Urinary Tract Infection Frequency and Prescription Prophylaxis in Females and Males with Recurrent Urinary Tract Infection.

Females and males with recurrent urinary tract infections may receive prescription prophylaxis to reduce the infection frequency. Little is known about how prescription prophylaxis differs between patients meeting and exceeding the minimum threshold for recurrent urinary tract infections. The objectives of this study were to estimate the association between infection frequency and receipt of prescription prophylaxis and describe the type of prescription prophylaxis initiated. This observational study used de-identified fully-insured commercial insurance data from the Midwest from 2003-2016 to identify females and males under age 64 with recurrent urinary tract infections. The patients were categorized as having three or more urinary tract infections in twelve months or only two infections in six months. Multiple logistic regression models were used to determine the association between the infection frequency and receipt of prophylaxis. The frequency of the type of prophylaxis initiated was measured. The odds of receiving prophylaxis were greater in the females and males with three or more infections compared to the patients with only two infections. Estrogen prophylaxis was initiated at a higher rate in females aged 45-63 with two infections than the females with three or more infections. Prescription prophylaxis in females and males with recurrent urinary tract infections differs between those meeting and exceeding the minimum frequency threshold.

A prospective observational study comparing outcomes before and after the introduction of an intubation protocol during the COVID-19 pandemic.

OBJECTIVE: Orotracheal intubation is a life-saving procedure commonly performed in the Intensive Care unit and Emergency Department as a part of emergency airway management. Prior to the COVID-19 pandemic, our center undertook a prospective observational study to characterize emergency intubation performed in the emergency department and critical care settings at Manitoba's largest tertiary hospital. During this study, a natural experiment emerged when a standardized "COVID-Protected Rapid Sequence Intubation Protocol" was implemented in response to the pandemic. The resultant study aimed to answer the question; in adult ED patients undergoing emergent intubation by EM and CCM teams, does the use of a "COVID-Protected Rapid Sequence Intubation Protocol" impact first-pass success or other intubation-related outcomes? METHODS: A single-center prospective quasi-experimental before and after study was conducted. Data were prospectively collected on consecutive emergent intubations. The primary outcome was the difference in first-pass success rates. Secondary outcomes included best Modified Cormack-Lehane view, hypoxemia, hypotension, esophageal intubation, cannot intubate cannot oxygenate scenarios, CPR post intubation, vasopressors required post intubation, Intensive Care Unit (ICU) mortality, ICU length of stay (LOS), and mechanical ventilation days. RESULTS: Data were collected on 630 patients, 416 in the pre-protocol period and 214 in the post-protocol period. First-pass success rates in the pre-protocol period were found to be 73.1% (n = 304). Following the introduction of the protocol, first-pass success rates increased to 82.2% (n = 176, p = 0.0105). There was a statistically significant difference in Modified Cormack-Lehane view favoring the protocol (p = 0.0191). Esophageal intubation rates were found to be 5.1% pre-protocol introduction versus 0.5% following the introduction of the protocol (p = 0.0172). CONCLUSION: A "COVID-Protected Protocol" implemented by Emergency Medicine and Critical Care teams in response to the COVID-19 pandemic was associated with increased first-pass success rates and decreases in adverse events.

RéSUMé: OBJECTIFS: L'intubation orotrachéale est une procédure de sauvetage couramment réalisée dans l'unité de soins intensifs et le service des urgences dans le cadre de la gestion des voies aériennes d'urgence. Avant la pandémie de COVID-19, notre centre a entrepris une étude prospective d'observation pour caractériser l'intubation d'urgence effectuée dans le service des urgences et les établissements de soins intensifs du plus grand hôpital tertiaire du Manitoba. Au cours de cette étude, une expérience naturelle est apparue lorsqu'un " protocole d'intubation à séquence rapide protégé contre le COVID " standardisé a été mis en œuvre en réponse à la pandémie. L'étude qui en a résulté visait à répondre à la question suivante : chez les patients adultes des urgences soumis à une intubation urgente par les équipes de médecine d'urgence et de médecine de soins critiques, l'utilisation d'un " protocole d'intubation à séquence rapide protégé par COVID " a-t-elle un impact sur la réussite du premier passage ou sur d'autres résultats liés à l'intubation ? MéTHODE: Une étude prospective quasi-expérimentale avant et après a été menée dans un seul centre. Les données ont été recueillies prospectivement sur des intubations émergentes consécutives. Le résultat principal était la différence entre les taux de réussite au premier passage. Les résultats secondaires comprenaient la meilleure vue de Cormack­Lehane modifiée, l'hypoxémie, l'hypotension, l'intubation œsophagienne, les scénarios d'impossibilité d'intubation et d'oxygénation, la réanimation cardio-pulmonaire après l'intubation, les vasopresseurs nécessaires après l'intubation, la mortalité en unité de soins intensifs (USI), la durée de séjour en USI et les jours de ventilation mécanique. RéSULTATS: Des données ont été recueillies sur 630 patients, 416 dans la période pré-protocole et 214 dans la période post-protocole. Les taux de réussite au premier passage dans la période pré-protocole se sont avérés être de 73,1 % (n = 304). Suite à l'introduction du protocole, les taux de réussite au premier passage ont augmenté à 82,2 % (n = 176, p = 0,0105). Il y avait une différence statistiquement significative dans la vue Cormack­Lehane modifiée en faveur du protocole (p = 0,0191). Les taux d'intubation œsophagienne se sont avérés être de 5,1 % avant l'introduction du protocole contre 0,5 % après l'introduction du protocole (p = 0,0172). CONCLUSION: Un « protocole protégé contre la COVID ¼ mis en œuvre par les équipes de médecine d'urgence et de médecine de soins critiques en réponse à la pandémie de COVID-19 a été associé à une augmentation des taux de réussite du premier passage et à une diminution des événements indésirables.

