A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system.

OBJECTIVE: To develop and evaluate a program to presvent hospital-acquired pneumonia (HAP). DESIGN: Prospective, observational, surveillance program to identify HAP before and after 7 interventions. An order set automatically triggered in programmatically identified high-risk patients. SETTING: All 21 hospitals of an integrated healthcare system with 4.4 million members. PATIENTS: All hospitalized patients. INTERVENTIONS: Interventions for high-risk patients included mobilization, upright feeding, swallowing evaluation, sedation restrictions, elevated head of bed, oral care and tube care. RESULTS: HAP rates decreased between 2012 and 2018: from 5.92 to 1.79 per 1,000 admissions (P = .0031) and from 24.57 to 6.49 per 100,000 members (P = .0014). HAP mortality decreased from 1.05 to 0.34 per 1,000 admissions and from 4.37 to 1.24 per 100,000 members. Concomitant antibiotic utilization demonstrated reductions of broad-spectrum antibiotics. Antibiotic therapy per 100,000 members was measured as follows: carbapenem days (694 to 463; P = .0020), aminoglycoside days (154 to 61; P = .0165), vancomycin days (2,087 to 1,783; P = .002), and quinolone days (2,162 to 1,287; P < .0001). Only cephalosporin use increased, driven by ceftriaxone days (264 to 460; P = .0009). Benzodiazepine use decreased between 2014 to 2016: 10.4% to 8.8% of inpatient days. Mortality for patients with HAP was 18% in 2012% and 19% in 2016 (P = .439). CONCLUSION: HAP rates, mortality, and broad-spectrum antibiotic use were all reduced significantly following these interventions, despite the absence of strong supportive literature for guidance. Most interventions augmented basic nursing care. None had risks of adverse consequences. These results support the need to examine practices to improve care despite limited literature and the need to further study these difficult areas of care.

A randomized controlled trial of orthodontist-based brief advice to prevent child obesity.

OBJECTIVE: We conducted a randomized controlled trial to test whether brief exercise and diet advice provided during child patient visits to their orthodontic office could improve diet, physical activity, and age-and-gender-adjusted BMI. METHODS: We enrolled orthodontic offices in Southern California and Tijuana, Mexico, and recruited their patients aged 8-16 to participate in a two-year study. At each office visit, staff provided the children with "prescriptions" for improving diet and exercise behaviors. Multilevel models, which adjusted for clustering, determined differential group effects on health outcomes, and moderation of effects. RESULTS: We found differential change in BMI favoring the intervention group, but only among male participants (p < 0.001; Cohen's d = 0.085). Of four dietary variables, only junk food consumption changed differentially, in favor of the intervention group (p = 0.020; d = 0.122); the effect was significant among overweight/obese (p = 0.001; d = 0.335) but not normal weight participants. Physical activity declined non-differentially in both groups and both genders. CONCLUSION: The intervention, based on the Geoffrey Rose strategy, had limited success in achieving its aims. IMPLICATIONS: Orthodontists can deliver non-dental prevention advice to complement other health-practitioner-delivered advice. Higher fidelity to trial design is needed to adequately test the efficacy of clinician-based brief advice on preventing child obesity and/or reversing obesity.

Youth receiving orthodontic care are not immune to poor diet and overweight: a call for dental providers to participate in prevention efforts.

OBJECTIVES: While obesity is common in the US, disparities exist. Orthodontic samples are assumed to be more affluent than the general population and not in need of assistance in developing or maintaining healthy lifestyles. This paper evaluates the need of the orthodontic population for intervention by examining diet and weight status of an orthodontic patient sample and describes a role for dental clinicians in obesity prevention efforts. METHODS: 552 patients age 8-14 years, 54% female, 51% non-Hispanic white, 26% Hispanic were recruited from orthodontic practices in Southern California to participate in a randomized controlled trial of clinician-delivered health promotion. Height, weight, demographics, and diet were recorded. Chi-Square analyses were used to test for differences at baseline by gender, age, ethnicity, and income. RESULTS: 13% of the sample was overweight and 9% was obese. Males had a higher rate of obesity than females. Lower income youth had a higher rate than higher income youth. Hispanic youth had a higher rate than non-Hispanic white youth. Failure to meet national dietary guidelines was common, differing significantly by demographic group. CONCLUSIONS: Within a sample not typically thought of as needing assistance, nearly 25% were overweight or obese and the majority failed to meet dietary recommendations. While most patients could benefit from intervention, male, Hispanic, and lower income groups were in greatest need of assistance. Dental providers, who see youth frequently and already discuss nutrition in the context of oral health, have the opportunity to contribute to obesity prevention.

