Jacobs Institute of Women's Health
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Increased Utilization of Overtime and Agency Nurses and Patient Safety
No full textIMPORTANCE: The use of nurse overtime and agency nurses has increased in recent years, making it important to understand the opportunities and limits of these alternative staffing strategies on patient safety outcomes. OBJECTIVE: To examine the association between overtime and agency nurse staffing hours and hospital patient safety. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study used data from 70 US hospitals, from January 2019 through December 2022. Participants included patients and nurse staff across the 70 hospitals. EXPOSURE: The use of overtime and agency nursing. MAIN OUTCOMES AND MEASURES: The main outcomes were 10 of the US Agency for Healthcare Research and Quality\u27s patient safety indicators and their associations with regular, overtime, and agency nursing hours per patient day: pressure ulcers, iatrogenic pneumothorax, in-hospital fall with hip fracture, perioperative hemorrhage or hematoma, postoperative acute kidney injury requiring dialysis, postoperative respiratory failure, perioperative thromboembolism, postoperative sepsis, postoperative wound dehiscence, and accidental puncture or laceration. A baseline Poisson regression model and a structural breakpoint analysis were used to identify safety thresholds. Pairwise interactions between staffing intensity variables and hospital bed size were also included. Adjustments were made for the COVID-19 hospital census, patient case mix, and hospital characteristics. RESULTS: The sample included 46 hospitals in the South, 20 in the West, and 4 in the Northeast; 48 hospitals were urban, 32 hospitals had fewer than 200 beds, 26 had between 200 and 399 beds, and 12 had 400 or more beds. The average use of nurse overtime and agency nurse hours exceeded safe thresholds for pressure ulcers by 140.0% for agency staffing and by 63.6% for overtime, representing a 6.44% increase associated with excess agency nurse hours and a 2.09% increase for excess use of overtime. There also was a statistically significant association of agency hours with postsurgery hemorrhage or hematoma rates, but no breakpoint threshold. There were no significant associations with other outcomes. CONCLUSIONS AND RELEVANCE: These findings suggest that both nurse overtime and nurse agency hours are associated with increased rates of pressure ulcers, a measure that is one of the most sensitive to nursing care. In future research, hospitals could use their own data to track safe thresholds
Examining isokinetic knee peak torque and time to peak torque as predictors of vertical jump height in division I men\u27s basketball players
No full textThe vertical jump (VJ) is one of the most important movements for basketball athletes and therefore determining modifiable predictors of the VJ would aid substantially in crafting more effective training regimens. The purpose of this study was to determine if isokinetic quadriceps strength and torque predict VJ height and which characteristics and testing speed is the strongest predictor of VJ height. Fifteen subjects (age: 18.5 ± 1.0 years, height: 195.9 ± 6.9 cm, weight: 96.2 ± 13.7 kg) from a single Division I men\u27s basketball team were recruited for this study. All participants performed a standing vertical jump with arm-swing to assess their maximum VJ height. Participants also completed an isokinetic knee extension strength protocol that included testing at multiple speeds. Pearson and Spearman tests found no significant correlation between jump height and peak torque at any of the speeds. Regression analysis showed a statistically significant relationship between time to peak torque at 300°/s and VJ height (R2 = 0.23, p = 0.04). These findings suggest that in a population of elite basketball players, the knee\u27s ability to rapidly generate torque likely plays a greater role in VJ performance than its ability to generate high magnitude of torque. This presents a potential benefit of explosive training regimens such as plyometrics for maximization of jump performance
Correction to: The Psychometric Properties of Autism Mental Status Examination (AMSE) in Turkish Sample
No full textDifferential Treatment Effects on β-Cell Function Using Model-Based Parameters in Type 2 Diabetes: Results From the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)