Voices from the landscape: Storytelling as emergent counter-narratives and collective action from northern BC watersheds.

The 'Ecohealth and Watersheds in Northern BC'' project, situated in a resource rich, settler colonial context, generated three digital stories at the request of the project's Steering Committee members that sought to connect health, environment, and community. Three Steering Committee members championed these stories from their distinct watersheds, resulting in emergent counter-narratives that respond directly to their social-ecological contexts. Nested in literature on blue and green spaces, we present and examine the process of storytelling as emergent counter-narrative and how these narratives challenge us to think of blue and green spaces in interconnected and nuanced ways.

Nipple-Sparing Mastectomy is Not Associated with a Delay of Adjuvant Treatment.

BACKGROUND: High-volume single-institution studies support the oncologic safety of nipple sparing mastectomy (NSM). Concerns remain regarding the increased potential for complications, recurrence, and delays to subsequent adjuvant therapy. A national database was used to examine treatment and outcomes for NSM patients. METHODS: Women undergoing unilateral NSM or skin sparing mastectomy (SSM) for stage 0-4 breast cancer from 2004 to 2013 were identified from the National Cancer Database. Demographic and oncologic characteristics, short-term outcomes and time to local and systemic treatment were compared. RESULTS: NSM was performed on 8173 patients: 8.7% were node positive, and for stage 1-4 disease, 10.6% were triple negative (TN) and 15.3% were HER2-positive. NSM patients were less likely than SSM patients to receive chemotherapy [CT] (37.4 vs. 43.4%) or radiation [PMRT] (15.6 vs. 16.9%), and were also more likely to present with clinically early-stage disease. NSM patients with high-risk features were more likely to receive CT in the neoadjuvant [NCT] than adjuvant setting [AC] (OR 3.76, 1.81, and 1.99 for clinical N2/3, TN, and HER2-positive disease, all p < 0.001). On multivariate analysis, NSM patients had a higher rate of pathologic complete response [pCR] (OR 1.41, p < 0.001). Readmission rate, positive margin rate and time to CT, PMRT or hormonal therapy were not increased for NSM compared to SSM patients. CONCLUSIONS: Over one third of NSM patients received chemotherapy and/or radiation. NSM patients with high-risk features were more likely to receive NAC and obtain a pCR. NSM patients did not experience worse outcomes or delayed adjuvant therapy compared to SSM.

Impact of debates on student perceptions and competency scores in the advanced pharmacy practice setting.

BACKGROUND AND PURPOSE: Advanced pharmacy practice experience (APPE) students are faced with the difficult reality that there is rarely one correct answer to a patient care question. Faculty preceptors developed a clinical debate activity to provide students with an opportunity to explore pharmacy topics with competing viewpoints. EDUCATIONAL ACTIVITY AND SETTING: The clinical debate activity was implemented in the APPE setting as a collaboration between three faculty preceptors from Drake University and University of Iowa. Student pre-debate and post-debate survey data was collected to assess the perceived impact of clinical debates on student confidence in skills related to the debate. Students were also asked to provide which skills were developed through the debate, whether participation in the debate changed their opinion on the issue, and if debates should be used as a teaching tool. Faculty preceptor scores on midpoint and final evaluations for applicable APPE competencies were also evaluated. FINDINGS: Forty-two students participated in a clinical debate over a 12-month period. Students demonstrated improved confidence in almost all areas assessed, and 90.5% of students felt debates should be used as a teaching tool. Assessment of faculty midpoint (pre-debate) and final (post-debate) evaluation scores revealed statistically significant improvements in competencies related to literature evaluation and communication skills. DISCUSSION AND CONCLUSIONS: Clinical debates have had a positive impact on both subjective and objective results in this APPE setting. Preceptors are encouraged to consider implementing a similar activity. Debates are a useful teaching tool in developing confidence and skills.

Innovative dengue vector control interventions in Latin America: what do they cost?

