Pre-post Cohort Study Research Articles

Sustaining Teamwork Behaviors Through Reinforcement of TeamSTEPPS Principles.

Teamwork training improves short-term teamwork behaviors. However, improvements are often not sustained. The purpose of this study was to explore the extent to which teamwork reinforcement activities for orthopedic surgery teams lead to sustained teamwork behaviors. Seven months after 104 staff from an orthopedic surgical unit were trained in Team Strategies and Tools to Enhance Performance and Patient Safety principles, 4 reinforcement activities were implemented regarding leadership and communication: lectures with videos on leadership skills for nursing staff; an online self-paced learning program on communication skills for nursing staff; a 1-page summary on leadership skills e-mailed to surgical staff; and a 1-hour perioperative grand rounds on Team Strategies and Tools to Enhance Performance and Patient Safety principles for anesthesia staff and new staff. Twenty-four orthopedic surgical teams were evaluated on teamwork behaviors during surgery by 2 observers before and after the reinforcement period using the Observational Teamwork Assessment for Surgery tool. After reinforcement, leadership (P = 0.022) and communication (P = 0.044) behaviors improved compared with prereinforcement levels. Specifically, nursing staff improved in leadership (P = 0.016) and communication (P = 0.028) behaviors, surgical staff improved in leadership behaviors (P = 0.009), but anesthesia staff did not improve in any teamwork behaviors. Sustained improvement in teamwork behaviors requires reinforcement. Level III, prospective pre-post cohort study.

The Use of Acceptance and Commitment Therapy in Oncology Settings: A Narrative Review.

Various psychotherapeutic approaches have been developed to address the psychosocial stressors and distress associated with cancer diagnosis and treatment. One such approach, Acceptance and Commitment Therapy (ACT), may be particularly well suited to people with cancer as it offers a model of healthy adaptation to difficult circumstances. This paper provides a description and theoretical rationale for using ACT in psychosocial oncology care that emphasizes emotional distress and cancer-related pain and provides a narrative review of the current state of evidence for this setting. Six studies met eligibility criteria for inclusion in the review. The research designs included one case study, three pre-post cohort studies, and two randomized controlled trials. Cancer diagnoses of patients included breast cancer, ovarian cancer, colorectal cancer, and mixed cancer populations at various stages of disease progression or recovery. ACT interventions demonstrated significant improvements in symptoms including quality of life and psychological flexibility as well as reductions in symptoms including distress, emotional disturbances, physical pain, and traumatic responses. Overall, although there is limited published research currently available, there is some evidence to support ACT as an effective psychotherapeutic approach for cancer patients. Further research is needed for different cancer populations across the illness trajectory. Barriers to implementation are discussed.

Parent-Mediated Intervention Training Delivered Remotely for Children With Autism Spectrum Disorder Living Outside of Urban Areas: Systematic Review.

BackgroundParent training programs for families living outside of urban areas can be used to improve the social behavior and communication skills in children with autism spectrum disorder (ASD). However, no review has been conducted to investigate these programs.ObjectiveThe aim of this study was to (1) systematically review the existing evidence presented by studies on parent-mediated intervention training, delivered remotely for parents having children with ASD and living outside of urban areas; (2) provide an overview of current parent training interventions used with this population; (3) and provide an overview of the method of delivery of the parent training interventions used with this population.MethodsGuided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement, we conducted a comprehensive review across 5 electronic databases (CINAHL, Embase, ERIC, PsycINFO, and Pubmed) on July 4, 2016, searching for studies investigating parent-mediated intervention training for families living outside of urban centers who have a child diagnosed with ASD. Two independent researchers reviewed the articles for inclusion, and assessment of methodological quality was based on the Kmet appraisal checklist.ResultsSeven studies met the eligibility criteria, including 2 prepost cohort studies, 3 multiple baseline studies, and 2 randomized controlled trials (RCTs). Interventions included mostly self-guided websites: with and without therapist assistance (n=6), with training videos, written training manuals, and videoconferencing. Post intervention, studies reported significant improvements (P<.05) in parent knowledge (n=4), parent intervention fidelity (n=6), and improvements in children’s social behavior and communication skills (n=3). A high risk of bias existed within all of the studies because of a range of factors including small sample sizes, limited use of standardized outcome measures, and a lack of control groups to negate confounding factors.ConclusionsThere is preliminary evidence that parent-mediated intervention training delivered remotely may improve parent knowledge, increase parent intervention fidelity, and improve the social behavior and communication skills for children with ASD. A low number of RCTs, difficulty in defining the locality of the population, and a paucity of standardized measures limit the generalization of the findings to the target population. Future studies should investigate the appropriateness and feasibility of the interventions, include RCTs to control for bias, and utilize standard outcome measures.

