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    New England Journal of Medicine and Nature iPad Applications, Vol.10 (4)

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    Peripheral Intravenous Infiltrates: Engaging Staff to Increase Reporting

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    A large free standing children’s academic hospital aimed to improve patient safety and outcomes by decreasing the overall severity of peripheral intravenous infiltration and extravasations (PIVIEs). A care bundle was developed by creating a PIVIE measurement tool within the electronic medical record (EMR) and integrating the tool into standardized daily practice for nurses. The care bundle included creating a team of clinical leaders consisting of empowered bedside nurses acting as mobilized resources embedded into each unit. The initiative resulted in a large scale increase in reported PIVIEs system-wide within 1 month of education dissemination to bedside RN staff. The QI interventions captured a realistic interpretation allowing for a more global and accurate reflection of the number and severity of PIVIE events system-wide, while creating documentation for the PIVIE tool in the EMR and a clinical leader model. The results reflected a dramatic rise in the number of reported PIVIE events, increase in staff awareness of PIVIEs, increased peripheral intravenous line assessments, and decreased severity of PIVIEs that do occur


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    The aims of the study were to determine whether ENDS device types (i.e., disposable devices, replaceable cartridges, and refillables) at initial, or first ENDS use is longitudinally associated with subsequent initiation of combustible tobacco products (cigarettes, hookah, cigars) and continued, past 30-day use of combustible and ENDS products. This study is a secondary analysis of data from the Texas Adolescent Tobacco and Marketing Surveillance system (TATAMS) study, a longitudinal cohort study of students who were in the 6th, 8th, and 10th grades (n = 3907) during the 2014-2015 academic year. Data were collected every 6 months, from 2014-2018. Using data from all 8 waves of the study, descriptive statistics were computed for initial ENDS device type (disposables, cartridges, and refillables), initial and past 30-day use of combustible tobacco products (subsequent to ENDS use), and past 30-day ENDS use (among ever ENDS users). Unadjusted and adjusted logistic regression models were computed to assess the likelihood of (a) initiation of combustible tobacco products in subsequent waves, (b) continued use of combustible tobacco products (past 30-day use) and (c) continued use of ENDS products (past 30-day use) in the same or subsequent waves, by initial ENDS device type. After adjusting for the sociodemographic variables, compared to participants initiating with Refillables, participants initiating ENDS use with Cartridges and Disposables were 58% (AOR = 0.42; 95% CI = 0.18 – 0.98; p = 0.05) and 53% (AOR = 0.47; 95% CI = 0.21-1.07; p = 0.07) less likely to initiate combustible tobacco use in a subsequent wave. Compared to participants initiating with Disposables, participants initiating ENDS use with Cartridges were 12% (AOR = 0.89; 95% CI = 0.32 – 2.50; p = 0.89) less likely to initiate combustible tobacco use in a subsequent wave. Compared to participants initiating with Disposables, participants initiating ENDS use with Cartridges were 12% (AOR = 0.88; 95% CI = 0.21 – 3.68; p = 0.86) less likely to have reported combustible tobacco use in the past 30-days. Compared to participants initiating with Disposables, participants initiating ENDS use with Cartridges were 62% (AOR = 0.38; 95% CI = 0.16 – 0.92; p = 0.03) less likely to have reported ENDS use in the past 30-days. The study provides an insight into the impact device types can have on future smoking behavior and the implication it can have on policy and regulation

    Using Intervention Mapping to Develop an Efficacious Multicomponent Systems-Based Intervention to Increase Human Papillomavirus (HPV) Vaccination in a Large Urban Pediatric Clinic Network

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    Background: The CDC recommends HPV vaccine for all adolescents to prevent cervical, anal, oropharyngeal, vaginal, vulvar, and penile cancers, and genital warts. HPV vaccine rates currently fall short of national vaccination goals. Despite evidence-based strategies with demonstrated efficacy to increase HPV vaccination rates, adoption and implementation of these strategies within clinics is lacking. The Adolescent Vaccination Program (AVP) is a multicomponent systems-based intervention designed to implement five evidence-based strategies within primary care pediatric practices. The AVP has demonstrated efficacy in increasing HPV vaccine initiation and completion among adolescents 10-17 years of age. The purpose of this paper is to describe the application of Intervention Mapping (IM) toward the development, implementation, and formative evaluation of the clinic-based AVP prototype. Methods: Intervention Mapping (IM) guided the development of the Adolescent Vaccination Program (AVP). Deliverables comprised: a logic model of the problem (IM Step 1); matrices of behavior change objectives (IM Step 2); a program planning document comprising scope, sequence, theory-based methods, and practical strategies (IM Step 3); functional AVP component prototypes (IM Step 4); and plans for implementation (IM Step 5) and evaluation (IM Step 6). Results: The AVP consists of six evidence-based strategies implemented in a successful sequenced roll-out that (1) established immunization champions in each clinic, (2) disseminated provider assessment and feedback reports with data-informed vaccination goals, (3) provided continued medical and nursing education (with ethics credit) on HPV, HPV vaccination, message bundling, and responding to parent hesitancy, (4) electronic health record cues to providers on patient eligibility, and (5) patient reminders for HPV vaccine initiation and completion. Conclusions: IM provided a logical and systematic approach to developing and evaluating a multicomponent systems-based intervention to increase HPV vaccination rates among adolescents in pediatric clinics