No full textOBJECTIVE: To evaluate how model-based parameters of β-cell function change with glucose-lowering treatment and associate with glycemic deterioration in adults with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS: In the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), β-cell function parameters derived from mathematical modeling of oral glucose tolerance tests were assessed at baseline (N = 4,712) and 1, 3, and 5 years following randomization to insulin glargine, glimepiride, liraglutide, or sitagliptin, added to baseline metformin. Parameters included insulin secretion rate (ISR), glucose sensitivity (insulin response to glucose), rate sensitivity (early insulin response), and potentiation. Linear mixed-effects models were used to compare changes across treatments. With Cox proportional hazards and Classification And Regression Tree (CART) analyses we evaluated associations between model parameters and glycemic failure (A1C \u3e7.5%; 58.5 mmol/mol). RESULTS: β-Cell function parameters increased variably at year 1 across treatments but subsequently declined for all treatments. Statistically significant changes were noted. Liraglutide led to the greatest increases in ISR, glucose sensitivity and potentiation, remaining above baseline at study end. Sitagliptin improved glucose sensitivity, with modest effects on other parameters. Glimepiride temporarily increased ISR and rate sensitivity but minimally increased glucose sensitivity or potentiation. Rate sensitivity increased most with glargine. Higher β-cell function parameters were protective against glycemic deterioration, but treatment did not alter the relationship between these parameters and glycemic outcomes. CONCLUSIONS: Common glucose-lowering medications impact different physiologic components of β-cell function in T2D. Regardless of treatment modality, lower β-cell function associated with early glycemic failure, and β-cell function progressively declined after initial improvement
Intestinal Gastrin/CCKBR Axis Protects against Type 2 Diabetes by Reducing Intestinal Glucose Absorption through the PI3K/Akt/eIF4B Signaling Pathway
No full textThe Gastrin/CCKBR axis is essential for inhibiting intestinal sodium absorption, but its effects on intestinal glucose metabolism remain elusive. This study aims to determine the role of intestinal Gastrin/CCKBR on glucose absorption in the development of type 2 diabetes (T2D). Intestinal epithelial cell-specific Cckbr knockout mice and control wild-type mice are fed normal diet (ND, 10% fat) or high fat diet (HFD, 60% fat) to study the effect of intestinal Gastrin/CCKBR on blood glucose levels. Gastrin-SiO microspheres (20 mg kg d) are designed so that gastrin specifically stimulates intestinal CCKBR, without its absorption into the circulation. Mice with silenced intestinal Cckbr has pre-diabetes mellitus (Pre-DM) that rapidly progressed into T2D when fed HFD. Moreover, Gastrin-SiO microspheres markedly reduce glucose absorption in duodenum obtained from patients with T2D. In mice with HFD-induced T2D, Gastrin-SiO microspheres reduce intestinal glucose absorption by down-regulating intestinal SGLT1 and GLUT2 expressions and stimulating incretin secretion. This study shows the important role of intestinal Gastrin/CCKBR in intestinal glucose absorption. Gastrin-SiO microspheres may be a promising strategy for the treatment of patients with T2D
Prophylactic antibiotic use in trauma patients with non-operative facial fractures: A prospective AAST multicenter trial
No full textBACKGROUND: Craniofacial trauma affects approximately 3 million individuals in the United States annually. Historically, low overall data quality and inadequate sample size have limited the development of clinical practice guidelines for prophylactic antibiotic use in facial fractures. We sought to examine the current use patterns and effects of prophylactic antibiotics in non-operative facial fractures. METHODS: A prospective analysis of adult patients with nonoperative facial fractures was conducted across 19 centers from January 2022 to December 2023. Kruskal-Wallis H , Mann-Whitney U , Pearson\u27s χ 2 , Fisher\u27s exact tests, and logistic regression models were used to evaluate the association between antibiotic duration (no antibiotics, ≤24 hours, and \u3e24 hours) and facial fracture-associated infectious complications. RESULTS: Among 1,835 patients, 1,168 (63.7%) received no antibiotics and 667 (36.4%) received antibiotics (≤24 hours, n = 264 (14.4%); \u3e24 hours, n = 403 (22.0%). Nineteen (1.0%) patients developed infectious complications (0.7% in the no antibiotic group vs. 1.7% with antibiotics). Most patients (99.0%) did not develop an infection despite the majority (63.7%) receiving no antibiotics. Injuries were predominately closed fractures (86.3%), without mucosal disruption (83.9%) or foreign bodies (97.7%). Antibiotic administration had a statistically significant association with the occurrence of infectious complications ( p = 0.050). However, no significant association was seen between antibiotic duration and infectious complications following multivariable logistic regression, adjusting for confounders (≤24 hours: adjusted odds ratio, 1.24; 95% confidence interval, 0.30-5.14; p = 0.766; \u3e24 hours: adjusted odds ratio, 1.32; 95% confidence interval, 0.37-4.69; p = 0.668). CONCLUSION: Despite most patients not receiving antibiotics, infection rates remained low. This indicates prophylactic antibiotic use does not reduce the risk of fracture-associated infections for most injury patterns. While a randomized trial is optimal to validate these data, at this time, there is no evidence to support presumptive antibiotics for closed non-operative facial fractures. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II