Integrating Hospital and Community Care for Homeless People with Unmet Mental Health Needs: Program Rationale, Study Protocol and Sample Description of a Brief Multidisciplinary Case Management Intervention

The Coordinated Access to Care for Homeless People (CATCH) program is a brief multidisciplinary case management intervention for homeless adults discharged from hospital in Toronto, Canada. Here we describe the rationale for CATCH program development, details of the mixed methods evaluation underway, and the characteristics of 225 CATCH service users. Funded in 2010 by the local health authority, CATCH aimed to improve access, continuity of care, health and service use outcomes for homeless adults discharged from hospital. To assess the feasibility, acceptability and impact of the program, a mixed methods case study was undertaken in 2013. In total, 225 CATCH program users were enrolled in the study and completed quantitative survey measures at program entry to assess key health and social outcomes using a pre-post cohort study design. Follow-up assessments took place at 3- and 6-months. At study entry, most participants were male (79%), white (65%), Canadian-born (74%), single or never married (60%), and their average age was 39.9 ± 12.0 years. Nearly all participants (88%) had at least one emergency department visit in the past 6 months, more than half (53%) indicated at least three chronic health conditions, and 44% indicated at least three mental health diagnoses. In addition, qualitative data was collected to evaluate the experiences of continuity of care and challenges during care transitions for this population using in-depth interviews with a sample of CATCH service users (n = 22) and managers of partnered organizations (n = 7), as well as focus groups with CATCH staff (n = 8), other service providers (n = 7) and people with lived experience of homelessness (n = 8). Improving health and health service use outcomes among homeless adults with chronic health conditions are key priorities in many jurisdictions. Future findings can inform service delivery to homeless adults discharged from hospital, by exposing factors associated with positive program outcomes, as well as barriers and facilitators to continuity of care for this disadvantaged population.

Abstract TMP70: The Emergency Department Screen is Associated with Lower Rates of Pneumonia in Acute Hemorrhagic Stroke Patients

Introduction: Dysphagia is a common problem in acute hemorrhagic stroke (AHS) patients, predisposing them to pneumonia and leading to poor outcomes. The Joint Commission mandated that dysphagia screening be performed at hospital presentation, which for most patients with AHS is the Emergency Department (ED). No evidence exists to demonstrate if the use of an ED dysphagia screen is associated with lower rates of pneumonia. Hypothesis: We assessed the hypothesis that the use of our ED dysphagia screen would not be associated with lower rates of pneumonia in AHS patients. Methods: We performed a pre-post cohort study evaluating the rates of pneumonia in AHS patients presenting to our ED before and after instituting dysphagia screening in 2010. Our pre group were AHS patients presenting from 2005-2009 and our post group from 2011-2015. The presence of pneumonia was pre-defined as new pulmonary infiltrate treated with antibiotics. We collected demographic and clinical data including rates of dysphagia and stroke severity. Data are presented as frequencies and medians with interquartile ranges (IQR) where appropriate. Rates of pneumonia were compared using the t-test. Results: We evaluated 469 pre screen and 462 post screen AHS patients. Both groups were 53% male. The rates of parenchymal bleed in the pre and post groups were 78% and 82%, respectively, with the remainder comprising subarachnoid hemorrhages or combination bleeds. Mean ICH scores were similar, pre 2.0 (SD 1.5) post 1.7 (SD 1.4). Dysphagia was present in 65% of the pre group and 63% of the post group. Incidence of pneumonia in the post group (13%) was significantly lower than the pre group (19%, P&lt;0.001). Conclusion: The use of an ED dysphagia screen is associated with a lower rate of pneumonia in AHS patients. This study was not designed to prove causation. Other factors not measured may have contributed to the reduction in rates of pneumonia. With the very high rates of dysphagia seen in this population, early dysphagia screening at ED presentation seems appropriate.

