Spray Drying Enzyme-Treated Cellulose Nanofibrils.

Enzyme-treated cellulose nanofibrils (CNFs) were produced via a lab-scale mass colloider using bleached kraft pulp (BKP) to evaluate their processability and power requirements during refining and spray-drying operations. To evaluate the energy efficiency in the CNF refining process, the net energy consumption, degree of polymerization (DP), and viscosity were determined. Less energy was consumed to attain a given fines level by using the endoglucanase enzymes. The DP and viscosity were also decreased using the enzymes. The morphological properties of the enzyme-pretreated spray-dried CNF powders (SDCNFs) were measured. Subsequently, the enzyme-pretreated SDCNFs were added to a PP matrix with MAPP as a coupling agent. The mixture was then compounded through a co-rotating twin-screw extruder to determine whether the enzyme treatment of the CNFs affects the mechanical properties of the composites. Compared to earlier studies on enhancing PMCs with SDCNF powders, this research investigates the use of enzyme-pretreated SDCNF powders. It was confirmed that the strength properties of PP increased by adding SDCNFs, and the strength properties were maintained after adding enzyme-pretreated SDCNFs.

Does maternal vitamin D status influence placental weight or vascular and inflammatory pathology? Secondary analysis from the Kellogg Pregnancy Study.

INTRODUCTION: Positive effects of vitamin D (vitD) supplementation on comorbidities of pregnancy (COP) have been explored; however, few studies have elucidated the pathophysiology behind the development of these COP and the potential relationship with derangements in placental development and morphology. Additionally, it is known that placentas weighing 10th-90th % for gestational age are associated with better outcomes. Therefore, the objective of this study was to assess the impact of resulting circulating serum 25(OH)D concentrations associated with intake of high or low doses of supplementary vitD on placental development and morphology in women who participated in a randomized double blind, placebo-controlled trial of vitD supplementation. We hypothesized that if maternal serum 25(OH)D concentration (vitD status marker) is insufficient/deficient, then placental weight and % for gestational age (GA) will be smaller and will correlate with increased vascular and inflammatory placental pathologic findings. METHODS: The findings of the present study are a secondary analysis of data generated from a previously reported randomized controlled trial (RCT), the Kellogg Vitamin D Pregnancy Study. Pregnant women (n = 297) in this RCT (January 2013 - April 2018) were randomly assigned to 400 IU vs. 4400 IU vitD/day (10-14 weeks' gestational age) and followed to delivery. 132 placentas were analyzed by pathologists blinded to treatment, and the 2016 Amsterdam Consensus Criteria were used to categorize grouping/grading of placental pathology and weight. Total [25(OH)D] was measured using radioimmunoassay (ng/mL). Chi-square and Student's t-test were used to show the difference in maternal characteristics by treatment group and by placental weight. Chi-square analysis was used to determine differences between the percent pathology findings by treatment group. Students t-test was used to determine the differences in vitD status and the frequency of placental lesions. Association between [25(OH)D] area under the curve (AUC) and placental morphology were determined in a regression model that included maternal BMI ≥ 30 kg/m2, race/ethnicity, and vitD treatment group allocation. Data were analyzed using SAS v9.4 (Cary, NC) and statistical significance was indicated by p < 0.05. RESULTS: The percent pathology findings by treatment group were not significantly different for each of the placental pathology categories as defined by the 2016 Amsterdam Consensus Criteria including placental weight. However, when using 25(OH)D as a biomarker for vitD status, linear regression model showed maternal serum [25(OH)D] AUC was significantly associated with greater placental weight (p = 0.023). Logistic regression models showed mothers with BMI ≥ 30 kg/m2 had larger placental weight (p = 0.046), and Hispanic and white/Caucasian mothers had greater placental weights than Black American mothers (p = 0.025). When placentas ≥ 90th % for GA, n = 7, were removed from the placental pool, Pearson correlation still showed a positive association between maternal serum 25(OH)D AUC and placental weight (p = 0.011). In a second linear regression model of placentas ≥ 90th % for GA (n = 7) vs. placentas < 90th % (n = 108), maternal serum 25(OH)D AUC was significantly greater in those placentas ≥ 90th % (p = 0.03); however, this was not associated with increased perinatal mortality. CONCLUSION FINDINGS: suggest increasing maternal serum [25(OH)D] via vitamin D supplementation during pregnancy did not adversely affect placental morphology; trends showed those in the treatment group had fewer placental lesions. Placental weight was found to be significantly associated with [25(OH)D] AUC, which represents maternal vitamin D status over the course of pregnancy; 7 placentas ≥ 90th % for GA were not associated with perinatal mortality.

