Multi-state study of Enterobacteriaceae harboring extended-spectrum beta-lactamase and carbapenemase genes in U.S. drinking water.

Community-associated acquisition of extended-spectrum beta-lactamase- (ESBL) and carbapenemase-producing Enterobacteriaceae has significantly increased in recent years, necessitating greater inquiry into potential exposure routes, including food and water sources. In high-income countries, drinking water is often neglected as a possible source of community exposure to antibiotic-resistant organisms. We screened coliform-positive tap water samples (n = 483) from public and private water systems in six states of the United States for blaCTX-M, blaSHV, blaTEM, blaKPC, blaNDM, and blaOXA-48-type genes by multiplex PCR. Positive samples were subcultured to isolate organisms harboring ESBL or carbapenemase genes. Thirty-one samples (6.4%) were positive for blaCTX-M, ESBL-type blaSHV or blaTEM, or blaOXA-48-type carbapenemase genes, including at least one positive sample from each state. ESBL and blaOXA-48-type Enterobacteriaceae isolates included E. coli, Kluyvera, Providencia, Klebsiella, and Citrobacter species. The blaOXA-48-type genes were also found in non-fermenting Gram-negative species, including Shewanella, Pseudomonas and Acinetobacter. Multiple isolates were phenotypically non-susceptible to third-generation cephalosporin or carbapenem antibiotics. These findings suggest that tap water in high income countries could serve as an important source of community exposure to ESBL and carbapenemase genes, and that these genes may be disseminated by non-Enterobacteriaceae that are not detected as part of standard microbiological water quality testing.

Medicare and Medicaid users speak out about their health care: the real, the ideal, and how to get there.

To inform the design of an integrated health and social service program that will better coordinate care for individuals dually eligible for Medicare and Medicaid, a qualitative study was conducted using 13 focus groups. Participants consisted of a purposeful sample of dually eligible individuals (1) aged 65+ years (8 focus groups: N=71), and (2) aged 18-64 years with disabilities (5 focus groups: N=45), recruited in collaboration with the Connecticut Legislature's Medical Assistance Program Oversight Council and numerous community-based agencies across the state. Older adult participants included nursing home residents, community-dwelling healthy individuals and individuals with chronic illness or disability, family members of individuals with chronic illness or disability, and 1 community-dwelling group of Spanish-speakers. Younger adult participants included persons with physical, intellectual/developmental, and/or mental health disabilities, and parents, case managers, nurses, and residential managers of persons with intellectual/developmental disabilities. Through the constant comparative method, results clustered in 4 domains: current experiences, care coordination, consumer protection, and elements of an ideal health care program. Significant findings include difficulty finding providers who accept Medicare/Medicaid, medication management, age and racial/ethnic discrimination, and care coordination. Findings highlight the policy implications of designing a person-centered, coordinated dual coverage system. Desired elements of an ideal system include greater choice in providers of all types, including culturally competent medical and home care providers, increased coordination among medical providers and between medical and home care/social service providers, and a prominent role for pharmacists in counseling participants and in serving as part of care coordination teams. (Population Health Management 2015;18:123-130).

Sustaining the development and implementation of student-centered teaching nationally: the importance of a community of practice.

Although the idea of using a workshop to educate potential users about a set of materials or techniques is not new, the workshops described here go beyond simple dissemination and create ongoing communities of practice that support widespread and sustained improvement in the biochemistry classroom. The degree to which pedagogical innovations improve student learning on a national level depends on how broadly they are disseminated and how they are implemented and sustained. Workshops can be effective in disseminating ideas and techniques, but they often fail to sustain implementation. This paper describes Core Collaborators Workshops (CCWs) that were specifically designed for biochemistry faculty to improve the quality of active learning materials, support faculty in transforming their classrooms, and disseminate these efforts nationally. This CCW model proved very effective to date as shown by the fact that, 8 months after the last CCW, all workshop participants reported using at least some of the instructional materials discussed during the workshop. In addition, participants remarked that the superior community building and direct mentoring available through the CCWs greatly increased their confidence in implementing this new curricular approach and has made them more likely to act as leaders themselves.

Enhancement of DNA cleavage activity of an unnatural ferrocene-amino acid conjugate.

The nucleolytic activity of an unnatural ferrocenyl amino acid can be significantly enhanced under reducing or Fenton conditions while exploiting different mechanisms of DNA cleavage. In addition, results from high resolution electrophoresis indicate that the ferrocenyl amino acid exhibits non-sequence specific cleavage of the DNA backbone.

A qualitative study of the relationship between clinician attributes, organization, and patient characteristics on implementation of a disease management program.

