Showing papers by "Saint Francis University published in 2011"

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention

Abstract: Objectives To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention. Design Pre- and post intervention survey. Setting Eight hospitals participating in a trial of a WHO surgical safety checklist. Participants Clinicians actively working in the designated study operating rooms at the eight hospitals. Survey instrument Modified operating-room version Safety Attitudes Questionnaire (SAQ). Main outcome measures Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability. Results Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation. Conclusions Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.

Pregnancy and reproduction in autoimmune rheumatic diseases

Abstract: Despite evidence for the important role of oestrogens in the aetiology and pathophysiology of chronic immune/inflammatory diseases, the previous view of an unequivocal beneficial effect of oestrogens on RA compared with a detrimental effect on SLE has to be reconsidered. Likewise, the long-held belief that RA remits in the majority of pregnant patients has been challenged, and shows that only half of the patients experience significant improvement when objective disease activity measurements are applied. Pregnancies in patients with SLE are mostly successful when well planned and monitored interdisciplinarily, whereas a small proportion of women with APS still have adverse pregnancy outcomes in spite of the standard treatment. New prospective studies indicate better outcomes for pregnancies in women with rare diseases such as SSc and vasculitis. Fertility problems are not uncommon in patients with rheumatic disease and need to be considered in both genders. Necessary therapy, shortly before or during the pregnancy, demands taking into account the health of both mother and fetus. Long-term effects of drugs on offspring exposed in utero or during lactation is a new area under study as well as late effects of maternal rheumatic disease on children.

Relaxation response-based yoga improves functioning in young children with autism: a pilot study.

Abstract: Objectives: The study objectives were to develop and objectively assess the therapeutic effect of a novel movement-based complementary and alternative medicine approach for children with a

Association between Helicobacter pylori Infection and Pancreatic Cancer. A Cumulative Meta-Analysis

Abstract: Context Infection with Helicobacter pylori (H. pylori) has been implicated in the etiopathogenesis of various malignant conditions. Notwithstanding, its etiological association with pancreatic cancer remains inconclusive. Studies focusing on the relationship between H. pylori infection and pancreatic cancer risk have yielded conflicting results. Objective The aim of this study was to obtain a reliable estimate of the risk of H. pylori infection in causing pancreatic cancer, by performing a meta-analysis of the existing observational studies evaluating the association. Methods/Statistics Observational studies comparing the prevalence of H. pylori infection in patients with pancreatic cancer and healthy controls, conducted in adult populations and published in all languages, were identified through systematic search in the MEDLINE and EMBASE up to April 2010. H. pylori infection was confirmed by serological testing using an antigen-specific enzyme-linked immunosorbent assay. Pooled adjusted odds ratios (AOR) and associated 95% confidence intervals (CI) were obtained by using a DerSimonian and Laird random-effects model. Results Six studies involving a total of 2,335 patients met our eligibility criteria. A significant association between H. pylori seropositivity and development of pancreatic cancer (AOR 1.38, 95% CI: 1.08-1.75; P=0.009) was seen. No significant association was seen on pooled analysis of the three studies assessing the relationship between cytotoxin-associated gene A (CagA) positivity and pancreatic cancer. A cumulative meta-analysis suggested a reducing, albeit statistically significant association as the evidence was accumulated. Conclusions The pooled data suggests an association between infection with H. pylori and the development of pancreatic cancer. Further research is needed to confirm our findings. Image: Forest plot of the association between H. pylori and pancreatic cancer.

Explanatory Models of Health and Disease Among South Asian Immigrants in Chicago

Abstract: To identify concepts of health and disease as part of a study on designing culturally-targeted heart disease prevention messages for South Asians. We conducted qualitative, semi-structured interviews in English, Hindi and Urdu with 75 respondents from a federally qualified health center and at a community center for South Asian immigrants in Chicago, Illinois. Age ranged from 20 to 70 years; 60% were women; 60% held advanced degrees; 70% migrated to the US in the last 10 years; and 60% of the interviews were in Hindi or Urdu. Concepts of health and disease fell into four domains: behavioral, physical, psycho-social and spiritual. Muslim participants consistently evoked spiritual factors such as faith and prayer. Women more frequently included performing home duties and positive affect in their concept of health. Men more frequently cited behavioral factors such as smoking and drinking as the cause of disease. Many South Asians have a holistic conceptualization of health and disease, incorporating spiritual, physical and psycho-social factors. Health promotion strategies aimed at South Asians in the US should take into account this holistic model of health and disease, while also recognizing that variations exist within South Asians, by gender and religion.