Assessing the Influence of a Fitbit Physical Activity Monitor on the Exercise Practices of Emergency Medicine Residents: A Pilot Study.

BackgroundTargeted interventions have improved physical activity and wellness of medical residents. However, no exercise interventions have focused on emergency medicine residents.ObjectiveThis study aimed to measure the effectiveness of a wearable device for tracking physical activity on the exercise habits and wellness of this population, while also measuring barriers to adoption and continued use.MethodsThis pre-post cohort study enrolled 30 emergency medicine residents. Study duration was 6 months. Statistical comparisons were conducted for the primary end point and secondary exercise end points with nonparametric tests. Descriptive statistics were provided for subjective responses.ResultsThe physical activity tracker did not increase the overall self-reported median number of days of physical activity per week within this population: baseline 2.5 days (interquartile range, IQR, 1.9) versus 2.8 days (IQR 1.5) at 1 month (P=.36). There was a significant increase in physical activity from baseline to 1 month among residents with median weekly physical activity level below that recommended by the Centers for Disease Control and Prevention at study start, that is, 1.5 days (IQR 0.9) versus 2.4 days (IQR 1.2; P=.04), to 2.0 days (IQR 2.0; P=.04) at 6 months. More than half (60%, 18/30) of participants reported a benefit to their overall wellness, and 53% (16/30) reported a benefit to their physical activity. Overall continued use of the device was 67% (20/30) at 1 month and 33% (10/30) at 6 months.ConclusionsThe wearable physical activity tracker did not change the overall physical activity levels among this population of emergency medicine residents. However, there was an improvement in physical activity among the residents with the lowest preintervention physical activity. Subjective improvements in overall wellness and physical activity were noted among the entire study population.

Impact of a Targeted Fluoroquinolone Restriction on Antimicrobial Usage at Two Community Hospitals

BackgroundA broad spectrum of activity and excellent oral bioavailability have made the fluoroquinolone (FQ) drug class the first-line option for treating various inpatient and outpatient infections. These advantages have resulted in overuse of FQ, resulting in wide-spread resistance to FQ, increasing reports of adverse effects, and superinfections. The Food and Drug Administration (FDA) issued an updated Boxed Warning for FQ antibiotics in July of 2016 to warn of serious and possibly permanent adverse effects. It also warned against the use of FQ to treat infections when other treatment options are available. In response to these strengthened warnings, our system implemented a protocol for FQ prescribing. This study was performed to determine the effects of this protocol on FQ usage and patient outcomes at two community hospitals in our system.MethodsThis is a multi-center pre-post observational cohort study conducted to analyze the impact of a FQ restriction protocol on FQ utilization in two acute care community hospitals. The FQ protocol was developed by our Antimicrobial Stewardship (AS) Team and approved by the Pharmacy and Therapeutics Committee. It was distributed to all medical staff, and the AS Team performed physician and staff education. A pharmacist reviewed all orders for FQ to determine whether the patient met criteria for the use of the FQ or not. If criteria were not met, the physician was contacted and alternatives discussed. The AS team provided one-on-one education as needed.ResultsOver the first four months of the implementation of the protocol, our hospitals saw a reduction of total FQ use from 357 days of therapy per 1000 patient days at risk (DOT) at baseline in 2016 to 101 DOT in 2017 (71.7% reduction, P < 0.001). Preliminary readmission rates for patients treated for urinary tract infection and for diverticulitis were similar between time periods, and C. difficile rates decreased.ConclusionOur study demonstrated a significant reduction in FQ utilization as a result of a targeted FQ restriction that helped guide physicians to appropriate alternative antibiotics. Preliminary data showed no increase in patient readmissions for the primary groups targeted by the protocol, and the hospitals’ C. difficile infection rate decreased, as well.Disclosures All authors: No reported disclosures.