The purpose of this study was to examine the challenges of integrating an asthma disease management (DM) program into a primary care setting from the perspective of primary care practitioners. A second goal was to examine whether barriers differed between urban-based and nonurban-based practices. Using a qualitative design, data were gathered using focus groups in primary care pediatric practices. A purposeful sample included an equal number of urban and nonurban practices. Participants represented all levels in the practice setting. Important themes that emerged from the data were coded and categorized. A total of 151 individuals, including physicians, advanced practice clinicians, registered nurses, other medical staff, and nonmedical staff participated in 16 focus groups that included 8 urban and 8 nonurban practices. Content analyses identified 4 primary factors influencing the implementation of a DM program in a primary care setting. They were related to providers, the organization, patients, and characteristics of the DM program. This study illustrates the complexity of the primary care environment and the challenge of changing practice in these settings. The results of this study identified areas in a primary care setting that influence the adoption of a DM program. These findings can assist in identifying effective strategies to change clinical behavior in primary care practices.

How type of excuse defense, mock juror age, and defendant age affect mock jurors' decisions.

The authors investigated the effects of mock juror age (younger vs. older), defendant age (22 vs. 65), and type of excuse defense used by defendants (a highly self-inflicted condition, Cocaine Dependency Disorder, vs. a less self-inflicted condition, Posttraumatic Stress Disorder) on mock juror decisions. Ninety-six younger and 96 older adults read a scenario and answered a questionnaire. Results indicated that the defendant using the highly self-inflicted excuse was more likely to receive a guilty verdict and a longer sentence than was the defendant using the less self-inflicted excuse. Older jurors were more certain of their verdicts and saw the defendant as more responsible for his condition than did younger jurors. Defendant age did not affect juror decisions. In addition, excuse type and juror age affected the jurors' perceptions of the victim's responsibility for the attack. The authors discuss the potential influence of juror age on perceptions of defendant responsibility.

Asthma guideline use by pediatricians in private practices and asthma morbidity.

OBJECTIVE: We sought to examine whether pediatric clinicians in private, non-health maintenance organization practices could implement the national asthma guidelines and whether, when implemented, these guidelines would decrease medical services utilization and improve asthma care for children. METHODS: A trial of a disease management program (Easy Breathing II) involving 20 private pediatric practices in the greater Hartford, Connecticut area was conducted between January 1, 2001, and December 31, 2003. Demographic data on participating practitioners and patients were obtained from questionnaires. Medical services utilization data from claims were obtained from ConnectiCare, a regional managed care organization. RESULTS: Of the 16750 children enrolled in Easy Breathing II, 2458 were enrolled in ConnectiCare and 490 had asthma. Inhaled corticosteroid use increased in the community overall during the study period. After enrollment in Easy Breathing II, with adjustment for age, gender, ethnicity, asthma severity, season, and calendar year, children with persistent asthma experienced an additional 47% increase in inhaled corticosteroid use, a 56% reduction in outpatient visits, and a 91% decrease in emergency department visits for treatment of asthma. Adherence to national asthma guidelines for prescribing inhaled corticosteroids was 95%. Seventeen of the 20 practices are still using Easy Breathing, 5 years after program implementation. CONCLUSIONS: Pediatric primary care clinicians in private practice settings can implement an asthma management program patterned after the national asthma guidelines. When implemented, this program is successful in reducing medical services utilization for children with asthma. Just as differences in patterns of medical services utilization exist in private practices, compared with urban clinics, the impact of disease management on medical services utilization differs in private practices, compared with urban clinics.

Risk factors for asthma and asthma severity in nonurban children in Connecticut.

STUDY OBJECTIVE: To examine asthma diagnosis, asthma severity, and the presence of established asthma risk factors in children who reside in nonurban communities. DESIGN: A cross-sectional study was conducted of 19,076 children (6 months to 18 years of age) who lived in 146 nonurban communities in the greater Hartford, CT, region and who were enrolled in a disease-management program (Easy Breathing II; Michelle Cloutier, MD; Hartford, CT) designed to improve asthma diagnosis and treatment. RESULTS: The overall frequency of physician-confirmed asthma in children seeking health care was 18%. Asthma frequency was related to low socioeconomic status (SES), non-Caucasian ethnicity, male gender, age > or = 5 years, and exposure to tobacco smoke, dust, or cockroaches in the multivariate analysis. When controlling for SES, African-American children were 1.33 times more likely (95% confidence interval [CI], 1.15 to 1.53) and Hispanic children were 1.60 times as likely (95% CI, 1.38 to 1.85) as Caucasian children to have asthma. In contrast, asthma severity was related to dust exposure, a family history of asthma, non-Caucasian ethnicity, and age < or = 4 years in the multivariate analysis. African-American children (odds ratio, 1.31; 95% CI, 1.03 to 1.67) had more severe asthma diagnosed as compared to Caucasian children. Hispanic ethnicity was not associated with an increase in asthma severity. CONCLUSION: Risk factors for asthma in nonurban children are similar to risk factors in urban children. Ethnicity is a risk factor for asthma regardless of SES. Even in nonurban environments, African-American and Hispanic children have more asthma, and African-American children have more severe disease than their Caucasian counterparts.