Subcutaneous or intravenous administration of romiplostim in thrombocytopenic patients with lower risk myelodysplastic syndromes.

Abstract: BACKGROUND: Romiplostim is a peptibody protein that augments thrombopoiesis by activating the thrombopoietin receptor. METHODS: In this phase 2, multicenter, open-label study, 28 thrombocytopenic patients with lower risk myelodysplastic syndromes (MDS) were assigned to receive romiplostim 750 μg administered subcutaneously either weekly or biweekly or administered as biweekly intravenous injections for 8 weeks. Patients also could enter a 1-year study extension phase. RESULTS: At least 1 adverse event was observed in 93% of patients. The most common adverse events were fatigue and headache (18% for both, and 5 events were grade 3 or 4. There was 1 serious treatment-related adverse event in the biweekly intravenous cohort (hypersensitivity). This hypersensitivity resolved without discontinuation of study treatment. No patients developed neutralizing antibodies or bone marrow fibrosis. Of the patients who completed 8 weeks of treatment, 57% had a complete platelet response, an additional 8% had a major platelet response, and 61% did not require a platelet transfusion during this period. Weekly subcutaneous injections achieved the highest mean trough concentrations. CONCLUSIONS: The safety and efficacy profiles of romiplostim in this study suggested that weekly subcutaneous administration of 750 μg romiplostim is an appropriate starting dose for future clinical studies in patients with MDS and thrombocytopenia. Cancer 2011. © 2010 American Cancer Society.

End-of-Life Care for People with Intellectual Disabilities: Paid Carer Perspectives

Abstract: Background Little is known of paid carers’ perspectives when caring for people with intellectual disabilities at the end-of-life. Materials and methods Sixty four individuals from intellectual disability services took part in 12 focus groups. Interviews were analysed using framework analysis. Results Participants wanted to provide palliative care and felt the experience enriched practice. However, they were inadequately prepared to meet need and this often led to staff stress. A number of issues appeared to heighten stress: situations when end-of-life care decision making was challenging, when staff felt ‘pushed out’ by relatives and when staff did not have sufficient support or time to provide care or mourn the loss of service users. Conclusions The study describes issues which contribute to the development of staff stress when providing palliative care and draws attention to areas where strategies should be developed in order to improve the quality of care provided to people with intellectual disabilities.

Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania

Abstract: Although clinical audit is an important instrument for quality care improvement, the concept has not yet been adequately taken on board in rural settings in most resource limited countries where the problem of maternal mortality is immense. Maternal mortality and morbidity audit was established at Saint Francis Designated District Hospital (SFDDH) in rural Tanzania in order to generate information upon which to base interventions. Methods are informed by the principles of operations research. An audit system was established, all patients fulfilling the inclusion criteria for maternal mortality and severe morbidity were reviewed and selected cases were audited from October 2008 to July 2010. The causes and underlying factors were identified and strategic action plans for improvement were developed and implemented. There were 6572 deliveries and 363 severe maternal morbidities of which 36 women died making institutional case fatality rate of 10%. Of all morbidities 341 (94%) had at least one area of substandard care. Patients, health workers and administration related substandard care factors were identified in 50% - 61% of women with severe morbidities. Improving responsiveness to obstetric emergencies, capacity building of the workforce for health care, referral system improvement and upgrading of health centres located in hard to reach areas to provide comprehensive emergency obstetric care (CEmOC) were proposed and implemented as a result of audit. Our findings indicate that audit can be implemented in rural resource limited settings and suggest that the vast majority of maternal mortalities and severe morbidities can be averted even where resources are limited if strategic interventions are implemented.

Using technology to deliver healthcare education to rural patients.

