Improving food insecurity screening across a health system throughout the COVID-19 pandemic.

BACKGROUND: Food insecurity has direct and indirect negative outcomes on the physical and mental health of children, with impacts throughout adult life. Rates of food insecurity have increased dramatically since the start of the COVID-19 pandemic. The American Academy of Pediatrics recommends paediatricians screen and intervene to address food insecurity. We aimed to increase the percentage of patient encounters with food insecurity screening completion at the paediatric medical home from 0% to 85% by July 2020 with extension to the paediatric emergency department (ED) and paediatric specialty clinic in the following year. METHODS: This multicentre project occurred in three sites within our health system: a teaching safety-net, paediatric medical home; a paediatric ED; and five divisions within paediatric specialty medical clinics. A screening tool was created using the validated Hunger Vital Sign Questionnaire. A standard screening, documentation and referral process was developed. The Model for Improvement was used testing changes via Plan-Do-Study-Act cycles. RESULTS: The percentage of households screened for food insecurity increased from a median of 0% to 30% for all sites combined. There was significant variability in screening with the ED screening a median of 24% and the medical home screening 80% by the end of the study period. A total of 9842 households (20.9%) screened were food insecure. During the study period, 895 families with 3925 household members received 69 791 pounds of food from our primary community resource using our clinic's food prescription. Of these families, 44% (398) also qualified for the US Department of Agriculture programme ensuring ongoing food distribution up to twice a month. DISCUSSION: Using quality improvement methodology to address a critical community need, we implemented food insecurity screening across a hospital system including multiple sites and specialties and provided critical resources to households in need.

Contamination acts as a genotype-dependent barrier to gene flow, causing genetic erosion and fine-grained population subdivision in Mussels from the Strait of Istanbul.

This study provides evidence of fine-grained genetic structuring in Mediterranean mussels (Mytilus galloprovincialis) from the Strait of Istanbul, caused by barriers to gene flow via contaminant-mediated selection. In this study, mitochondrial D-loop sequences were analyzed in mussels from 8 localities, all less than 30 kilometers apart, with differing contaminant loads. The results were: 1) Intra-population genetic differentiation (ΦST) between sites with high and low contaminant loads was high (up to 0.459), even at distances of only a few kilometers. 2) Genetic diversity was negatively correlated with the contaminant load ("genetic erosion"). 3) There was evidence of selection, based on haplotype frequencies and neutrality tests (Tajima's D), with purifying selection at the most contaminated site and balancing selection at the least contaminated. 4) Genetic distance was not correlated with geographic distance (no isolation-by-distance), but was correlated with contaminant load at each site. 5) Population dendrograms and Bayesian estimators of migration indicated that gene flow between sites was affected by contamination. For the dendrograms of the sampling sites, the clades clustered according to contaminant load more than geographic distance. Overall, these results suggest that 1) contamination may serve as a genotype-dependent dispersal barrier (i.e., contamination may not affect total number of migrants, just the relative proportions of the haplotypes in the established immigrants), leading strong population differentiation over short distances, and 2) genetic erosion may occur by a combination of selection and altered patterns of haplotype-specific gene flow. These effects may be more pronounced in the Strait of Istanbul than in other locations because of the riverine nature and strong, uni-directional current of the strait.

Immunizations in Children With Chronic Diseases: A State of the Science Review With Implications for Practice Change.

INTRODUCTION: Chronic diseases afflict more than 25% of America's children, and it has been reported that some children with chronic illness are underimmunized, compounding their risks of complications from vaccine-preventable infections. METHOD: To better assess vaccination rates in this population, we systematically reviewed PubMed and CINAHL. Publications were included if specific to immunization rates in U.S. children aged < 18 years and were published between 2010 and 2020. A total of 18 studies were reviewed. RESULTS: Compared with healthy children, children with chronic illnesses have significantly lower vaccination rates, and they face higher risks if they contract a preventable disease. DISCUSSION: Barriers to on-time vaccinations included inadequate education for both parents and providers and misconceptions from nonmedical sources. In addition, lack of provider comfort serves to lower vaccination rates of children with chronic illness. This topic requires further research and discussion until all children are protected from preventable illness.

The Effects of a Deliberate Practice Debriefing During a Response to Rescue Patient Simulation With Undergraduate Nursing Students.