A model of early integration of palliative care into oncology care for patients with metastatic colorectal cancer.

142 Background: Current NCCN guidelines recommend that “institutions should develop processes for integrating palliative care into cancer care.” However, it is not clear what the best method is for implementing this integrated care. Palliative care needs specific to patients with metastatic colorectal cancer (mCRC) and best practices for integration of outpatient palliative and oncologic care in mCRC are not well understood. Methods: We conducted a pre-post prospective cohort study to evaluate the palliative care needs of mCRC patients and the implementation of an integrated palliative care program. In both the control and implementation phase, we enrolled patients with mCRC within 90 days of diagnosis or establishing care for mCRC at UCSF. Patients were surveyed regarding their symptoms, quality of life, psychosocial concerns, functional status and understanding of prognosis. During the control phase, patients received usual oncologic care. Based on survey results from the control phase, we designed a palliative care program to target the needs identified. In the intervention phase, patients are receiving longitudinal palliative care integrated into their usual cancer care. Results: The 30 patients in the control phase reported anorexia, fatigue and poor quality of life as their most common symptoms. Common psychosocial challenges were transportation, insurance/financial and difficulty with treatment decisions. Patients also had unrealistic expectations of their prognosis. In order to improve these identified issues, we designed and implemented an integrated palliative care program that includes weekly multidisciplinary meetings with oncology and palliative care providers and proactive palliative care visits from the time of diagnosis, which occur within the oncology clinic at a time that coincides with oncology visits. Conclusions: Physical symptoms, psychosocial concerns and poor prognostic awareness are common among patients with mCRC. We have implemented an integrated palliative care program to address these needs. Evaluation of the effectiveness of this intervention is ongoing.

Formula Feeding Is Independently Associated With Acute Kidney Injury in Very Low Birth Weight Infants.

Successful strategies to prevent neonatal acute kidney injury are lacking. Nevertheless, it is well known that in breastfed babies the excretory needs of the kidney are low because the intake of most nutrients is just above the nutritional requirement. This study aimed to determine whether feeding type predicts acute kidney injury in the very low birth weight infant. One hundred and eighty-six infants were enrolled in this pre-post cohort study (114 infants were included in the only human milk-fed group and 72 in the formula-fed group). Routine biological markers of acute kidney injury were collected in both groups from birth to discharge. Compared with formula feeding, human milk feeding was associated with almost 80% lower odds of acute kidney injury (odds ratio [OR] = 0.2; 95% confidence interval [CI], 0.05-0.77). After confounding variables had been controlled for, formula feeding was independently associated with acute kidney injury in very low birth weight infants. The study showed that, at our institution, acute kidney injury in the neonatal period is frequently associated with the avoidable procedure of formula feeding. Further prospective multicenter studies are needed to determine the generality of this association.