BACKGROUND: Five studies were conducted in Fortaleza (Brazil), Girardot (Colombia), Machala (Ecuador), Acapulco (Mexico), and Salto (Uruguay) to assess dengue vector control interventions tailored to the context. The studies involved the community explicitly in the implementation, and focused on the most productive breeding places for Aedes aegypti. This article reports the cost analysis of these interventions. METHODS: We conducted the costing from the perspective of the vector control program. We collected data on quantities and unit costs of the resources used to deliver the interventions. Comparable information was requested for the routine activities. Cost items were classified, analyzed descriptively, and aggregated to calculate total costs, costs per house reached, and incremental costs. RESULTS: Cost per house of the interventions were $18.89 (Fortaleza), $21.86 (Girardot), $30.61 (Machala), $39.47 (Acapulco), and $6.98 (Salto). Intervention components that focused mainly on changes to the established vector control programs seem affordable; cost savings were identified in Salto (-21%) and the clean patio component in Machala (-12%). An incremental cost of 10% was estimated in Fortaleza. On the other hand, there were also completely new components that would require sizeable financial efforts (installing insecticide-treated nets in Girardot and Acapulco costs $16.97 and $24.96 per house, respectively). CONCLUSIONS: The interventions are promising, seem affordable and may improve the cost profile of the established vector control programs. The costs of the new components could be considerable, and should be assessed in relation to the benefits in reduced dengue burden.

Integrating participatory community mobilization processes to improve dengue prevention: an eco-bio-social scaling up of local success in Machala, Ecuador.

BACKGROUND: This project investigates the effectiveness and feasibility of scaling-up an eco-bio-social approach for implementing an integrated community-based approach for dengue prevention in comparison with existing insecticide-based and emerging biolarvicide-based programs in an endemic setting in Machala, Ecuador. METHODS: An integrated intervention strategy (IIS) for dengue prevention (an elementary school-based dengue education program, and clean patio and safe container program) was implemented in 10 intervention clusters from November 2012 to November 2013 using a randomized controlled cluster trial design (20 clusters: 10 intervention, 10 control; 100 households per cluster with 1986 total households). Current existing dengue prevention programs served as the control treatment in comparison clusters. Pupa per person index (PPI) is used as the main outcome measure. Particular attention was paid to social mobilization and empowerment with IIS. RESULTS: Overall, IIS was successful in reducing PPI levels in intervention communities versus control clusters, with intervention clusters in the six paired clusters that followed the study design experiencing a greater reduction of PPI compared to controls (2.2 OR, 95% CI: 1.2 to 4.7). Analysis of individual cases demonstrates that consideration for contexualizing programs and strategies to local neighborhoods can be very effective in reducing PPI for dengue transmission risk reduction. CONCLUSIONS: In the rapidly evolving political climate for dengue control in Ecuador, integration of successful social mobilization and empowerment strategies with existing and emerging biolarvicide-based government dengue prevention and control programs is promising in reducing PPI and dengue transmission risk in southern coastal communities like Machala. However, more profound analysis of social determination of health is called for to assess sustainability prospects.

Ecological, biological and social dimensions of dengue vector breeding in five urban settings of Latin America: a multi-country study.

BACKGROUND: Dengue is an increasingly important public health problem in most Latin American countries and more cost-effective ways of reducing dengue vector densities to prevent transmission are in demand by vector control programs. This multi-centre study attempted to identify key factors associated with vector breeding and development as a basis for improving targeted intervention strategies. METHODS: In each of 5 participant cities in Mexico, Colombia, Ecuador, Brazil and Uruguay, 20 clusters were randomly selected by grid sampling to incorporate 100 contiguous households, non-residential private buildings (businesses) and public spaces. Standardized household surveys, cluster background surveys and entomological surveys specifically targeted to obtain pupal indices for Aedes aegypti, were conducted in the dry and wet seasons. RESULTS: The study clusters included mainly urban low-middle class populations with satisfactory infrastructure and -except for Uruguay- favourable climatic conditions for dengue vector development. Household knowledge about dengue and "dengue mosquitoes" was widespread, mainly through mass media, but there was less awareness around interventions to reduce vector densities. Vector production (measured through pupal indices) was favoured when water containers were outdoor, uncovered, unused (even in Colombia and Ecuador where the large tanks used for household water storage and washing were predominantly productive) and -particularly during the dry season- rainwater filled. Larval infestation did not reflect productive container types. All productive container types, including those important in the dry season, were identified by pupal surveys executed during the rainy season. CONCLUSIONS: A number of findings are relevant for improving vector control: 1) there is a need for complementing larval surveys with occasional pupal surveys (to be conducted during the wet season) for identifying and subsequently targeting productive container types; 2) the need to raise public awareness about useful and effective interventions in productive container types specific to their area; and 3) the motivation for control services that-according to this and similar studies in Asia- dedicated, targeted vector management can make a difference in terms of reducing vector abundance.