A case report of CFTR modulator administration via carrier mother to treat meconium ileus in a F508del homozygous fetus.

We report elexacaftor-tezacaftor-ivacaftor (ETI) treatment of a F508del carrier who was pregnant with a F508del homozygous fetus. At 23-weeks gestation meconium ileus (MI) was evident on ultrasound including dilated, hyperechoic bowel, which persisted on subsequent imaging. Through shared decision-making, the mother began ETI at 32 weeks with intent to treat fetal MI. The ultrasound findings persisted at treatment day 13, but bowel dilation had resolved by imaging on treatment day 27. A female infant was delivered vaginally at 36 weeks with no complications. The mother continued ETI while breastfeeding. Stool elastase at age 2 weeks was 240 mcg/g. Sweat chloride measurement was 64 and 62 mEq/L. Maternal and infant liver function testing have been normal. Maternal ETI treatment likely led to resolution of the MI and there is evidence supporting continued infant benefit through breastmilk. Logistical and ethical considerations regarding treatment of a carrier mother for infant benefit are discussed.

Review on Nonconventional Fibrillation Methods of Producing Cellulose Nanofibrils and Their Applications.

The production of cellulose nanofibrils (CNFs) continues to receive considerable attention because of their desirable material characteristics for a variety of consumer applications. There are, however, challenges that remain in transitioning CNFs from research to widespread adoption in the industrial sectors, including production cost and material performance. This Review covers CNFs produced from nonconventional fibrillation methods as a potential alternative solution. Pretreating biomass by biological, chemical, mechanical, or physical means can render plant feedstocks more facile for processing and thus lower energy requirements to produce CNFs. CNFs from nonconventional fibrillation methods have been investigated for various applications, including films, composites, aerogels, and Pickering emulsifiers. Continued research is needed to develop protocols to standardize the characterization (e.g., degree of fibrillation) of the lignocellulosic fibrillation processes and resulting CNF products to make them more attractive to the industry for specific product applications.

The impact of DNA adenine methyltransferase knockout on the development of triclosan resistance and antibiotic cross-resistance in Escherichia coli.

BACKGROUND: DNA adenine methyltransferase (dam) has been well documented for its role in regulation of replication, mismatch repair and transposition. Recent studies have also suggested a role for dam in protection against antibiotic stress, although this is not yet fully defined. We therefore evaluated the role of dam in the development of antibiotic resistance and triclosan-associated cross-resistance. RESULTS: A significant impact on growth rate was seen in the dam knockout compared to the parental strain. Known triclosan resistance-associated mutations in fabI were seen regardless of dam status, with an additional mutation in lrhA seen in the dam knockout. The expression of multiple antibiotic resistance-associated genes was significantly different between the parent and dam knockout post-resistance induction. Reversion rate assays showed that resistance mechanisms were stable. CONCLUSIONS: dam knockout had a significant effect on growth, but its role in the development of antibiotic resistance is likely confined to those antibiotics using acrAD-containing efflux pumps.

Infection prevention and control for labor and delivery, well baby nurseries, and neonatal intensive care units.

During the early months of the COVID-19 pandemic, infection prevention and control (IP&C) for women in labor and mothers and newborns during delivery and receiving post-partum care was quite challenging for staff, patients, and support persons due to a relative lack of evidence-based practices, high rates of community transmission, and shortages of personal protective equipment (PPE). We present our IP&C policies and procedures for the obstetrical population developed from mid-March to mid-May 2020 when New York City served as the epicenter of the pandemic in the U.S. For patients, we describe screening for COVID-19, testing for SARS-CoV-2, and clearing patients from COVID-19 precautions. For staff, we address self-monitoring for symptoms, PPE in different clinical scenarios, and reducing staff exposures to SARS-CoV-2. For visitors/support persons, we address limiting them in labor and delivery, the postpartum units, and the NICU to promote staff and patient safety. We describe management of SARS-CoV-2-positive mothers and their newborns in both the well-baby nursery and in the neonatal ICU. Notably, in the well-baby nursery we do not separate SARS-CoV-2-positive mothers from their newborns, but emphasize maternal mask use and social distancing by placing newborns in isolates and asking mothers to remain 6 feet away unless feeding or changing their newborn. We also encourage direct breastfeeding and do not advocate early bathing. Newborns of SARS-CoV-2-positive mothers are considered persons under investigation (PUIs) until 14 days of life, the duration of the incubation period for SARS-CoV-2. We share two models of community-based care for PUI neonates. Finally, we provide our strategies for enhancing communication and education during the early months of the pandemic.