Abstract: Introduction The prevalence of chronic disease in the US population is increasing. Projections indicate that half the US population will live with at least one chronic disease by the year 2030. Statistics indicate that chronic illnesses account for 70% of all deaths. Developing healthy self-management behaviors can lower the risk of developing chronic disease and also minimize the magnitude of subsequent morbidity and disability. Individuals need access to reliable information in order to learn successful self-management skills. Delivering healthcare information in rural areas is difficult. Geography, distance, inclement weather and/or the lack of financial resources are barriers that can prevent individuals from accessing health care and health education. Likewise, rural health clinics often lack the financial resources to provide the most current patient education materials. However, the internet allows remote and immediate access to this type of information if individuals know how and where to search for it. An internet portal, My Health Education & Resources Online (MyHERO) was created to facilitate locating current, non-commercial, reliable, evidence-based health information. The authors sought to assess the impact of a publically accessible internet information portal on diabetes knowledge, quality of life (QOL) measures, and self-management behaviors in a US rural area. Methods Participants (n=48) with type 2 diabetes in one clinic received regularly scheduled, one-on-one individualized diabetes-related health education and hands-on instructions on how to use an internet portal from a nurse educator. Each health clinic was supplied with a laptop computer for participants to use if they lacked internet access. Control participants (n=50) in a second clinic received a pamphlet describing how to access the portal. All participants completed baseline and end-of-study surveys. Disease knowledge was measured with the BASICS test developed by the International Diabetes Center. Problem Areas In Diabetes (PAID), developed by the Joslin Diabetes Center, was utilized to measure diabetes QOL. All participants completed a behavior modification survey at the conclusion of the study. Intervention participants were asked to complete a satisfaction survey at the conclusion of the study. Demographic and relevant laboratory values (eg serum glucose, HbA1c, lipids) were collected via chart review at baseline, 3, and 6 months. Results Demographic and baseline scores were similar between groups. At 6 months, the intervention group showed significant increases in disease knowledge and self-blood glucose monitoring behavior. There were no differences in QOL between the groups at 6 months. Participants in the intervention group were highly satisfied with the nurse educator, but not with the internet as a resource. Conclusion Disease knowledge and self-blood glucose monitoring improved with one-on-one education. High attrition and a short study period were limitations of this study. The researchers speculate that the age of the participants and low internet penetration affected satisfaction scores. Future recommendations include a longer data collection period, more widespread publically accessible internet kiosks (grocery stores, malls, churches etc), other chronic disease states, and younger participants.

Acid mine drainage at Cerro Rico de Potosí I: unabated high-strength discharges reflect a five century legacy of mining

Abstract: Intensive mining and processing of Ag, Sn, Pb and Zn ores have occurred in various locations within and around the city of Potosi, Bolivia since 1545. Surface and subsurface waters, stream sediments and soils are contaminated with various ecotoxic metals in the headwaters of the economically vital, yet highly impacted, upper Rio Pilcomayo watershed. Previous studies have documented downstream trace metal contamination, however, not addressed specific sources. The AMD discharges identified in this study help link downstream pollution to primary origins. The majority of AMD would be considered high-strength due to metal concentrations and acidity orders of magnitude greater than typical AMD. Discharges from both operating and abandoned portals as well as tailings-related deposits displayed a high degree of heterogeneity with total metal concentrations ranging from 0.11 to 7480, <0.022 to 889, <0.0006 to 65.3, <0.001 to 310, 0.12 to 72,100, 0.3 to 402, <0.012 to 34.8, and 0.24 to 19,600 mg/L of Al, As, Cd, Cu, Fe, Mn, Pb and Zn, respectively. Net acidity and pH ranged from −10 to 246,000 mg/L as CaCO3 equivalent and 0.90–6.94 standard units, respectively. Data were gathered during two sampling events centered around the most extreme periods of the dry and wet seasons of one water-year. Loadings to local streams were marginally greater for most metals in the wet season. If observed loadings are historically representative, Cerro Rico AMD has contributed thousands of tonnes of ecotoxic metals to the upper Rio Pilcomayo over the last five centuries. Metal and hydrogen ion concentrations in the majority of AMD sampled were several orders of magnitude above discharge limits set by the Bolivian government, yet no action has historically or contemporarily been taken.

Acid mine drainage at Cerro Rico de Potosí II: severe degradation of the Upper Rio Pilcomayo watershed

Abstract: Ag, Pb, Sn and Zn ores have been intensively mined and processed at Cerro Rico de Potosi, Bolivia since 1545. Acid mine drainage (AMD) and mineral processing plant effluent are prime sources of water contamination in the headwaters of the Upper Rio Pilcomayo watershed. Streams receiving AMD drainage from the slopes of Cerro Rico and surrounding landscapes were sampled during the dry (July–August 2006) and wet (March 2007) seasons of one water-year. In-stream waters contained total metal concentrations of up to 16 mg/L As, 4.9 mg/L Cd, 0.97 mg/L Co, 1,100 mg/L Fe, 110 mg/L Mn, 4.1 mg/L Pb, and 1,500 mg/L Zn with pH ranging from 2.8 to 9.5. AMD-impacted streams contained elevated concentrations of the same major ecotoxic constituents present in AMD discharges at concentrations orders of magnitude greater than in those streams unimpacted by AMD. Many of the AMD impacted water bodies are more degraded than class “D” of the Bolivian receiving water body criteria, rendering them unfit for domestic or agricultural use. Natural attenuation is insufficient to render waters safe for use, however, some of these waters are currently being utilized for irrigation and livestock watering. The data indicate that historic and current mining activities have transformed these key natural resources into potential human and environmental health hazards.

