Clostridium difficile infection in the United States: A national study assessing preventive practices used and perceptions of practice evidence

We surveyed 571 US hospitals about practices used to prevent Clostridium difficile infection (CDI). Most hospitals reported regularly using key CDI prevention practices, and perceived their strength of evidence as high. The largest discrepancy between regular use and perceived evidence strength occurred with antimicrobial stewardship programs.Infect. Control Hosp. Epidemiol. 2015;36(8):969–971</jats:p

Activation of Nrf2-Regulated Glutathione Pathway Genes by Ischemic Preconditioning

Prophylactic pharmacological activation of astrocytic gene expression driven by the transcription factor Nrf2 boosts antioxidant defences and protects against neuronal loss in ischemia and other disease models. However, the role of Nrf2 in mediating endogenous neuroprotective responses is less clear. We recently showed that Nrf2 is activated by mild oxidative stress in both rodent and human astrocytes. Moreover, brief exposure to ischemic conditions was found to activate Nrf2 both in vivo and in vitro, and this was found to contribute to neuroprotective ischemic preconditioning. Here we show that transient ischemic conditions in vitro and in vivo cause an increase in the expression of Nrf2 target genes associated with the glutathione pathway, including those involved in glutathione biosynthesis and cystine uptake. Taken together, these studies indicate that astrocytic Nrf2 may represent an important mediator of endogenous neuroprotective preconditioning pathways

Using A3 thinking to improve the STAT medication process

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107994/1/jhm2222.pd

Differences in Veterans' and Nonveterans' End-of-Life Preferences: A Pilot Study

Background: Investigators conducting focus groups on end-of-life preferences noted that veterans voiced opinions that strongly differed from those of nonveterans. Objective: The objective of this study was to further explore differences between veterans' and nonveterans' end-of-life preferences. Methods: Ten focus groups and a pilot survey were conducted. Setting and sample: The focus groups consisted of Arab Muslims, Arab Christians, Hispanics, blacks, and whites stratified by gender (n = 73). Fifteen male veterans were included across all five racial groups. Measures: A moderator discussion guide was used to lead the focus groups and a pilot survey asked about demographic information and end-of-life preferences. Results: Veterans were more likely to be married (p < 0.05) and less connected to their cultural group (p < 0.05) than nonveterans. The focus group results indicated that veterans in this study were more likely to oppose the use of heroic measures compared to nonveterans. More so than nonveterans, veterans felt that their doctors should be frank and open (p < 0.05) were strongly in favor of do-not-resuscitate (DNR) orders (p < 0.10), yet were less likely to have a proxy (p < 0.10) or durable power of attorney p < 0.01). Comparing end-of-life preferences, veterans felt less strongly than nonveterans about remembering personal accomplishments (p < 0.05), being listened to (p < 0.05), being with friends (p < 0.01), or being comfortable with their nurse (p < 0.05), but did want to be around their pets at the end of life p < 0.10). Implications: The Department of Veterans Affairs is in a unique position to improve endof- life care for veterans. Providing end-of-life care that is congruent with the veteran's wishes can improve satisfaction and increase cost effectiveness by eliminating unacceptable services.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63253/1/jpm.2006.9.1099.pd

Predictors of poor sleep quality among head and neck cancer patients

Objectives/Hypothesis: The objective of this study was to determine the predictors of sleep quality among head and neck cancer patients 1 year after diagnosis. Study Design: This was a prospective, multisite cohort study of head and neck cancer patients (N = 457). Methods: Patients were surveyed at baseline and 1 year after diagnosis. Chart audits were also conducted. The dependent variable was a self-assessed sleep score 1 year after diagnosis. The independent variables were a 1 year pain score, xerostomia, treatment received (radiation, chemotherapy, and/or surgery), presence of a feeding tube and/or tracheotomy, tumor site and stage, comorbidities, depression, smoking, problem drinking, age, and sex. Results: Both baseline (67.1) and 1-year postdiagnosis (69.3) sleep scores were slightly lower than population means (72). Multivariate analyses showed that pain, xerostomia, depression, presence of a tracheotomy tube, comorbidities, and younger age were statistically significant predictors of poor sleep 1 year after diagnosis of head and neck cancer ( P < .05). Smoking, problem drinking, and female sex were marginally significant ( P < .09). Type of treatment (surgery, radiation and/or chemotherapy), primary tumor site, and cancer stage were not significantly associated with 1-year sleep scores. Conclusions: Many factors adversely affecting sleep in head and neck cancer patients are potentially modifiable and appear to contribute to decreased quality of life. Strategies to reduce pain, xerostomia, depression, smoking, and problem drinking may be warranted, not only for their own inherent value, but also for improvement of sleep and the enhancement of quality of life. Laryngoscope, 2010Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75789/1/20924_ftp.pd