Implementing the patient care collaborative model in three general internal medicine units: a mixed-methods healthcare improvement initiative.

BACKGROUND: As part of the scale-up of the Patient Care Collaborative (PCC) at our institution, we explored staff perceptions and patient outcomes at different levels of model implementation in three general internal medicine units. METHODS: We conducted a mixed-methods embedded experimental healthcare improvement initiative. In the qualitative strand, we conducted five focus group discussions. In the quantitative strand, we used hospital administrative data to compare outcomes (falls per 1000, median length of stay in days and resource use measured as resource intensity weights (RIW), before and after the implementation of the PCC, using χ2 tests, Wilcoxon's rank sum tests and interrupted time series analyses. RESULTS: Staff showed considerable knowledge and acceptance of the PCC but expressed mixed feelings with regards to patient safety, workload, communication and teamwork. Staff perceptions varied by level of implementation of the PCC. A number of falls (overall) in the full implementation phase were not significantly different from the preimplementation phase (227 per 1000 vs 200 per 1000; p=0.449), but the number of moderate to severe falls dropped (12 vs 2 per 1000); p<0.001). Median length of stay (5 vs 6 days; p<0.001) and resource use were lower (0.1 vs 0.4; p<0.001) in the full implementation phase compared with the preimplementation phase. The trend analyses showed differences across units. CONCLUSIONS: The PCC was moderately well adopted. Perceptions of the PCC among staff and patient outcomes are likely linked to the levels of implementation. The PCC resulted in improved safety, shorter hospital stays and lower costs of care.

Treatment of Opioid Use Disorder in Pregnant Women via Telemedicine: A Nonrandomized Controlled Trial.

Importance: There are high rates of maternal and newborn morbidity and mortality associated with opioid use disorder (OUD). Integrating OUD treatment in obstetric practices for pregnant and postpartum women via telemedicine can increase access to care and reduce the consequences of OUD. Evaluation of this care delivery model, however, is needed before widespread adoption. Objective: To compare maternal and newborn outcomes among pregnant women with OUD receiving care via telemedicine vs in person. Design, Setting, and Participants: A nonrandomized controlled trial including 98 women receiving perinatal OUD treatment in 4 outpatient obstetric practices by telemedicine or in person and followed up until 6 to 8 weeks post partum was conducted from September 4, 2017, to December 31, 2018. Logistic regression with propensity score adjustment was applied to reduce group selection bias and control for potentially confounding variables. Interventions: Participants were seen weekly for 4 weeks, every 2 weeks for 4 weeks, and monthly thereafter and provided relapse prevention therapy and buprenorphine. Main Outcomes and Measures: The outcomes were retention in treatment, defined as uninterrupted addiction treatment during pregnancy through 6 to 8 weeks post partum; urine drug screen results at delivery and 6 to 8 weeks post partum; and a neonatal abstinence syndrome (NAS) diagnosis collected via electronic health records. Results: The mean (SD) age of the 98 pregnant women was 30.23 (5.12) years. Of these, 41 of 44 women (93.2%) in the telemedicine group and 48 of 54 women (88.9%) in the in-person group chose to continue treatment in the program after an initial evaluation. After propensity score weighting and doubly robust estimation, no significant differences were found between groups in retention in treatment at 6 to 8 weeks post partum (telemedicine: 80.4% vs in person: 92.7%; treatment effect, -12.2%; 95% CI, -32.3% to -4.4%). Similarly, after propensity score weighting and doubly robust estimation, there were no significant group differences in rates of NAS (telemedicine: 45.4% vs in person: 63.2%; treatment effect, -17.8%; 95% CI, -41.0% to 8.9%). Conclusions and Relevance: In this nonrandomized controlled trial, virtually integrated OUD care in obstetric practices produced similar maternal and newborn outcomes compared with in-person care. These findings may have important public health implications for combatting the opioid crisis and its consequences on pregnant women and their families. Future large randomized clinical trials are needed. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT04049032.