Transtracheal Ultrasound as a Preventive Tool for ETT Related Adverse Events and Malpositioning in the ICU
No full textIntroductionEndotracheal tube (ETT) malpositioning can result in a myriad of complications. Daily chest radiographs (CXR) is the gold standard in monitoring these complications. Point-of-care transtracheal ultrasound (TTUS) is an emerging imaging modality for ETT positioning. We compared ETT malpositioning related adverse events and diagnostic accuracy of ETT malpositioning of a combined TTUS and CXR surveillance protocol to CXR alone.MethodsWe performed a randomized control trial of mechanically ventilated patients in an academic multidisciplinary ICU. In the intervention group, the clinical team was provided the results of the TTUS with CXR results to aid in clinical decision making. In the control group only CXR results were used. Adverse events included bronchial migration, vocal cord herniation, balloon rupture, unplanned extubation, and the development of aspiration pneumonia. Data was analyzed via Fisher\u27s Exact Test. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated
Medical Support to Irregular Warfare: A Systematic Literature Review, 2000-2024
No full textINTRODUCTION: Irregular Warfare (IW) is used by the United States and other nations to shape the environment, deter, or prevent conflict, and prevail in war through asymmetric activities. Irregular Warfare occurs in resource-constrained environments with inadequate medical infrastructure or in those that are contested, denied, or sensitive. These environments pose challenges to providing medical care to U.S., ally, and partner nation forces and civilians. The purpose of this research was to identify what global lessons learned since 9/11 can be applied to current challenges and future direction that enhance medical support to IW. MATERIALS AND METHODS: A systematic literature review of peer-reviewed and grey literature using 88 databases within PubMed, Scopus, EBSCOhost, and ProQuest was conducted. Data on the characteristics of irregular warfare medicine from 2000 to the present were extracted and documented. This included the US Department of Defense (DoD) doctrine, organization, training, materiel, leadership and education, personnel, facilities, and policy (DOTMLPF-P) framework and DoD medical functional areas. RESULTS: Of the 12,656 sources identified, 7,988 remained after excluding duplicate matches. A total of 1,063 met the inclusion criteria and were primarily written by civilians (51.7%), covering 81 different countries, representing all Geographical Combatant Commands. US Central Command featured most prominently (61.9%) and was therefore heavily biased toward counterinsurgency (30.3%) as a form of IW. Most publications focused on hemorrhage (14.5%), with disease non-battle injury closely behind (14.2%). Noncombatants were the focus of a majority of the articles (29.6%) while service members were most cited as the recipients of care (41.6%). From a DOTMLPF-P perspective, organization was discussed the most (17.2%) followed by personnel (15.2%). When considering medical functional areas, medical treatment featured prominently (28.9%) trailed by medical logistics (17.6%). The key findings were categorized into 10 themes: (1) interagency and multinational synchronization are essential, (2) medical resiliency requires strategic planning, (3) Global Health Engagement is an important enabler, (4) gaps remain in medical doctrine, (5) low-signature operations drive new needs, (6) host nation capabilities are vital, (7) extended care drives new training requirements, (8) ethics and human rights remain a concern, (9) mental health remains a priority, (10) and technological innovations are required. CONCLUSIONS: The advancement in medical care during the past 24 years of IW have enhanced survivability of combatants and noncombatants alike. Unfortunately, challenges remain. The lack of clear IW medicine policy and doctrine has obscured roles, responsibilities, requirements, and capabilities among the various stakeholders within the DoD and beyond. Efforts to advance the provision of medical support in IW have progressed without a cardinal direction or universally shared foundation of knowledge. This research provides a DOTMLPF-P framework to support closing existing gaps and moving forward recommended solutions in the near and long term. Now is the time in this era of potential Large Scale Combat Operations to leverage IW medicine as part of integrated deterrence to mitigate the risk to force and mission while preparing for future conflicts across continents, climates, and geopolitical circumstances