Prevalence and risk factors for reduced sound tolerance (hyperacusis) in children.

OBJECTIVE: To estimate the prevalence of reduced sound tolerance (hyperacusis) in a UK population of 11-year-old children and examine the association of early life and auditory risk factors with report of hyperacusis. DESIGN: A prospective UK population-based study. STUDY SAMPLE: A total of 7097 eleven-year-old children within the Avon longitudinal study of parents and children (ALSPAC) were asked about sound tolerance; hearing and middle-ear function was measured using audiometry, otoacoustic emissions, and tympanometry. Information on neonatal risk factors and socioeconomic factors were obtained through parental questionnaires. RESULTS: 3.7% (95% CI 3.25, 4.14) children reported hyperacusis. Hyperacusis report was less likely in females (adj OR 0.64, 95% CI 0.49, 0.85), and was more likely with higher maternal education level (adj OR 1.72, 95% CI 1.08, 2.72) and with readmission to hospital in first four weeks (adj OR 1.98, 95% CI 1.20, 3.25). Report of hyperacusis was associated with larger amplitude otoacoustic emissions but with no other auditory factors. CONCLUSIONS: The prevalence of hyperacusis in the population of 11-year-old UK children is estimated to be 3.7%. It is more common in boys.

Changes in microbial communities along redox gradients in polygonized Arctic wet tundra soils.

This study investigated how microbial community structure and diversity varied with depth and topography in ice wedge polygons of wet tundra of the Arctic Coastal Plain in northern Alaska and what soil variables explain these patterns. We observed strong changes in community structure and diversity with depth, and more subtle changes between areas of high and low topography, with the largest differences apparent near the soil surface. These patterns are most strongly correlated with redox gradients (measured using the ratio of reduced Fe to total Fe in acid extracts as a proxy): conditions grew more reducing with depth and were most oxidized in shallow regions of polygon rims. Organic matter and pH also changed with depth and topography but were less effective predictors of the microbial community structure and relative abundance of specific taxa. Of all other measured variables, lactic acid concentration was the best, in combination with redox, for describing the microbial community. We conclude that redox conditions are the dominant force in shaping microbial communities in this landscape. Oxygen and other electron acceptors allowed for the greatest diversity of microbes: at depth the community was reduced to a simpler core of anaerobes, dominated by fermenters (Bacteroidetes and Firmicutes).

Facial allotransplantation: a 3-year follow-up report.

INTRODUCTION: Long term follow-up of face transplant patients is fundamental to our understanding of risks and benefits of this procedure. Worldwide experience has shown that function improves gradually over time. METHODS: In April of 2009, a multidisciplinary team at Brigham and Women's Hospital performed face transplantation on a male patient to address a severe facial defect caused by high-voltage burns. Physical and occupational therapy was performed for the first six post-operative months. Close monitoring of the patient's functional recovery, immunosuppression, and quality of life was performed at set time points. RESULTS: Three years after face transplantation, the patient has recovered near-normal sensation. Along with satisfactory aesthetic results, his motor function continues to improve, aiding his speech, facial expressions, and social interaction. Furthermore, the patient reports continued improvements in quality of life. Infectious, metabolic, and immunologic complications have been successfully managed in a team approach. Immunosuppression doses have been effectively reduced, and steroid therapy was withdrawn before the end of the first postoperative year. CONCLUSIONS: The presented outcomes demonstrate the procedure's growing role in reconstructive surgery as teams continue to focus their efforts on further optimization of immunosuppression and surgical technique.

Sir John Tomes FRS, Fellows of the Royal Society, and dental reform in the nineteenth century.

In this paper Sir John Tomes HonFRCS LDS FRS (1815-95), surgeon-dentist, is presented as the agent through whose membership of the Royal Society the previously disorganized profession of dentistry shared in the process of reform and scientific progress that engaged the medical profession in the second half of the nineteenth century. The study identifies 70 of the Fellows of the Royal Society who were involved in medical and dental research and/or who gave structure and effect to the governance of the medical and dental professions. In recording the education of Tomes as a scientist, his election to the Society and his place in the process of reform, the paper identifies the Royal Society as a superculture, enabling him to act at a functional remove from the cultures of the surgeons and the dentists of the day.