Evaluation of 2012 US EHDV-2 outbreak isolates for genetic determinants of cattle infection.

Following a summer of severe drought and abnormally high temperatures, a major outbreak of EHDV occurred during 2012 in the USA. Although EHDV-1, -2 and -6 were isolated, EHDV-2 was the predominant virus serotype detected during the outbreak. In addition to large losses of white-tailed deer, the Midwest and northern Plains saw a significant amount of clinical disease in cattle. Phylogenetic analyses and sequence comparisons of newly sequenced whole genomes of 2012 EHDV-2 cattle isolates demonstrated that eight of ten EHDV-2 genomic segments show no genetic changes that separate the cattle outbreak sequences from other EHDV-2 isolates. Two segments, VP2 and VP6, did show several unique genetic changes specific to the 2012 cattle outbreak isolates, although the impact of the genetic changes on viral fitness is unknown. The placement of isolates from 2007 and 2011 as sister group to the outbreak isolates, and the similarity between cattle and deer isolates, point to environmental variables as having a greater influence on the severity of the 2012 EHDV outbreak than viral genetic changes.

School Lunch Entrées Before and After Implementation of the Healthy, Hunger-Free Kids Act of 2010.

BACKGROUND: The Healthy, Hunger-Free Kids Act (HHFKA) 2010 updated standards to increase the nutritional quality of school meals. Studies of HHFKA outcomes have focused primarily on fruit and vegetables, nutrient quality of whole meals, and plate waste. OBJECTIVE: To examine changes in school lunch entrée nutrient quality and student selections after HHFKA implementation. DESIGN: Descriptive, longitudinal study analyzing 1.7 million student-selected lunch entrées in eight entrée categories. PARTICIPANTS/SETTING: Three middle schools and three high schools in an urban school district in Washington State, from January 2011 to January 2014 (16 months before and 15 months after HHFKA implementation). MAIN OUTCOME MEASURES: Nutritional quality of each entrée category was assessed by analyzing mean adequacy ratio, energy density, and energy per serving. Selection was determined by analyzing number of entrées in each category selected by students. STATISTICAL ANALYSES PERFORMED: Comparison of indices of pre- and postimplementation nutritional quality using a combination of Wilcoxon two-sample test with t approximation and a two-sided alternative t test assuming equal variances and t test assuming unequal variances using Satterthwaite approximation. Quantity of entrée categories selected was also determined by Satterthwaite approximation. RESULTS: After implementation, there was significant improvement in mean adequacy ratio and energy per serving overall for all entrées combined. There were significant improvements in both mean adequacy ratio and energy per serving for salads, burritos, and pizza in middle schools and for hot sandwiches and burritos in high schools. For energy density, middle schools also had significant decreases for casseroles and salads, with no significant changes found in high schools. The variety of entrées decreased by 44%, and there were significant changes in the proportions of entrées selected from specific food categories. CONCLUSION: Nutritional quality of lunch entrées, variety of entrées available, and student entrée selections changed after implementation of HHFKA policy in one urban school district in Washington State.

An Assessment of Perceived Barriers to Farmers' Market Access.

OBJECTIVE: To explore whether Supplemental Nutrition Assistance Program-Education (SNAP-Ed) stakeholders (individuals involved in work to increase access to farmers' markets [FMs] for low-income populations) perceive the same barriers to shopping at FMs as those reported by SNAP participants in Washington State. DESIGN: Descriptive study; data included a stratified clustered random sample of SNAP participants and stakeholder interviews. SETTING: Washington State. PARTICIPANTS: A total of 400 SNAP participants and 51 SNAP-Ed stakeholders. MAIN OUTCOME MEASURES: The SNAP participants' reported barriers to accessing FMs and the SNAP-Ed stakeholders' perceptions of FM access barriers. ANALYSIS: Thematic content analysis, descriptive statistics, 2-sample tests of proportion, and Pearson chi-square tests (P < .025). RESULTS: A majority of SNAP participants reported they did not shop at an FM because it is inconvenient (n = 193; 51%) and not financially viable (n = 84; 22%). Moreover, 9% of SNAP participants (n = 34) stated that they experienced no barriers. The SNAP-Ed stakeholders placed increased emphasis on transportation and cost barriers compared with the SNAP participants. CONCLUSIONS AND IMPLICATIONS: Comprehensive, multilevel strategies that reflect the perspectives of SNAP participants could increase SNAP use at FMs. Opening FMs in diverse locations at variable operating times may address convenience barriers while engaging the targeted populations' communities to promote FMs, and FM incentive programs may address financial and awareness barriers.