Unmet Health and Childcare Needs After Neonatal Intensive Care Unit Discharge
No full textThis study aimed to identify unmet health and childcare needs and associations with infant characteristics, parent characteristics, and parent self-efficacy after neonatal intensive care unit (NICU) discharge.We conducted a secondary mixed-methods analysis of data from a single-center randomized control trial. Twelve months after discharge, parents reported if their child did not need, need and received, or needed but did not receive seven health and childcare services. Associations with infant characteristics, parent characteristics, and parent self-efficacy were assessed using logistic regression. Open-ended responses were analyzed for themes.A total of 241 families completed assessments 12 months after discharge. Thirty-three respondents (14%) reported at least one unmet need. Increasing gestational age decreased the odds of unmet needs (odds ratio [OR]: 0.91; 95% confidence interval [CI]: 0.84-0.97), while longer length of stay and moderate or severe infant functional status increased odds (OR: 1.01; 95% CI: 1.01-1.02; OR: 2.93; 95% CI: 1.14-8.17). Greater self-efficacy was associated with lower odds of unmet needs (OR: 0.91; 95% CI: 0.85-0.97). Black parents had 2.8 times the odds of unmet needs compared to White parents after adjusting for length of stay (95% CI: 1.15-7.54). Self-efficacy may have a moderating effect on this racial disparity. Parents reported needing childcare, psychosocial support, and financial assistance in open-ended responses.We found families experienced unmet health and childcare needs with evident racial disparities in the year after NICU discharge. Greater parental self-efficacy may reduce this racial gap. Pediatric practices and health care systems, especially NICU follow-up programs, should continue to screen and connect this high-risk population to support and resources. · Greater unmet needs after NICU discharge were associated with greater infant illness severity.. · Black parents had greater odds of reporting unmet needs compared to White parents.. · Greater parent self-efficacy was associated with lower odds of unmet needs.
Validation of eight endotypes of lupus based on whole-blood RNA profiles
No full textOBJECTIVE: We previously described a classification system of persons with SLE based on whole blood RNA profiles and a random forest (RF) algorithm to predict individual patient endotypes. Here, we apply this algorithm prospectively in an independent set of patients to validate its use as a staging biomarker. METHODS: Whole blood from 101 patients participating in three clinical trials (NCT03626311, NCT03180021 and NCT05845593) meeting American College of Rheumatology (ACR) or Systemic Lupus Collaborating Clinics (SLICC) criteria for SLE classification was obtained at baseline, and RNA isolated and sequenced. Gene expression values were used as input to gene set variation analysis (GSVA), and the RF algorithm was applied using GSVA enrichment scores of 32 informative gene sets as input. Composite scores summarising gene expression perturbations were assigned to each patient using a ridge logistic regression algorithm. RESULTS: Patients with SLE were subset into eight endotypes identified by the algorithm. Patterns of gene enrichment in the identified endotypes mirrored those found in the previously reported endotypes. Differences in clinical characteristics, including serum complement levels, autoantibody positivity and the presence of nephritis, were observed between patients in various endotypes. Patients with active, concurrent nephritis were disproportionately assigned to the more molecularly perturbed endotypes. Composite scores were significantly, but modestly, inversely correlated with complement but not SLE Disease Activity Index (SLEDAI) or anti-double-stranded DNA antibody (anti-dsDNA) titre. CONCLUSIONS: The identification of eight molecular endotypes of lupus based on whole blood gene expression was validated in an independent data set of diverse patients. Endotyping patients with SLE based on transcriptional profiles can provide important status (presence of nephritis) information and provide novel molecular insights in support of personalised management