UR-INE Good Hands in the Neuroscience Intensive Care Unit

Purpose: The purpose of this performance improvement project was to decrease the harm to patients related to catheter associated urinary tract infections (CAUTIs) in the Neuroscience Intensive Care Unit (NSICU). Historically, the NSICU had the highest CAUTI rates in our organization with as many as 6 CAUTIs per calendar year quarter. A core group of nurses partnered with providers, hospital infection preventionists and nursing leaders to improve practices for placing, removing, and managing urinary catheters and to implement guidelines for urine testing stewardship. Description: Significance: In 2020, the NSICU had 12 CAUTIs, the highest number of CAUTIs in the entire healthcare enterprise (n=16). The Standard Infection Ratio (SIR) reached a high of 5.12 despite a Standard Utilization Ratio (SUR) less than 1.0. Catheter associated urinary tract infection is a common healthcare associated infection. Approximately 14% of hospitalized adults will have a urinary catheter during their hospitalization and with each day the risk of CAUTI increases by 3- 7%. CAUTIs are associated with increased length of stay, increased cost and increased mortality and morbidity (NHSN, 2023). With an estimated additional cost of $14,000 to treat a CAUTI, reducing this HAI in NSICU was a top organizational priority. Strategy: The NSICU had previously implemented multiple strategies to reduce CAUTIs (male and female alternative devices, daily review for necessity, chlorhexidine (CHG) bath treatment, and utilization of the organizational nurse-led bladder management algorithm for urinary catheter removal). We included these strategies as well as compliance with CAUTI related process measures (hand hygiene, CHG bathing, daily review for necessity) in our annual education. We held skills fairs for nursing team members to demonstrate aseptic insertion technique, daily catheter care and best practices for management of the system. Each CAUTI was thoroughly investigated, and, seeing no change in our CAUTI rates, nurses were asked to redouble their efforts in catheter care and maintenance and timely removal. Due to the lack of overall improvement in CAUTI rates, we consulted with our infection preventionist (IP) who provided data on urine testing practices in the NSICU. Like many other providers, NSICU physicians routinely ordered urine cultures as part of a fever work-up. Urine cultures without the presence of indication is considered inappropriate based on CDC guidelines. Our IP noted that many of our patients did not have clinical indications for urine culture testing. It was possible that our CAUITs were the result of colonization of the catheter with the development of biofilm or catheter-associated asymptomatic bacteriuria (CDC, 2019). As this pattern of inappropriate urine testing emerged, we decided to add urine testing stewardship (UTS) to our bundle of strategies to reduce CAUTIs. Our goal was to obtain urine cultures only when indicated (i.e. recent kidney transplant recipients, neutropenia, recent genitourinary surgery, known genitourinary obstruction or stents, pregnancy, spinal cord injury with signs or symptoms of autonomic dysreflexia, organ donor or patient with classic signs of urinary tract infection without alternative explanation). Implementation: In November 2020 NSICU nurse leaders partnered with the IP and medical director to identify opportunities to implement UTS. All strategies were developed with the understanding that this was not simply a practice change but also a culture change. Team meetings (nursing and physician) were held to discuss the new approach to urine testing. Signs with testing criteria were affixed to each computer so that providers would use that information when placing orders. To ensure adherence to the change, in January 2021 all orders for urine cultures were to be reviewed by nurse leaders before being obtained. Nurse leaders were well versed in the literature supporting the reduction of unnecessary testing and frequently provided just-in-time education to nurses and providers to answer any questions and address concerns about urine testing. Evaluation and Implications for Nursing Practice and Patient Outcomes:   With the addition of urine testing stewardship, CAUTI rates dropped from a high of 5.12 in 2020 Q3 to 0.0 in 2021 Q3. Between 2020 Q1 and 2021 Q3 there were 16 CAUTIs. From May 27, 2021 to April 24, 2023 (696 days) there were no CAUTIs. As of July 2023, no patients hospitalized in the NSICU with an indwelling urinary catheter were readmitted with a UTI or urosepsis. In addition to the CAUTI in April 2023, there was a second patient with a CAUTI on July 23, 2023. In both cases, the patients did not meet testing criteria nor were nursing leaders notified of the order. Combined with previous strategies, the introduction of urine testing stewardship reduced patient harm. We eliminated the unnecessary use of antimicrobials which, in turn, increases the proliferation of resistant organisms (AHRQ, May 2023). Furthermore, providers have become more likely to approve catheter removal earlier in the course of hospitalization.   These initiatives were successful in that we reduced our CAUTI rates and changed the culture on the unit. Implementation of UTS in particular required collaboration among all team members and support from providers. Nurses are more confident in asking the “why” for other tests and procedures ordered on their patients. Nurse leader review of routine urine cultures was adopted as a best practice across the organization