Novel passive co-treatment of acid mine drainage and municipal wastewater.

Abstract: A laboratory-scale, four-stage continuous-flow reactor system was constructed to test the viability of high-strength acid mine drainage (AMD) and municipal wastewater (MWW) passive co-treatment. Synthetic AMD of pH 2.6 and acidity of 1870 mg L(-1) as CaCO3 equivalent containing a mean 46, 0.25, 2.0, 290, 55, 1.2, and 390 mg L(-1) of Al, As, Cd, Fe, Mn, Pb, and Zn, respectively, was added at a 1:2 ratio with raw MWW from the City of Norman, OK, to the system which had a total residence time of 6.6 d. During the 135-d experiment, dissolved Al, As, Cd, Fe, Mn, Pb, and Zn concentrations were consistently decreased by 99.8, 87.8, 97.7, 99.8, 13.9, 87.9, and 73.4%, respectively, pH increased to 6.79, and net acidic influent was converted to net alkaline effluent. At a wasting rate of 0.69% of total influent flow, the system produced sludge with total Al, As, Cd, Cr, Cu, Fe, Pb, and Zn concentrations at least an order of magnitude greater than the influent mix, which presents a metal reclamation opportunity. Results indicate that AMD and MWW passive co-treatment is a viable approach to use wastes as resources to improve water quality with minimal use of fossil fuels and refined materials.

Fecal osteoprotegerin may guide the introduction of second-line therapy in hospitalized children with ulcerative colitis

Abstract: Background: Osteoprotegerin (OPG) is increased in inflamed colonic mucosa and has a role in immune regulation and apoptosis resistance. Fecal OPG may be useful in predicting corticosteroid resistance in hospitalized children with severe ulcerative colitis (UC). We aimed to determine whether fecal OPG predicts the need for second-line therapies in children hospitalized for UC. Methods: We included 83 children with UC admitted for intravenous corticosteroid treatment. Children were classified as responders/nonresponders based on the need for therapy escalation. Fecal OPG results were compared with those of four other fecal markers. Results: Of the enrolled children, seven had day 1 samples only, 53 children had day 3 samples only, and 23 had both. Twenty-two children failed corticosteroid therapy and required infliximab (n = 20) or colectomy (n = 2). On the third treatment day the median fecal OPG levels were significantly higher in the nonresponders group compared with the responders: 77 pmol/L (interquartile range [IQR] 27–137) versus 13 pmol/L (3–109); P = 0.007. The best day 3 fecal OPG cutoff to predict second-line therapy was >50 pmol/L with a sensitivity of 71% and specificity of 69% (area under the receiver operator curve [ROC] of 0.70%–95% confidence interval [CI] 0.57–0.82). Fecal OPG was superior to day 3 fecal calprotectin, lactoferrin, and S100A12 as a predictor of corticosteroid nonresponse, but equivalent to the less commonly used M2-pyruvate kinase. Conclusions: Day 3 fecal OPG may guide the decision to institute second-line therapy in children with severe UC. The role of OPG in the inflammatory response in pediatric UC deserves further study. (Inflamm Bowel Dis 2010;)

Alkalinity Generation in a Novel Multi-stage High-strength Acid Mine Drainage and Municipal Wastewater Passive Co-treatment System

Abstract: Passive co-treatment of high-strength acid mine drainage (AMD) and municipal wastewater (MWW) was examined in a laboratory-scale, four-stage continuous flow reactor system with a total residence time of 6.6 d. Synthetic AMD of pH 2.60 and an acidity of 1,870 mg/L (as CaCO3) was mixed at a 1:2 ratio with raw MWW (pH 7.67, 288 mg/L alkalinity (as CaCO3), and 265 mg/L BOD5) from the City of Norman, Oklahoma and introduced into the system. Alkalinity generated by limestone dissolution and bacterial SO4 2− reduction (BSR) processes was sufficient to support various metal removal processes and produce an effluent with circumneutral pH (6.98) and a net alkalinity of 10.4 mg/L (as CaCO3). Alkalinity generation from limestone dissolution was comparable with conventional AMD passive treatment systems. BSR proceeded at a relatively high rate (0.56 mol/m3 day) despite inhibitory pH and metals concentrations. Results indicate that the diverse electron donors in the MWW may be as suitable for BSR and their supporting microbial communities as commonly used substrates, presenting an opportunity to use a common waste as a resource for passive treatment.