Effects of a Behavioral Economics Intervention on Food Choice and Food Consumption in Middle-School and High-School Cafeterias.

INTRODUCTION: Changing food choice architecture in school cafeterias through behavioral economics may increase student selection and consumption of healthy foods. However, most research assesses the effects of short-term interventions. We evaluated a year-long choice architecture intervention implemented by school food service staff. METHODS: Food service staff from 6 secondary schools in one school district received training and support to implement behavioral economics strategies in their cafeterias to promote student selection of fruit, vegetables, and low-fat white milk. We compared student selection and consumption of these foods in the intervention schools to 5 comparison schools in the same district on the basis of visual assessment of plate waste. We applied a difference-in-differences approach to estimate intervention effect. RESULTS: Data for 902 students were assessed at baseline, and data for 1,407 were assessed at follow-up. In fully adjusted analyses for all students, there were significantly greater absolute increases in the proportions of intervention school students selecting any fruit, including (0.09) and excluding (0.16) juice, and students selected more fruit items including (0.21) and excluding (0.17) juice. The absolute increase in proportion of intervention students consuming fruit excluding juice (0.14) was significantly greater. However, in some analyses, fewer intervention students who selected fruits or vegetables ate them, or they ate fewer of them. There were no intervention effects for vegetables or low-fat white milk. CONCLUSION: Our results indicate that behavioral economics-based choice architecture can promote student selection of healthy foods, but they raise questions about whether it increases their consumption.

An Evaluation of Washington State SNAP-Ed Farmers' Market Initiatives and SNAP Participant Behaviors.

OBJECTIVE: To describe Supplemental Nutrition Assistance Program-Education (SNAP-Ed)-supported farmers' market (FM) access activities in Washington State communities and identify associations between participation in these activities and SNAP participants' FM shopping and fruit and vegetable consumption. DESIGN: Descriptive study; data included stakeholder interviews and surveys with FM managers and a stratified clustered random sample of SNAP participants. SETTING: Washington State. PARTICIPANTS: A total of 51 SNAP-Ed stakeholders, 400 SNAP participants, and 94 FM managers participated. MAIN OUTCOME MEASURE(S): Partnership measures and SNAP-Ed FM access activities; SNAP participants' participation in FM access activities, FM shopping frequency, and fruit and vegetable consumption. ANALYSIS: Thematic content analysis, descriptive statistics, and 0-inflated Poisson and ordinary least-squares regression models. RESULTS: A total of 343 FM access activities and strong multi-sector partnerships were identified. Fifty percent of SNAP participants shopped at an FM in the past year, and 30% at least monthly. The SNAP participants participating in FM access activities shopped at FMs more frequently (P=.005). The SNAP participants shopping at FMs ate fruit and vegetables more frequently than did non-FM shoppers (P<.001). CONCLUSIONS AND IMPLICATIONS: Through nutrition education and systems and environmental changes, Washington SNAP-Ed developed effective programming and multi-sector partnerships. These efforts are associated with SNAP participants' FM shopping and fruit and vegetable consumption.

Validation of a Two-Item Food Security Screening Tool in a Dental Setting.

Purpose: The United States is typically viewed as a wealthy country, yet not all households have access to enough food for an active, healthy life. The purpose of this study was to validate a two-item written food security screen that health providers may use to identify food insecurity in their patient populations.Methods: Data were obtained from 150 parents or guardians who brought a child to a dental appointment at The Center for Pediatric Dentistry, University of Washington, Seattle, Wash., USA. The sensitivity and specificity of two written questions were determined by comparing with the United States Department of Agriculture Six-item Short Form of the Food Security Survey Module.Results: The sample consisted of 141 surveys after those with critical questions left blank were removed. The prevalence of food insecurity was found to be 31 percent at the Center for Pediatric Dentistry. The six-item screen identified 44 foodinsecure families with an affirmative response to two or more questions. Compared with the six-item screen, the two-item screen was found to have 95.4 percent sensitivity and 83.5 percent specificity.Conclusions: The two-item food security screen was found to be sensitive and reasonably specific, providing a quick and accurate method to identify food-insecure families.