Memory Aging: Deficits, Beliefs, and Interventions

Of all mental faculties, memory is unique. It defines who we are and places our lives on a narrative continuum from birth to death. It helps to structure our days, it guides our daily tasks and goals, and it provides pleasurable interludes as we anticipate the future and recall the past. As a core, defining feature of the self (Birren & Schroots, 2006), memory takes on heightened meaning as we age. In the face of other losses that accumulate with age, memory can serve to preserve our sense of self and place in time. In normal aging, memory loss is minor and relatively inconsequential to functional well-being, other than passing annoyance at not being able to retrieve a name or a location from time to time. In non-normal or pathological aging, as characterized by Alzheimer\u27s disease (AD), the loss of memory is severe and debilitating. In addition to functional disability, people with AD ultimately lose their sense of self. Connections to the past, to current events and relationships, and to what the future holds fade and ultimately disappear. Such a bleak fate for the self continues to spur researchers to look for causes and cures for normal and pathological memory failure. Current cutting-edge research examines the transition from normal to pathological memory aging, with particular emphasis on mild cognitive impairment (MCI) as a transitional phase and as an independent risk factor for AD. Concurrent efforts have focused on developing effective intervention and treatment programs aimed at biological, psychosocial, and cognitive levels. This chapter highlights current research on normative memory change with age, with a focus on self-regulation, self efficacy, and memory maintenance and maximization. We also look at the special contexts of mild cognitive impairment and Alzheimer\u27s disease, and close with an eye toward future directions in theory, research, and intervention

Early Mobility in the Hospital: Lessons Learned from the STRIDE Program

Immobility during hospitalization is widely recognized as a contributor to deconditioning, functional loss, and increased need for institutional post-acute care. Several studies have demonstrated that inpatient walking programs can mitigate some of these negative outcomes, yet hospital mobility programs are not widely available in U.S. hospitals. STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) is a supervised walking program for hospitalized older adults that fills this important gap in clinical care. This paper describes how STRIDE works and how it is being disseminated to other hospitals using the Replicating Effective Programs (REP) framework. Guided by REP, we define core components of the program and areas where the program can be tailored to better fit the needs and local conditions of its new context (hospital). We describe key adaptations made by four hospitals who have implemented the STRIDE program and discuss lessons learned for successful implementation of hospital mobility programs

Simultaneously Bound Guests and Chiral Recognition: A Chiral Self-Assembled Supramolecular Host Encapsulates Hydrophobic Guests

Driven by the hydrophobic effect, a water-soluble, chiral, self-assembled supramolecular host is able to encapsulate hydrophobic organic guests in aqueous solution. Small aromatics can be encapsulated in the supramolecular assembly, and the simultaneous encapsulation of multiple guests is observed in many cases. The molecular host assembly is able to recognize different substitutional isomers of disubstituted benzenes with ortho substitution leading to the encapsulation of two guests, but meta or para substitution leading to the encapsulation of only one guest. The scope of hydrophobic guest encapsulation is further explored with chiral natural product guests. Upon encapsulation of chiral guests into the racemic host, diastereomeric host-guest complexes are formed with observed diastereoselectivities of up to 78:22 in the case of fenchone