ABSTRACT: The purpose of this multisite, randomized, pretest/posttest quasi-experimental study was to compare student nurse competency, learning retention, and perceived student support after exposure to a deliberate practice debriefing versus standardized debriefing. Fifty undergraduate students participated in the complex response to rescue simulation. The intervention group had significantly higher total mean and three subscale scores on the competency tool than the comparison group, although differences in learning retention and student support were not significant. This study provides preliminary support for the effectiveness of deliberate practice debriefing to enhance students' mastery of skills and behaviors in complex simulations.

Novel Variants in Individuals with RYR1-Related Congenital Myopathies: Genetic, Laboratory, and Clinical Findings.

The ryanodine receptor 1-related congenital myopathies (RYR1-RM) comprise a spectrum of slow, rare neuromuscular diseases. Affected individuals present with a mild-to-severe symptomatology ranging from proximal muscle weakness, hypotonia and joint contractures to scoliosis, ophthalmoplegia, and respiratory involvement. Although there is currently no FDA-approved treatment for RYR1-RM, our group recently conducted the first clinical trial in this patient population (NCT02362425). This study aimed to characterize novel RYR1 variants with regard to genetic, laboratory, muscle magnetic resonance imaging (MRI), and clinical findings. Genetic and histopathology reports were obtained from participant's medical records. Alamut Visual Software was used to determine if participant's variants had been previously reported and to assess predicted pathogenicity. Physical exams, pulmonary function tests, T1-weighted muscle MRI scans, and blood measures were completed during the abovementioned clinical trial. Six novel variants (two de novo, three dominant, and one recessive) were identified in individuals with RYR1-RM. Consistent with established RYR1-RM histopathology, cores were observed in all biopsies, except Case 6 who exhibited fiber-type disproportion. Muscle atrophy and impaired mobility with Trendelenburg gait were the most common clinical symptoms and were identified in all cases. Muscle MRI revealed substantial inter-individual variation in fatty infiltration corroborating the heterogeneity of the disease. Two individuals with dominant RYR1 variants exhibited respiratory insufficiency: a clinical symptom more commonly associated with recessive RYR1-RM cases. This study demonstrates that a genetics-led approach is suitable for the diagnosis of suspected RYR1-RM which can be corroborated through histopathology, muscle MRI and clinical examination.

Training students to detect delirium: An interprofessional pilot study.

AIM: The purpose of this paper is to report nursing student knowledge acquisition and attitude after completing and interprofessional simulation with medical students. INTRODUCTION: The IOM has challenged healthcare educators to teach teamwork and communication skills in interprofessional settings. Interprofessional simulation provides a higher fidelity experience than simulation in silos. Simulation may be particularly useful in helping healthcare workers gain the necessary skills to care for psychiatric clients. Specifically, healthcare providers have difficulty differentiating between dementia and delirium. Recognizing this deficit, an interprofessional simulation was created using medical students in their neurology rotation and senior nursing students. METHOD: Twenty-four volunteer nursing students completed a pre-survey to assess delirium knowledge and then completed an education module about delirium. Twelve of these students participated in a simulation with medicine students. Pre and Post Kid SIM Attitude questionnaires were completed by all students participating in the simulation. After the simulations were complete, all twenty-four students were asked to complete the post-survey regarding delirium knowledge. RESULTS: While delirium knowledge scores improved in both groups, the simulation group scored higher, but the difference did not reach significance. The simulation group demonstrated a statistically significant improvement in attitudes toward simulation, interprofessional education, and teamwork post simulation compared to their pre-simulation scores. CONCLUSION: Nursing students who participated in an interprofessional simulation developed a heightened appreciation for learning communication, teamwork, situational awareness, and interprofessional roles and responsibilities. These results support the use of interprofessional simulation in healthcare education.

Shape selection in Landsat time series: a tool for monitoring forest dynamics.