ChIP: An early activation protocol for isolated blunt chest injury improves outcomes, a retrospective cohort study

BackgroundBlunt chest injuries not treated in a timely manner with sufficient analgesia, physiotherapy and respiratory support are associated with increased morbidity and mortality. The aim of the study was to determine the impact of a blunt chest injury early activation protocol (ChIP) on patient and hospital outcomes. MethodsIn this pre-post cohort study, the outcomes of patients with blunt chest injury who received ChIP were compared against those who did not. Data including injury severity, patient outcomes, hospital treatments and comorbidites were extracted from medical records. The primary outcome was pneumonia. Secondary outcomes evaluated health service delivery. Logistic and multiple regressions were used to adjust for potential confounding variables. Results546 patients were included, 273 in the before-ChIP cohort and 273 in the after-ChIP cohort. The incidence of pneumonia following the introduction of ChIP was reduced by 4.8% (95% CI 0.5–9.2, p=0.03). In the after-ChIP cohort, more patients received a pain team review (32% vs. 13%, p<0.001), physiotherapy (93% vs. 86%, p=0.005) and trauma team review (95% vs. 39%, p<0.001). There was no difference in length of stay (p=0.50). ConclusionsChIP improved the delivery of healthcare services and reduced the rate of pneumonia among patients with isolated chest trauma.

Efficacy and safety of fluconazole prophylaxis in extremely low birth weight infants: multicenter pre-post cohort study.

BackgroundThere have been many studies supporting fluconazole prophylaxis in preterm infants for prevention of invasive fungal infections (IFIs). However, the routine use of fluconazole prophylaxis in neonatal intensive care units (NICUs) raises concerns with respect to resistance development, including the selection of resistant Candida species. We aimed to evaluate the efficacy and safety of fluconazole prophylaxis in extremely low birth weight (ELBW) infants.MethodsAn interventional pre-post cohort study at two tertiary NICUs was conducted. Data from two 5-year periods with and without fluconazole prophylaxis (Mar 2008–Feb 2013 and Mar 2003–Feb 2008) was compared. Prophylactic fluconazole was administered starting on the 3rd day at a dose of 3 mg/kg twice a week for 4 weeks during the prophylaxis period.ResultsThe fluconazole prophylaxis group consisted of 264 infants, and the non-prophylaxis group consisted of 159 infants. IFI occurred in a total of 19 neonates (4.7 %) during the 10-year study period. Fluconazole prophylaxis lower the fungal colonization rate significantly (59.1 % vs. 33.9 %, P <0.001). However, the incidence of IFIs in ELBW infants was not reduced after fluconazole prophylaxis (4.4 % vs. 5.5 %, P = 0.80). Rather, although the increase did not reach statistical significance, fluconazole prophylaxis tended to increase the incidence of invasive infections involving fluconazole-resistant C. parapsilosis (0 % vs. 41.7 %, P = 0.11).ConclusionsFluconazole prophylaxis was not efficacious in decreasing IFIs in ELBW infants. There is a need for targeting prophylaxis to greatest risk population and prospective studies to measure the long-term effect of fluconazole prophylaxis on the emergence of organisms with antifungal resistance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-016-0605-y) contains supplementary material, which is available to authorized users.

Summer undergraduate research: A new pipeline for pain clinical practice and research.

BackgroundMost medical schools fail to provide adequate training of clinicians in the treatment of pain. Similarly, despite the fact that over 1/3 of Americans suffer from chronic pain, National Institutes of Health (NIH) funding for pain represents only ~1 % of the NIH budget. These issues may dissuade students from pursing pain in their clinical and research careers. To address these gaps in training and funding, we argue that exposing students to pain science early in their careers, at the undergraduate level, may be an effective method to develop a pipeline for future pain clinicians and scientists. To highlight our argument, we will describe our recent successful implementation of a cross-disciplinary and community-engaged biomedical summer research program. The Pain Undergraduate Research Experience (PURE) summer program involved both off-site and on-site experiences to expose undergraduate students to the range of careers in the pain field from basic science to clinical practice. The objective of the 10-week long PURE program was to evaluate whether a combination of basic science research, clinical practice visits, and patient interactions would increase student understanding of and exposure to the underlying science of pain.MethodsA pre-post cohort study was used without a comparison group. Entry and exit surveys were used to evaluate students’ perceptions about pain clinical practice and research, student interest in pain, and student confidence about communicating about pain and doing basic science pain research.ResultsStudents reported significant increases to a number of questions in the survey. Questions were scored on 5 point Likert scales and there was significant increases in student understanding of what life is like with chronic pain (2.6 vs 4.3 post survey), their confidence in explaining pain to a patient (2.8 vs 4.1) or researcher (2.8 vs 4), and their comfort with pain terminology(2.8 vs 3.9).ConclusionsWith the PURE program, we wanted to entice top undergraduates to consider pain as a future area of study, practice, and/or research. We present a model that can be easily implemented at research universities throughout the United States.

