversations. Initial shifts were noted in the documentation of patient goal alignment totaling 73% (136/187). A total of 18% (34/187) of ADs were completed which was an increase of 3% in comparison to the preceding year. Conclusion: The aim of this project was to enhance clinical practice at a heart failure clinic related to standardizing ACP discussions to increase AD completion rates. Future implications include assessment of literacy levels and comprehension of ADs. Translating this evidence into practice was reasonable, yet limitations include episodic care provided post-discharge in this care transition clinic, highlighting the need to engage with community primary care providers (PCP) to further address this practice gap.
    • Improving Asynchronous Handoff Communication by Implementing an Electronic Handoff Documentation Tool

      Meek, Rachel M.; Bennett, DeNiece (2022-05)
      Problem: Miscommunication during provider handoffs is linked to negative impacts on patient care, delays in treatment, inappropriate treatment, and increased lengths of stay. Prior to implementation there was no standardized handoff tool in the electronic health record (EHR). Only 4% of patients referred to the Emergency Department (ED) by their primary care team had any documentation of a handoff in the EHR. Purpose: This quality improvement project aimed to improve pre-arrival information documentation and implement and evaluate the effectiveness of an electronic documentation tool on clinician handoff documentation compliance. Methods: The ED Expected Patient Admission form was developed in the EHR for primary care clinicians to document handoff information. The form automatically created an expected patient on the ED track board view with links to pertinent information when the form is complete. ED providers could select a patient to review the handoff in a side-by-side view on the track board. This view created an ED summary for the ED provider that included previous ED visits, clinic referral summary, active patient FYIs, and other essential details. This workflow was communicated broadly to providers at the pilot sites; coaches and nurses were trained to use the form to support the new workflow. Results: There was broad acceptance and use of the new tool by primary care clinicians as evidence by attaining the target of 100% prior to goal date. Hospitalizations following the referral were reduced from a baseline of 50% to 28.5%. Referring clinicians felt they were able to communicate patient needs and felt safe using the form instead of giving traditional verbal handoff. Conclusions: This tool supported documentation compliance and asynchronous communication through standardized documentation and referral guidelines.