We present a new methodology for fitting nonparametric shape-restricted regression splines to time series of Landsat imagery for the purpose of modeling, mapping, and monitoring annual forest disturbance dynamics over nearly three decades. For each pixel and spectral band or index of choice in temporal Landsat data, our method delivers a smoothed rendition of the trajectory constrained to behave in an ecologically sensible manner, reflecting one of seven possible 'shapes'. It also provides parameters summarizing the patterns of each change including year of onset, duration, magnitude, and pre- and postchange rates of growth or recovery. Through a case study featuring fire, harvest, and bark beetle outbreak, we illustrate how resultant fitted values and parameters can be fed into empirical models to map disturbance causal agent and tree canopy cover changes coincident with disturbance events through time. We provide our code in the r package ShapeSelectForest on the Comprehensive R Archival Network and describe our computational approaches for running the method over large geographic areas. We also discuss how this methodology is currently being used for forest disturbance and attribute mapping across the conterminous United States.

Coaching Model + Clinical Playbook = Transformative Learning.

Health care employers demand that workers be skilled in clinical reasoning, able to work within complex interprofessional teams to provide safe, quality patient-centered care in a complex evolving system. To this end, there have been calls for radical transformation of nursing education including the development of a baccalaureate generalist nurse. Based on recommendations from the American Association of Colleges of Nursing, faculty concluded that clinical education must change moving beyond direct patient care by applying the concepts associated with designer, manager, and coordinator of care and being a member of a profession. To accomplish this, the faculty utilized a system of focused learning assignments (FLAs) that present transformative learning opportunities that expose students to "disorienting dilemmas," alternative perspectives, and repeated opportunities to reflect and challenge their own beliefs. The FLAs collected in a "Playbook" were scaffolded to build the student's competencies over the course of the clinical experience. The FLAs were centered on the 6 Quality and Safety Education for Nurses competencies, with 2 additional concepts of professionalism and systems-based practice. The FLAs were competency-based exercises that students performed when not assigned to direct patient care or had free clinical time. Each FLA had a lesson plan that allowed the student and faculty member to see the competency addressed by the lesson, resources, time on task, student instructions, guide for reflection, grading rubric, and recommendations for clinical instructor. The major advantages of the model included (a) consistent implementation of structured learning experiences by a diverse teaching staff using a coaching model of instruction; (b) more systematic approach to present learning activities that build upon each other; (c) increased time for faculty to interact with students providing direct patient care; (d) guaranteed capture of selected transformative learning experiences; (e) increased student reflection to promote transformative learning; and (f) provided avenues for timely feedback to students.

The effect of simulation on clinical performance: a junior nursing student clinical comparison study.

INTRODUCTION: Patient simulation has been used to augment the traditional clinical model, but its value is unclear. The aim of this study was to evaluate the effects of a theory-driven pediatric simulation curriculum on nursing students' clinical performance. METHODS: The convenience sample included 116 junior nursing students enrolled in a pediatric course. Using a staggered timing model, students attended simulation instead of clinical for 2 weeks (25%) of an 8-week semester. The students spent the same amount of time in simulation as in clinical (12 hours per week). Student clinical performance was assessed using a Likert-style tool at 2-week intervals by the clinical faculty. Scores of students who attended simulation in the first 2 weeks were compared with students who had not yet attended simulation. Data were analyzed using repeated measure analysis with the mixed model, and covariate effects were considered. A Compound Symmetry covariance model was used to control the correlation between weeks within each subject. Statistical significance was determined at the 5% level. RESULTS: Faculty rated students with patient simulation experience higher than those who had not yet attended simulation (mean ± standard error: 1.74 ± 0.75, P = 0.02). On item-level analysis, therapeutic skills were positively impacted by simulation (P = 0.02). CONCLUSIONS: Time in simulation enhanced clinical performance, as simulation students achieved higher scores more quickly than those without simulation and maintained high performance levels. These findings suggest patient simulation is a valuable addition to augment the apprenticeship model.

Respiratory effects of household exposures to tobacco smoke and gas cooking.

The records of 1,724 residents of Washington County, Maryland, who had participated in 2 studies of respiratory symptoms and ventilatory function were analyzed to evaluate the effects of exposures at home to tobacco smoke generated by other members of their households and to fumes from the use of gas as a cooking fuel. Currently smoking subjects showed the highest frequency of respiratory symptoms and impaired ventilatory function; former smokers showed a lower frequency of these findings; and persons who had never smoked had the lowest prevalence of abnormal respiratory findings. The presence of a smoker in the household other than the subject was not associated with the frequency of respiratory symptoms, and only suggestively associated with evidence of impaired ventilatory function. The use of gas for cooking was related to an increased frequency of respiratory symptoms and impaired ventilatory function among men, being most marked among men who had never smoked. There was no evidence that cooking with gas was harmful to women.