Human milk feeding protects very low-birth-weight infants from retinopathy of prematurity: a pre–post cohort analysis

Objectives: To examine the effect of early human milk (HM) feeding on the incidence of retinopathy of prematurity (ROP) among very low-birth-weight (VLBW) infants.Methods: Observational cohort research in a Level III neonatal intensive care unit. A total of 186 infants were enrolled in this pre–post cohort study (114 infants were included in the HM-fed group and 72 in the formula-fed group). ROP, type of feeding (early exclusive HM versus any formula), and potential confounding variables were measured. Differences between groups were explored.Results: The clinical characteristics of the neonates did not differ between the two groups. By bivariate analysis, HM feeding was associated with 75% lower odds of Stage 2 or 3 ROP (OR = 0.25, 95% CI: 0.091 to 0.705; p = 0.009) At multivariate logistic regression, type of milk feeding retained significance, exclusive HM being protective with p = 0.002.Conclusions: This study found an association between early exposure to formula in VLBW infants and ROP. An initial HM diet, devoid of cow milk-containing products before achieving full enteral feeding, may help prevent ROP.

Increased analgesia administration in emergency medicine after implementation of revised guidelines.

BackgroundThe most common complaint of patients attending the emergency department (ED) is pain, caused by different diseases. Yet the treatment of pain at the ED is suboptimal, and oligoanalgesia remains common. The objective of this study is to determine whether the administration of analgesia at the ED increases by implementation of revised guidelines in pain management.MethodsWe conducted a prospective pre-post intervention cohort study with implementation of a revised guideline for pain management at our ED, in which nurses are allowed to administer analgesia (including low-dosage piritramid (opioid) intravenous) without doctor intervention. Numeric Rating Scales (NRS) were measured, and administration of medication (main outcome) was documented. We included every adult patient presenting with pain (NRS 4–10) at the ED.ResultsA total of 2107 patients (1089 pre-implementation phase and 1018 post-implementation phase) were included in our study. During pre-implementation, 25.4 % of the patients with NRS between 4 and 10 received analgesia. After implementation, 32.0 % of these patients received analgesia (p < 0.001).ConclusionsAfter implementation of the revised guidelines in pain management at the ED, the administration of pain medication increased significantly. Nevertheless, the percentage of patients in pain receiving analgesia remain low (32 % after implementation).

Abstract TP255: The Emergency Department Dysphagia Screen is Associated With Lower Rates of Pneumonia in Acute Ischemic Stroke Patients