Alcohol screening and brief intervention in primary care settings: implementation models and predictors.

OBJECTIVE: This study compared two different implementation strategies for Cutting Back, a primary care alcohol screening and brief intervention (SBI) program for hazardous and harmful drinkers. It also identified organizational factors contributing to the success or failure of SBI implementation. METHOD: Cutting Back was implemented in 10 primary care practices associated with managed care organizations (MCOs) in five states, through a system of planning, training, technical assistance and clinic feedback. Clinics were randomly assigned to one of two brief intervention systems: In the P Model, medical providers were responsible for delivering interventions, whereas in the S Model mid-level professionals (usually nurses) acted as the clinic specialists to provide that service. Data were collected to measure the performance of screening and delivery of interventions in each clinic. RESULTS: The S Model screened a higher percentage of patients than did the P Model during the best month of program operation (50% vs 44%) and over all months of operation (24% vs 19%). Of those patients who screened positive, more patients in the S condition received an intervention than in the P condition (73.1% vs 57.1%), but there was a considerable range of performance among the five sites within each condition. Results at the clinic level were mixed, with some MCOs performing alcohol SBI significantly better with the S model and others doing better with the P model. The ability of clinics to conduct SBI was significantly correlated with both provider characteristics and organizational factors (e.g., prior SBI experience, MCO stability, number of clinicians trained and the quality of the MCO coordinator's work). Lack of provider time, staff turnover and competing priorities correlated negatively with SBI performance. CONCLUSIONS: The extent to which a given delivery model is likely to work best within an MCO depends on complex provider and organizational characteristics.

In Vitro synthesis and activity of reporter proteins in an Escherichia coli S30 extract system: An undergraduate experiment*.

This undergraduate laboratory experiment integrates multiple techniques (in vitro synthesis, enzyme assays, Western blotting) to determine the production and detection sensitivity of two common reporter proteins (ß-galactosidase and luciferase) within an Escherichia coli S30 transcription/translation extract. Comparison of the data suggests that luciferase is the more suitable reporter for this specific in vitro extract system. Simple modifications in the experimental design allow for flexibility in the use of materials and the time required to perform the study. Furthermore, extension into additional experiments and alternative techniques are also discussed.

Training medical providers to conduct alcohol screening and brief interventions.

Although progress has been made in developing a scientific basis for alcohol screening and brief intervention (SBI), training packages are necessary for its widespread dissemination in primary care settings. This paper evaluates a training package developed for the Cutting Back SBI program. Three groups of medical personnel were compared before and after SBI training: physicians (n = 44), medical students (n = 88), and non-physicians (n = 41). Although the training effects were at times dependent on group membership, all changes were in a direction more conducive to implementing SBI. Physicians and medical students increased confidence in performing screening procedures, and students increased self-confidence in conducting brief interventions. Non-physicians perceived fewer obstacles to screening patients after training. Trained providers reported conducting significantly more SBI than untrained providers, and these differences were consistent with patients' reports of their providers' clinical activity. Thus, when delivered in the context of a comprehensive SBI implementation program, this training is effective in changing providers' knowledge, attitudes, and practice of SBI for at-risk drinking.

Daily coping with pain from rheumatoid arthritis: patterns and correlates.

Seventy-five individuals with rheumatoid arthritis reported their pain coping, mood, and joint pain for 75 consecutive days. Pain coping strategies used most often were taking direct action to reduce the pain and using relaxation strategies; those used least often were expressing emotions about the pain and redefining the pain to make it more bearable. Several background characteristics, including gender, disability, neuroticism, and pain control perceptions predicted use of various coping strategies. Controlling for these characteristics, individuals who used relaxation more frequently as part of their daily coping repertoire had less daily pain during the course of the study, and those who reported more overall coping efforts were more likely to display declining levels of daily pain across time. Pain severity moderated the relations of seeking emotional support and use of distraction with daily mood. At low levels of pain, greater use of these strategies related to more positive mood but, at high levels of pain, related to less positive mood. Finally, individuals who reported a greater number of distinct forms of coping were more apt to enjoy improving daily mood over the course of the study. Findings are discussed in terms of the advantages of prospective daily research designs.