Communication contexts about illness, death and dying for people with intellectual disabilities and life-limiting illness.

Abstract: Objective: The general population has been involved in considerable debate about communication and awareness within the context of death and dying. However, there has been little research on how matters of communication on this topic are handled for people with life-limiting illness and intellectual disabilities. This qualitative study explored how staff managed communication about death and dying with people with intellectual disabilities in a Health Service Executive area in Ireland. Method: Ninety-one individuals took part in 16 focus groups. Interviews were analysed using framework analysis. Results: Participants infrequently discussed death and dying with people with intellectual disabilities. Participants operated most commonly in suspicious awareness environments with people with mild-to-moderate intellectual disabilities, and closed awareness environments with people with severe intellectual disabilities. The majority of participants did not hold absolute opinions that talking about illness, death, and dying with people with intellectual disabilities was “wrong.” Rather, they were concerned that their lack of skill and experience in the area would cause harm if they engaged in open conversations. Relatives had an influential role on the process of communication. Participants were strongly motivated to provide quality care and were willing to consider alternative approaches to communication if this would benefit people with intellectual disabilities. Significance of results: Although there has been a shift toward conditional open awareness of death and dying in Western society, people with intellectual disabilities have not been afforded the same opportunity to engage in open discussion of their mortality. This study points to the urgent need to engage in debate about this issue in order to ensure that people with intellectual disabilities receive high quality palliative care toward the end of life.

Loss of Gremlin Delays Primordial Follicle Assembly but Does Not Affect Female Fertility in Mice

Abstract: The transforming growth factor beta (TGFB) protein family is renowned for its diverse roles in developmental biology including reproduction. Gremlin is a member of the differential screening-selected gene aberrative in neuroblastoma (DAN)/cerberus family of bone morphogenetic protein (BMP) antagonists. Recent studies on gremlin focus on its involvement in embryonic skeletal, lung, and kidney development. To define the role of gremlin (Grem1) in female reproduction, we analyzed postnatal folliculogenesis using global and conditional knockout (cKO) mice for gremlin. Grem1(-/-) mice die within 48 h after birth, and ovaries collected from neonatal Grem1(-/-) mice demonstrated reduced oocyte numbers and delayed primordial follicle development. Transplanting Grem1(-/-) neonatal ovaries showed that folliculogenesis proceeded to large antral follicle stage, but Grem1(-/-) ovaries contained corpora lutea-like structures not found in control-transplanted ovaries. However, Grem1 cKO mice had comparable fertility to control mice. These data suggest that gremlin plays a previously uncharacterized role in the regulation of oocyte numbers and the timing of primordial follicle development, but either it is not required for later folliculogenesis or its loss is possibly compensated by other BMP antagonists.

Improved antiretroviral treatment outcome in a rural African setting is associated with cART initiation at higher CD4 cell counts and better general health condition

Abstract: Data on combination antiretroviral therapy (cART) in remote rural African regions is increasing. We assessed prospectively initial cART in HIV-infected adults treated from 2005 to 2008 at St. Francis Designated District Hospital, Ifakara, Tanzania. Adherence was assisted by personal adherence supporters. We estimated risk factors of death or loss to follow-up by Cox regression during the first 12 months of cART. Overall, 1,463 individuals initiated cART, which was nevirapine-based in 84.6%. The median age was 40 years (IQR 34-47), 35.4% were males, 7.6% had proven tuberculosis. Median CD4 cell count was 131 cells/μl and 24.8% had WHO stage 4. Median CD4 cell count increased by 61 and 130 cells/μl after 6 and 12 months, respectively. 215 (14.7%) patients modified their treatment, mostly due to toxicity (56%), in particular polyneuropathy and anemia. Overall, 129 patients died (8.8%) and 189 (12.9%) were lost to follow-up. In a multivariate analysis, low CD4 cells at starting cART were associated with poorer survival and loss to follow-up (HR 1.77, 95% CI 1.15-2.75, p = 0.009; for CD4 100 cells/μl). Higher weight was strongly associated with better survival (HR 0.63, 95% CI 0.51-0.76, p < 0.001 per 10 kg increase). cART initiation at higher CD4 cell counts and better general health condition reduces HIV related mortality in a rural African setting. Efforts must be made to promote earlier HIV diagnosis to start cART timely. More research is needed to evaluate effective strategies to follow cART at a peripheral level with limited technical possibilities.