An academic hospitalist model to improve healthcare worker communication and learner education: Results from a quasi‐experimental study at a veterans affairs medical center

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102160/1/jhm2105.pd

Urinary Retention Evaluation and Catheterization Algorithm for Adult Inpatients

Importance: Acute urinary retention (UR) is common, yet variations in diagnosis and management can lead to inappropriate catheterization and harm. Objective: To develop an algorithm for screening and management of UR among adult inpatients. Design, Setting, and Participants: In this mixed-methods study using the RAND/UCLA Appropriateness Method and qualitative interviews, an 11-member multidisciplinary expert panel of nurses and physicians from across the US used a formal multi-round process from March to May 2015 to rate 107 clinical scenarios involving diagnosis and management of adult UR in postoperative and medical inpatients. The panel ratings informed the first algorithm draft. Semistructured interviews were conducted from October 2020 to May 2021 with 33 frontline clinicians—nurses and surgeons from 5 Michigan hospitals—to gather feedback and inform algorithm refinements. Main Outcomes and Measures: Panelists categorized scenarios assessing when to use bladder scanners, catheterization at various scanned bladder volumes, and choice of catheterization modalities as appropriate, inappropriate, or uncertain. Next, qualitative methods were used to understand the perceived need, usability, and potential algorithm uses. Results: The 11-member expert panel (10 men and 1 woman) used the RAND/UCLA Appropriateness Method to develop a UR algorithm including the following: (1) bladder scanners were preferred over catheterization for UR diagnosis in symptomatic patients or starting as soon as 3 hours since last void if asymptomatic, (2) bladder scanner volumes appropriate to prompt catheterization were 300 mL or greater in symptomatic patients and 500 mL or greater in asymptomatic patients, and (3) intermittent was preferred to indwelling catheterization for managing lower bladder volumes. Interview findings were organized into 3 domains (perceived need, feedback on algorithm, and implementation suggestions). The 33 frontline clinicians (9 men and 24 women) who reviewed the algorithm reported that an evidence-based protocol (1) was needed and could be helpful to clinicians, (2) should be simple and graphically appealing to improve rapid clinician review, and (3) should be integrated within the electronic medical record and prominently displayed in hospital units to increase awareness. The draft algorithm was iteratively refined based on stakeholder feedback. Conclusions and Relevance: In this study using a systematic, multidisciplinary, evidence- and expert opinion–based approach, a UR evaluation and catheterization algorithm was developed to improve patient safety by increasing appropriate use of bladder scanners and catheterization. This algorithm addresses the need for practical guidance to manage UR among adult inpatients.</p

Antibiotic stewardship teams and Clostridioides difficile practices in United States hospitals: A national survey in The Joint Commission antibiotic stewardship standard era

OBJECTIVE: Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship. METHODS: Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression. RESULTS: Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies. CONCLUSIONS: Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non-ID-trained pharmacists and clinicians in antibiotic stewardship

The Subtype of GluN2 C-terminal Domain Determines the Response to Excitotoxic Insults

It is currently unclear whether the GluN2 subtype influences NMDA receptor (NMDAR) excitotoxicity. We report that the toxicity of NMDAR-mediated Ca(2+) influx is differentially controlled by the cytoplasmic C-terminal domains of GluN2B (CTD(2B)) and GluN2A (CTD(2A)). Studying the effects of acute expression of GluN2A/2B-based chimeric subunits with reciprocal exchanges of their CTDs revealed that CTD(2B) enhances NMDAR toxicity, compared to CTD(2A). Furthermore, the vulnerability of forebrain neurons in vitro and in vivo to NMDAR-dependent Ca(2+) influx is lowered by replacing the CTD of GluN2B with that of GluN2A by targeted exon exchange in a mouse knockin model. Mechanistically, CTD(2B) exhibits stronger physical/functional coupling to the PSD-95-nNOS pathway, which suppresses protective CREB activation. Dependence of NMDAR excitotoxicity on the GluN2 CTD subtype can be overcome by inducing high levels of NMDAR activity. Thus, the identity (2A versus 2B) of the GluN2 CTD controls the toxicity dose-response to episodes of NMDAR activity