    Addressing nutritional literacy in preschool learning environments

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    INTRODUCTION: Obesity among preschool children is more common among lower-income families. Prevalence of type 2 diabetes in U.S. Mexican and African American populations has steadily increased and is associated with modifiable risk factors, such as poor dietary habits. AIM: The purpose of this study was to conduct an assessment of the preschool Bienestar/NEEMA Health Program, focusing on: students’ knowledge increase, teacher input on the classroom materials used, parental feedback on take-home activities, and input on the program\u27s food service training by the school district\u27s nutrition coordinator. SAMPLE: Curriculum was implemented and assessed in one Head Start school over a six-week period. Teacher’s focus group discussion surrounded the classroom curriculum, parents attended a discussion of the parent curriculum and one school food service personnel was interviewed regarding the school food service personnel curriculum. RESULTS: Three and 4-year-old students (n=104) in Spanish-speaking, English-speaking, and English as a Second Language (ESL) classes participated in the study. Knowledge assessments showed a slight increase in nutrition knowledge. Teachers indicated the materials were cognitively appropriate, but materials should use actual photographs and not clip art to teach core concepts. Parents appreciated learning how chronic disease is nutritionally related and how to feed their families on a budget. IMPLICATIONS FOR HEALTH DISPARITIES IN PUBLIC HEALTH: Nutritional literacy is critical for decreasing the risk and financial burden of obesity and chronic disease in America. Food preference begins at an early age and sets the stage for lifelong eating habits. Developing appropriate and inexpensive nutrition education materials for preschool children should include social scientists, nutritionists and food scientists as an integral part of the interdisciplinary public health team focusing on decreasing health disparities

    A Case Study of an Agency\u27s Three Family Preservation Contracts

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    This article presents a case study of a nonprofit child welfare agency that delivered family preservation services under three different purchase-of-service (POS) contracts. The research specifically focuses on how certain POS contract provisions and reimbursement rates influence the delivery of family preservation services. The three contacts examined differed on criteria, such as reimbursement mechanism, service volume, definition of clientele, and reimbursement rate. The study found that as reimbursement rates decline and as administrative costs increase, the service provider struggled with cash flow, staffing, fundraising, and service provision, among other things. It is concluded that contract-related resources, policies, and procedures impact provider agencies in multiple, significant ways that are critical to the provision of services and the accomplishment of positive client outcomes

    Interview with Melinda Perrin

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    An oral history interview with Melinda Perrin about her career in the Texas Medical Center and work on the board of Hermann Hospital and later Memorial Hermann Healthcare System. Melinda Hill Perrin was born into a family known for the leadership it has provided both the city of Houston and the state of Texas. Her father John Hill served as the Texas’ secretary of state, then attorney general and finally Chief Justice of the state Supreme Court. Her work in the community and the non-profit sector led to her selection as a member of the Board of Hermann Hospital during its most controversial period. She was board chair when Hermann merged with the Memorial Health Care System in 1997, a perilous project that’s success meant the strengthening of two of the city’s most important healthcare institution. That work gives her a unique view of Houston, its institutions and the future of healthcare not only locally but across the nation. She is a volunteer and her willingness to provide leadership in that role makes her a role model for women in every walk of life

    Perceptions of Effectiveness of School Counselors with Former Graduates in a TRIO College Program