What does it mean when people call a place a shithole? Understanding a discourse of denigration in the United Kingdom and the Republic of Ireland

This paper investigates what people mean when they engage in the discourse of denigration. Building on existing literature on territorial stigmatisation that either focuses on macro‐scale uses and effects of territorial stigmatisation or micro‐scale ethnographic studies of effects, we develop a novel approach that captures the diverse voices that engage in the discourse of denigration by tracing the use of the word and hashtag “shithole” on the social media platform Twitter in order to examine who is engaged in the stigmatising discourse, the types of place that are stigmatised and the responses to stigmatised places. Using a robust data set, we highlight two key findings. First, the majority of tweets were aimed at places where the tweeter was not from, a form of othering consistent with how territories are stigmatised by those in positions of power such as policymakers, politicians and journalists. Second, we note that an important and gendered minority of tweets can be characterised by a “cry for help” and powerlessness, where the stigma is aimed at their own places. We offer an interpretive lens through which to understand and frame these minoritarian voices by engaging with theories of abjection that allow us to see how minoritarian voices relate to place

Correction: Whole-blood expression of inflammasome- and glucocorticoid-related mRNAs correctly separates treatment-resistant depressed patients from drug-free and responsive patients in the BIODEP study

We have corrected this Article post-publication, because Dr. Cattaneo’s affiliation details were originally incorrect (she was affiliated with three institutions but is in fact only linked to one: Biological Psychiatry Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia). These changes reflect in both the PDF and HTML versions of this Article

Correction: Whole-blood expression of inflammasome- and glucocorticoid-related mRNAs correctly separates treatment-resistant depressed patients from drug-free and responsive patients in the BIODEP study.

We have corrected this Article post-publication, because Dr. Cattaneo's affiliation details were originally incorrect (she was affiliated with three institutions but is in fact only linked to one: Biological Psychiatry Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia). These changes reflect in both the PDF and HTML versions of this Article

Whole-blood expression of inflammasome- and glucocorticoid-related mRNAs correctly separates treatment-resistant depressed patients from drug-free and responsive patients in the BIODEP study

Funder: DH | National Institute for Health Research (NIHR); doi: https://doi.org/10.13039/501100000272Abstract: The mRNA expression signatures associated with the ‘pro-inflammatory’ phenotype of depression, and the differential signatures associated with depression subtypes and the effects of antidepressants, are still unknown. We examined 130 depressed patients (58 treatment-resistant, 36 antidepressant-responsive and 36 currently untreated) and 40 healthy controls from the BIODEP study, and used whole-blood mRNA qPCR to measure the expression of 16 candidate mRNAs, some never measured before: interleukin (IL)-1-beta, IL-6, TNF-alpha, macrophage inhibiting factor (MIF), glucocorticoid receptor (GR), SGK1, FKBP5, the purinergic receptor P2RX7, CCL2, CXCL12, c-reactive protein (CRP), alpha-2-macroglobulin (A2M), acquaporin-4 (AQP4), ISG15, STAT1 and USP-18. All genes but AQP4, ISG15 and USP-18 were differentially regulated. Treatment-resistant and drug-free depressed patients had both increased inflammasome activation (higher P2RX7 and proinflammatory cytokines/chemokines mRNAs expression) and glucocorticoid resistance (lower GR and higher FKBP5 mRNAs expression), while responsive patients had an intermediate phenotype with, additionally, lower CXCL12. Most interestingly, using binomial logistics models we found that a signature of six mRNAs (P2RX7, IL-1-beta, IL-6, TNF-alpha, CXCL12 and GR) distinguished treatment-resistant from responsive patients, even after adjusting for other variables that were different between groups, such as a trait- and state-anxiety, history of childhood maltreatment and serum CRP. Future studies should replicate these findings in larger, longitudinal cohorts, and test whether this mRNA signature can identify patients that are more likely to respond to adjuvant strategies for treatment-resistant depression, including combinations with anti-inflammatory medications