Recent US bluetongue virus serotype 3 isolates found outside of Florida indicate evidence of reassortment with co-circulating endemic serotypes.

Since 1999, 11 serotypes of bluetongue virus (BTV) similar to Central American or Caribbean strains have been isolated in the southeastern United States, predominantly in Florida. The majority of the incursive serotypes have remained restricted to the southeastern US. In recent years, BTV serotype 3 (BTV-3) has been isolated in areas increasingly distant from Florida. The current study uses whole genome sequencing of recent and historical BTV-3 isolates from the US, Central America and the Caribbean with additional sequences from GenBank to conduct phylogenetic analyses. The individual segments of the BTV genome were analysed to determine if recent BTV-3 isolates are reassortants containing genomic segments from endemic US serotypes or if they retain a majority of Central American/Caribbean genotypes. The analyses indicate that BTV-3 isolates Mississippi 2006, Arkansas 2008 and Mississippi 2009 are closely related reassortants that contain five to six genomic segments that are of US origin and two to three segments of Central American/Caribbean origin. In contrast, the BTV-3 South Dakota 2012 isolate contains seven genomic segments that are more similar to isolates from Central American and the Caribbean. These different evolutionary histories of the BTV-3 isolates suggest that there are at least two different lineages of BTV-3 that are currently circulating in the US.

Analysis of Media Coverage on Breastfeeding Policy in Washington State.

BACKGROUND: Media coverage and message framing about breastfeeding polices can influence important policy decisions in institutional and governmental settings. Research aim: This study aimed to describe the media coverage of breastfeeding policies and the message frames that are found in print newspapers and web-only news publications in Washington State between 2000 and 2014. METHODS: For this retrospective media analysis study, 131 news articles published from January 2000 through June 2014 in Washington State that specifically discussed breastfeeding policy were identified, coded, and analyzed to explore the content of the sample and examine how arguments supporting or opposing breastfeeding policy were framed. The coding scheme was developed cooperatively and found to be reliable across coders. RESULTS: The number of articles published each year about breastfeeding policy grew overall between 2000 and 2014 and peaked during periods of specific policy development. Seventy-four articles had a neutral tone, 49 supported breastfeeding policy, and 4 were in opposition. Nine distinct supporting frames and six distinct opposing frames were identified. Common supporting frames were health benefits of breastfeeding and the need for policies because of challenges of breastfeeding in public. The most common opposing frame was indecency of breastfeeding in public. CONCLUSION: There is limited but growing media coverage of breastfeeding policies. For the most part, coverage is supportive of the need for policies. Breastfeeding advocates can apply information about media message frames to craft effective policy development strategies that counteract negative perceptions and promote the benefits of breastfeeding policies.

Reducing hospital-acquired pressure ulcers using bundle methodology in pediatric and neonatal patients receiving extracorporeal membrane oxygenation therapy: An integrative review and call to action.

PURPOSE: This review focuses on identifying (1) evidence of the effectiveness of care bundle methodology to reduce hospital-acquired pressure ulcers (HAPUs) in pediatric and neonatal patients receiving extracorporeal membrane oxygenation (ECMO) therapy and (2) barriers to implementing HAPU care bundles in this at-risk population. DESIGN AND METHODS: An integrative review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search of the scientific literature was performed. Studies included were published between January 2011 and February 2016. A total of seven articles met inclusion criteria. Data were extracted from each published article and analyzed to identify common themes, specifically bundle methodology and barriers to implementing HAPU bundles, in this population. RESULTS: There is limited research on effectiveness of care bundle methodology in reducing HAPUs in children, and no research specific to its effectiveness in pediatric or neonatal ECMO patients. No research was identified studying barriers to implementation of HAPU care bundles in this population. PRACTICE IMPLICATIONS: Nurses are well poised to test innovative strategies to prevent HAPUs. Nurses should consider implementing and testing bundle methodology to reduce HAPU in this at-risk population, and conduct research to identify any barriers to implementing this strategy. There is literature to support the use of nurses as unit-based skin care champions to facilitate teamwork and reliable use of the bundle, both critical components to the success of bundle methodology.