Roles and responsibilities of health care agents: views of patients and agents.

Two qualitative methods were used to explore, from the perspectives of both patients and agents, the roles and responsibilities of health care agents related to making end-of-life decisions. Results of the individual interviews revealed that both patients and agents did not have a clear understanding of the role, responsibility, and legal authority of health care agents. The results of the focus group of former agents indicated that when assuming the role, some agents had both knowledge and experience in making end-of-life decisions, whereas others had little understanding of their role. Former agents discussed serious communication difficulties they had encountered with health care professionals when making life-and-death decisions.

Theory of planned behavior and multivitamin supplement use in Caucasian college females.

The objective of this study was to identify predictors of the use of multivitamin supplements (MVS) among Caucasian college females utilizing the Theory of Planned Behavior (TPB). Variables of the TPB and the self-reported use of multivitamin supplements were measured by two separate surveys within 1 week with a convenience sample of 96 Caucasian college student females. Two attitudinal beliefs and one control belief significantly predicted behavioral intention to use multivitamin. A belief that taking multivitamin supplements helps to feel and look good was the most important predictor of the use of multivitamin supplements. EDITORS' STRATEGIC IMPLICATIONS: Findings from this study, although in need of replication, suggest that prevention campaigns would be more successful if messages used to reach these females were consistent with perceived beliefs regarding benefits of using MVS. More broadly, TPB appears to offer a useful framework for understanding or predicting behavior based on psychological constructs theorized to influence behavior.

N-acetylcysteine for patients with prolonged hypotension as prophylaxis for acute renal failure (NEPHRON).

BACKGROUND: Acute renal failure is a common complication in critically ill patients and carries an increased morbidity and mortality. N-acetylcysteine is an antioxidant and anti-inflammatory agent that may counteract some of the pathophysiologic derangements in shock states. OBJECTIVE: To test whether the administration of N-acetylcysteine, compared with placebo, reduces the incidence of acute renal failure in hypotensive patients. DESIGN: Prospective, randomized, double-blinded, placebo-controlled study. SETTING: Intensive care units of a university tertiary care hospital. PATIENTS: One hundred forty-two patients with new onset (within 12 hrs) of at least>or=30 consecutive minutes of hypotension and/or vasopressor requirement. INTERVENTIONS: Patients were randomized to receive either N-acetylcysteine or placebo for 7 days, in addition to standard supportive therapy. MEASUREMENTS AND MAIN RESULTS: Patients who received N-acetylcysteine had an incidence of acute renal failure (>or=0.5 mg/dL increase in creatinine) of 15.5%, compared with 16.9% in those receiving placebo (p=.82, not significant). There were no significant differences between treatment arms in any of the secondary outcomes examined, including incidence of a 50% increase in creatinine, maximal rise in creatinine, recovery of renal function, length of intensive care unit and hospital stay, requirement for renal replacement therapy, and mortality. Among patients receiving N-acetylcysteine, there were trends toward reduced incidence of acute renal failure in patients with baseline Sequential Organ Failure Assessment (SOFA) score>8 (p=.12), lower SOFA scores during the first 4 days of treatment (p=.28), and reduced mortality in patients<65 yrs of age (p=.20). CONCLUSIONS: There were no significant differences in any of our primary or secondary end points between patients treated with N-acetylcysteine or placebo. Trends toward reduced incidence of acute renal failure in patients with baseline SOFA score >8, reduced SOFA scores during the first 4 days, and reduced mortality in patients<65 yrs of age are provocative but require further study to determine their clinical significance.

Prevalence of overweight among elementary and middle school students in Mississippi compared with prevalence data from the Youth Risk Behavior Surveillance System.