Introduction: Dysphagia is a common problem in acute ischemic stroke (AIS) patients predisposing them to pneumonia and leading to worse outcomes. The Joint Commission mandated that dysphagia screening be performed at hospital presentation which for most patients with AIS, is the Emergency Department (ED). No evidence exists to demonstrate if the use of an ED dysphagia screen is associated with lower rates of pneumonia. Hypothesis: We assessed the hypothesis that the use of our ED dysphagia screen would not be associated with lower rates of pneumonia in AIS patients. Methods: We performed a pre-post cohort study evaluating the rates of pneumonia in AIS patients presenting to our ED. Our pre group were AIS patients presenting from 2005-2009 and our post group from 2011-2015. The presence of pneumonia was pre-defined as new pulmonary infiltrate treated with antibiotics. We collected demographic and clinical data including rates of dysphagia and stroke severity. Data are presented as frequencies and medians with interquartile ranges (IQR) where appropriate. Rates of pneumonia were compared using the t-test. Results: We evaluated 419 pre screen and 1022 post screen AIS patients. Both groups were 50% female. The use of thombolytics in the pre group was 10% and post group was 11%. The median ages and ED NIHSS scores for the pre and post population were 63 years (IQR 53-73), 6 (IQR 3-10) and 64 years (IQR 56-76), 4 (IQR 2-8). Rates of dysphagia during hospitalization were 20% and 31% for the pre-post groups respectively. Rates of pneumonia for the pre-post groups were 13.8% and 8.0% respectively which was significantly different P=0.0007. Conclusion: The use of an ED dysphagia screen is associated with a lower rate of pneumonia in AIS patients. This study was not designed to prove causation so other factors also may have influenced the lower rate of pneumonia including possibly slightly less severe strokes. The rates of diagnosed dysphagia were higher in the post group suggesting ED screening may heighten awareness resulting in increased diagnoses of dysphagia. Given the rates of dysphagia and pneumonia early screening of AIS patients in the ED seems prudent.

Cohort Analysis of a Pharmacokinetic-Modeled Methadone Weaning Optimization for Neonatal Abstinence Syndrome

To evaluate neonatal abstinence syndrome (NAS) treatment outcomes achieved using an optimized methadone weaning protocol developed using pharmacokinetic (PK) modeling compared with standard methadone weaning. This pre-post cohort study evaluated 360 infants who completed pharmacologic treatment for NAS with methadone as inpatients at 1 of 6 nurseries in southwest Ohio between January 2012 and March 2015. Infants were initially treated with a standard methadone weaning protocol (n = 267). Beginning in July 2014, infants were treated with a revised methadone weaning protocol developed using PK modeling (n = 93). Linear mixed models were used to calculate adjusted mean primary outcomes, including total duration of methadone treatment, total administered methadone dosage, and length of inpatient hospital stay, which were compared between weaning protocols. The use of adjunctive therapy for NAS treatment was examined as a secondary outcome. Infants who received NAS treatment with the revised protocol experienced a shorter duration of methadone treatment (13.1 vs 16.4 days; P < .001) and shorter duration of inpatient treatment (18.3 vs 21.7 days; P < .001) compared with infants receiving standard methadone weaning. No difference was observed in total methadone dosage administered (0.52 vs 0.52 mg/kg; P = .97) or in the use of adjunctive therapy (22.6% vs 25.5%; P = .68) between groups. Refinement of a standard methadone weaning protocol using PK modeling was associated with reduced duration of opioid weaning and shortened length of stay for pharmacologic treatment of NAS.

Knowledge , Attitudes and Perception of Medical Students about Elderly Patients before and after Implementation of a New Geriatrics Curriculum

Objectives: The aim of this study was to evaluate the attitudes, knowledge and perception of medical students about elderly patients before and after implementation of a new geriatrics curriculum and to assess perceived attainment of objectives in geriatric module. Methods: This was a pre-post cohort study of seventy 6th year (first clinical year) medical students. Questionnaires were provided prior and post geriatric assessment. Utilization of common geriatric tools was taught in a tutorial and then reinforced in small group (case based) discussions. Questionnaire was mainly comprised of pre and post ques- tions, perception of students regarding geriatric care and students' perceived attainment of objectives from geriatric module. Statistical analysis was performed using SPSS 20.v. Data were expressed in frequencies, mean and percent- ages. Paired t test was used to evaluate the significant difference between pre and post responses. Results: A total of 70 students participated in the study. 14.3% were male and 85.7% were female students with mean age of 22.84 ± 1.03. The mean scale score for students' basic understanding of geriatrics was significantly higher after completion of education program compared with scores prior to training (p < 0.001, 95% CI: 3.01-4.87) with an increase of 3.943 in the mean scale score. In the same way the mean scale score of students' knowledge of geriatrics was statistically higher after completion of education program compared with scores prior to training (p < 0.001, 95% CI: 3.13-4.5) with an increase of 3.829 in the mean scale score. Overall students' feedback about geriatric module at the end of rotation was good as more than two third clumped from achieved to outstandingly achieved. Conclusion: Medical students who received education during their module showed improvement in levels of knowl- edge about geriatrics.