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    The context and variables that affect at-risk students are constantly changing. It is imperative that school counselors understand the risk factors for students and the cultural and social contexts the individual lives within. Working with at-risk students is even more challenging with the millennial generation. The culture in this generation promotes instant gratification as society has reinforced that all individuals will succeed. At-risk students in this generation can be in disbelief of even being at-risk and may assume that others will solve their problems. Federally funded TRIO programs have shown to a positive impact on at-risk student development. Although there has been sufficient evaluation and review of TRIO programs’ impact on disadvantaged college students, there is a lack of research of student evaluation of their high school counselors after they graduate. It is important to consider the high school counselor’s impact on postsecondary success. College students involved in TRIO completed surveys rating their high school counselor. School counselor rating scores were correlated with the number of school counselors in that school, r(20) = 0.45, p = .043. This study has implications for school counselors and emphasizes the importance of school counselor contact. This research is the first step in the evaluation of high school counselors from students even when they are no longer high school students

    Adolescent Marijuana Use and Co-Occurrence with Tobacco Use: Implications for Tobacco Regulation

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    Background: Marijuana use among high school youth has been declining over the past two decades. However, there has been a notable shift in the national landscape with regards to social norms and marijuana legalization that could allow marijuana to become more available and may compete against prevention efforts among youth. Further, youth continue to utilize innovative ways to consume marijuana. There is a documented relationship between marijuana and tobacco use, particularly with the use of blunts. Despite the documented relationship between tobacco and marijuana use, little is known about the modes of marijuana use in relation to different tobacco products. With the recent FDA changes bringing cigars under the purview of the FDA Center for Tobacco Products (CTP), there may be an opportunity for CTP regulations of cigar products to impact youth use of both marijuana and tobacco. Methods: This study used data from the 2015 Cleveland Youth Risk Behavior Survey (n=6197) conducted as a census administration in 26 high schools; overall response rate was 66.5%. Youth were asked “During the past 30 days, how did you usually use marijuana?”. Responses were coded as a blunt; in a joint, bong, or pipe (JBP); or some other way. The standard CDC response categories for this item were altered to allow us to specifically examine blunt use. Analyses were restricted to those who smoked marijuana in the past 30 days and were conducted using SPSSv24. Demographic and tobacco use characteristics were examined for each mode of marijuana use. Result: Overall, 74.6% of past 30-day marijuana users reported usually smoking marijuana as a blunt, 15.1% smoked as a JBP, and 10.4% reported using in some other way. Females were more likely to smoke a blunt (79.5% v 71.1%) and less likely to use some other way (6.7% v 13.1%). Blacks were more likely to smoke a blunt compared to Whites and Hispanics (80.8% v 62.3% and 67.0% respectively); Whites were more likely to smoke a JBP compared to Black and Hispanics (33.8% v. 8.9% and 20.1% respectively). Past 30-day cigarette smokers were more likely to have smoked a JBP and less likely to have smoked a blunt compared to non-cigarette smokers. Conversely, past 30-day cigar smokers were more likely to have smoked a blunt and less likely to have smoked a JBP than non-cigar smokers. Youth who vaped in the past 30-days were more likely to use a JBP and use marijuana in some other way compared to youth who had not vaped. In a multivariable logistic regression predicting blunt use or JBP use, cigar product use increased odds of blunting (OR: 1.98) while hookah use was associated with increased odds of JBP. Conclusion: Cigar products are an easily accessible vehicle for smoking marijuana. Federal regulations to restrict youth access to cigar products could have significant impact on adolescent marijuana use, particularly among females and Black youth

    The Psychosocial Effects of the Li-Fraumeni Education and Early Detection (LEAD) Program on Indivdiuals with Li-Fraumeni Syndrome

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    Li-Fraumeni syndrome (LFS) is a hereditary cancer syndrome that leads to an increased risk of multiple cancers. In the past five years new screening protocols have been developed that provide improved screening options for individuals with LFS. However, very little has been published on the psychosocial impact of these screening protocols. The goals of this study were to determine how participation in screening impacts individuals psychosocially, to examine the benefits and drawbacks of screening, and to evaluate possible barriers to continued screening. This qualitative study consisted of phone interviews with 20 individuals that took part in an LFS screening program at M.D. Anderson Cancer Center. Data analysis showed that benefits of screening include early detection, peace of mind, centralized screening, knowledge providing power, and screening making LFS seem more livable. Perceived drawbacks included logistical issues, difficulty navigating the system, screening being draining, and significant negative emotional reactions such as anxiety, fear, and skepticism. Regardless of the emotions that were present, 100% of participants plan on continuing screening in the program. Our data indicates that the perceived benefits of screening outweigh the drawbacks of screening. Individuals in this screening program appear to have improved psychosocial well-being because of their access to the screening program


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