INTRODUCTION: The purpose of the Child and Youth Prevalence of Overweight Survey was to estimate the prevalence of overweight and at risk for becoming overweight among children in Mississippi (grades 1-8) using height and weight measures instead of self-report and to compare the findings for grades 6 through 8 with data from the Youth Risk Behavior Surveillance System for middle school students (grades 6-8). METHODS: Students in randomly selected classes from 37 sampled elementary and middle schools throughout Mississippi participated in the study. School staff were trained to collect height and weight data using a standardized procedure. RESULTS: Overall, 24.0% of students in grades 1 through 8 were found to be overweight, and another 14.7% were at risk for becoming overweight. With the exception of sixth grade, there was a trend of increasing prevalence of overweight by grade (17.5% in grade 1 compared with 31.3% in grade 8). In the Child and Youth Prevalence of Overweight Survey, 25.2% of students in grades 6 through 8 were found to be overweight, compared with 18.5% in the Youth Risk Behavior Surveillance System. CONCLUSION: A high percentage of students in Mississippi are already overweight in first grade, and the prevalence tends to increase by grade. Data collected from middle school students through measured heights and weights in the Child and Youth Prevalence of Overweight Survey were higher than self-reported data from the Youth Risk Behavior Surveillance System. Our data suggest that self-reported data underestimate the prevalence of overweight among middle school students. Efforts to monitor students' body mass index and assess effectiveness of interventions should include all grades and use measured heights and weights rather than self-reports.

A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing.

STUDY OBJECTIVE: We evaluate the safety and feasibility of a critical care pathway protocol in which patients with acute chest pain who are low risk for coronary artery disease and short-term adverse cardiac outcomes receive outpatient stress testing within 72 hours of an emergency department (ED) visit. METHODS: We performed an observational study of an ED-based chest pain critical pathway in an urban, community hospital in 979 consecutive patients. Patients enrolled in the protocol were observed in the ED before receiving 72-hour outpatient stress testing. The pathway was primarily analyzed for rates of death or myocardial infarction in the 6 months after ED discharge and outpatient stress testing. Secondary outcome measures included need for coronary intervention at initial stress testing and within 6 months after discharge, subsequent ED visits for chest pain, and subsequent hospitalization. RESULTS: Of 871 stress-tested patients aged 40 years or older, who had low risk for coronary artery disease and short-term adverse cardiac events, and had 6-month follow-up, 18 (2%) required coronary intervention, 1 (0.1%) had a myocardial infarction within 1 month, 2 (0.2%) had a myocardial infarction within 6 months, 6 (0.7%) had normal stress test results after discharge but required cardiac catheterization within 6 months, and 5 (0.6%) returned to the ED within 6 months for ongoing chest pain. Hospital admission rates decreased significantly from 31.2% to 26.1% after initiation of the protocol (P<.001). CONCLUSION: For patients with chest pain and low risk for short-term cardiac events, outpatient stress testing is feasible, safe, and associated with decreased hospital admission rates. With an evidence-based protocol, physicians efficiently identify patients at low risk for clinically significant coronary artery disease and short-term adverse cardiac outcomes.

Prevalence and degree of childhood and adolescent overweight in rural, urban, and suburban Georgia.

The prevalence and severity of child and adolescent overweight (OW) in the United States have been documented, but little is known regarding the prevalence of OW and "Extent of Overweight" (EOW) in individual states or specific regions within states. The aim of this study was to determine the prevalence of OW and EOW in school-aged youths from 4 regions of Georgia. A 2-stage cluster sampling procedure was performed in 2002, with participation of 4th-, 8th- and 11th-grade students (N = 3114). Measured height and weight were used to determine body mass index (BMI) for age percentiles and data were weighted to estimate population prevalence of OW. A logistic regression model determined predictors of OW. The overall estimate of OW prevalence was 20.2% and highest in males (22.0%), non-Hispanic blacks (21.8%), "other races" (32.4%), and students residing in rural growth (23.7%) and rural decline (23.0%) areas. Overweight prevalence was similar among grades. The overall estimated EOW was 4.3 and highest in males (4.7), other races (5.6), non-Hispanic blacks (5.2), and students from rural growth (5.4) and rural decline (5.0) areas. Sex, race, location, and economic tier were significant predictors (= 0.02) of OW. The prevalence and severity of OW was higher in youths residing in Georgia than nationally. School health professionals, community leaders, and parents should provide support for updated school policies aimed at providing BMI surveillance and a school environment that encourages physical activity and healthy nutrition practices.