The effectiveness of an internet support forum for carers of people with dementia: a pre-post cohort study

The effectiveness of an internet support forum for carers of people with dementia: a pre-post cohort study

The Effect of a Donor Milk Policy on the Diet of Very Low Birth Weight Infants.

Use of donor milk (DM) to supplement mother's own milk (MOM) in the neonatal intensive care unit (NICU) is steadily increasing based on health and developmental benefits to premature infants. A paucity of data exists documenting the effect of DM use on the diet of very low birth weight (VLBW) infants related to the implementation of a DM policy. This study aimed to compare VLBW enteral intake type in the first 28 days of life before versus after establishing a DM policy. This single-center pre-post prospective cohort study included all inborn infants ≤ 1500 grams in a level 4 NICU remaining hospitalized at 28 days and admitted either before (pre-DM period, October 2009-March 2010) or after (DM period, October 2010-September 2012) implementing a DM policy. The feeding protocol was unchanged in both periods. Collected data included maternal/infant demographics, infant clinical data, and daily volume of enteral intake as MOM, DM, and formula. The proportion of enteral feeds from these sources during the first 28 days of life was compared pre-DM versus DM. Compared to pre-DM baseline, formula exposure was significantly decreased, and human milk exposure and proportion of diet as human milk increased. The proportion of infants fed exclusively human milk increased. Exposure to and proportion of diet as MOM was unchanged. Infants were fed earlier in the DM period. Establishment of a DM policy was associated with reduced exposure to formula, promoting an exclusively human milk diet, with earlier initiation of feeds and no decrease in use of MOM.

The Effectiveness of an Internet Support Forum for Carers of People With Dementia: A Pre-Post Cohort Study

BackgroundThe well-being of informal carers of people with dementia is an important public health issue. Caring for an elderly relative with dementia may be burdensome and stressful, and can negatively affect the carer’s social, family, and professional life. The combination of loss, the physical demands of caregiving, prolonged distress, and biological vulnerabilities of older carers may compromise their physical health, increase social isolation, and increase the risk of anxiety and depressive disorders. Caregiver stress is also linked to negative outcomes for the recipient of care and costs to society, including increased nursing home and hospital admissions. Consequently, carer support interventions are an important component of dementia care. Computer-mediated carer support offers a range of potential advantages compared to traditional face-to-face support groups, including accessibility and the possibility of tailoring to meet individual needs, but there has been little research on its effectiveness so far.ObjectiveThis mixed-methods study examined the impact of a well-respected UK-based online support forum for carers of people with dementia.MethodsA total of 61 new forum users completed measures of anxiety (7-item Generalized Anxiety Disorder scale, GAD-7), depression (9-item Patient Health Questionnaire, PHQ-9), and quality of relationship with the person with dementia (Scale for the Quality of the Current Relationship in Caregiving, SQCRC), at baseline and again after 12 weeks of forum usage, within a pre-post design. In addition, 8 participants were interviewed about their experiences with using the forum.ResultsThere was an improvement in the quality of the relationship with the person with dementia (SQCRC: P=.003). There was no change in users’ depression (PHQ-9) or anxiety (GAD-7) over the 12-week study period. Interview participants reported a range of positive experiences and benefits from using the forum. Limited negative experiences were also reported.ConclusionsMany of the reported experiences and benefits are unique to online peer support. Further research into online peer support for carers of people with dementia is needed to clarify who benefits under what conditions.