Developing and refining a theory of change to improve time to antibiotic administration for febrile pediatric oncology patients in real-world settings

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Background: From May 2019 to November 2020, 23 institutions participated in the first Mexico in Alliance with St. Jude Golden Hour Quality Improvement Collaborative (MAS Collaborative) and successfully reduced the TTA in fPHOP from 156.8 minutes to 59.4 minutes and demonstrated improved clinical outcomes The MAS Collaborative followed the Institute for Healthcare Improvement’s Breakthrough Series (BTS) model, which involves using a shared Theory of Change (TOC). This report describes the process followed to develop and refine the TOC, which is currently being used at-scale in the second MAS Collaborative. Methods: The theory of change was built over the course of four phases: pilot testing, driver diagram refinement, multisite deployment, and consolidation and dissemination. A driver diagram (DD) was used to organize and visualize the TOC. The first version of the TOC was built based on the experience of four institutions that piloted the Golden Hour in Mexico in 2018. It was then refined based on the input from a multidisciplinary expert panel. The DD was shared with teams from participating institutions and teams used Plan-Do-Study-Act cycles to test and adapt change ideas to their local context using. At the end of the first MAS Collaborative, teams reported the change ideas they tested and their degree of belief (low to high) that the change ideas had led to improved outcomes. This information was used to refine the TOC, which was validated with a second expert panel in preparation for the second MAS Collaborative. Results: The initial DD included five primary drivers, 16 secondary drivers, and 32 change ideas. The primary drivers were effective availability of medications and supplies, dynamic data learning systems, early detection of fever, process reliability, and effective teamwork. The 23 teams tested change ideas for all primary drivers and 34 of the change ideas were reported as having a high degree of belief. Based on the experience and feedback from participating teams, two secondary drivers were added to the DD for the second MAS Collaborative: 1) promoting wellbeing and resilience and 2) promoting early detection of fever at home. The final DD included five primary drivers, 18 secondary drivers, and 97 change ideas. A refined and robust TOC is currently being used for the second MAS Collaborative. Conclusions: The multiphase process followed to develop the TOC was key to the success of the first MAS Collaborative. Contrary to more prescriptive approaches to project implementation, the inherent flexibility of this TOC allowed teams to operate with a greater sense of agency, developing, adapting and testing implementing changes. This TOC provides practitioners with practice-based evidence to reduce TTA and improve clinical outcomes for children with cancer in resource-limited real-world settings in the context of the second MAS Collaborative and beyond.

Sex differences in total brain volume in a cognitively unimpaired elderly population

Introduction

Although a large number of studies have shown brain volumetric differences between men and women, only a few investigations to date have analyzed brain tissue volumes in representative samples of the general elderly population.

Objectives

We investigated differences in gray matter (GM), white matter (WM) and intracranial volumes (ICVs) between sexes in individuals above 66 years old using structural magnetic resonance imaging (MRI).

Methods

Using FreeSurfer version 5.3, we automatically obtained the ICVs, GM and WM volumes from MRI datasets of 84 men and 92 women. To correct for interindividual variations in ICV, GM and WM volumes were adjusted with a method using the residuals of a least-square-derived linear regression between raw volumes and ICVs. We then performed an ANCOVA comparing men and woman including age and years of schooling as confounding factors.

Results

Women had a lower socioeconomic status overall and fewer years of schooling than men. The comparison of unadjusted brain volumes showed larger GM and WM volumes in men. After the ICV correction, the adjusted volumes of GM and WM were larger in women.

Conclusions

After the ICV correction and taking into account differences in socioeconomic status and years of schooling, our results confirm previous findings of proportionally larger GM in women, as well as larger WM volumes. These results in an elderly population indicate that brain volumetric differences between sexes persist throughout the aging process. Additional studies combining MRI and other biomarkers are warranted to identify the hormonal and molecular bases influencing such differences.

Microalgae population dynamics growth with AnMBR effluent: effect of light and phosphorus concentration

The aim of this study was to evaluate the effect of light intensity and phosphorus concentration on biomass growth and nutrient removal in a microalgae culture and their effect on their competition. The photobioreactor was continuously fed with the effluent from an anaerobic membrane bioreactor pilot plant treating real wastewater. Four experimental periods were carried out at different light intensities (36 and 52 μmol s^-1 m^-2) and phosphorus concentrations (around 6 and 15 mgP L^-1). Four green algae - Scenedesmus, Chlorella, Monoraphidium and Chlamydomonas- and cyanobacterium were detected and quantified along whole experimental period. Chlorella was the dominant species when light intensity was at the lower level tested, and was competitively displaced by a mixed culture of Scenedesmus and Monoraphidium when light was increased. When phosphorus concentration in the photobioreactor was raised up to 15 mgP L^-1, a growth of cyanobacterium became the dominant species in the culture. The highest nutrient removal efficiency (around 58.4 ± 15.8% and 96.1 ± 16.5% of nitrogen and phosphorus, respectively) was achieved at 52 μmol s^-1 m^-2 of light intensity and 6.02 mgP L^-1 of phosphorus concentration, reaching about 674 ± 86 mg L^-1 of volatile suspended solids. The results obtained reveal how the light intensity supplied and the phosphorus concentration available are relevant operational factors that determine the microalgae species that is able to predominate in a culture. Moreover, changes in microalgae predominance can be induced by changes in the growth medium produced by the own predominant species.

Association between lower urinary tract symptoms and erectile dysfunction

Our aim was to assess the association between lower urinary tract symptoms (LUTS) and erectile dysfunction by means of International Prostate Symptom Score (IPSS) and Sexual Health Inventory for Men (SHIM) questionnaire. A total of 69 eligible patients who were admitted to our outpatient clinic with lower urinary tract symptoms were included in the study. A self administered questionnaire of IPSS and SHIM were given to patients. Demographics and medical history data were recorded. Any risk factor that may be associated with erectile dysfunction, including coronary artery disease, diabetes, hypertension, and smoking status, was determined in each patient. Correlation tests were used to examine the relationship between lower urinary tract symptoms and erectile dysfunction by controlling the effects of age and comorbidities. Mean age was 58.6 +/- 13.1 31-86 years. Mean SHIM and IPSS total score was 14.3 +/- 7.5 and 11.5 +/- 8.1, respectively. Spearman correlation coefficient between IPSS and SHIM scores was found to be -0.41. There was a significant negative correlation with IPSS total scores of moderate degree when both age and presence of risk factor was controlled (r = -0.31; p = 0.009). Storage symptom scores showed significant correlation with SHIM scores (r = -0.33; p = 0.000). The association between SHIM score and each item of IPSS showed significant correlation for urgency, straining and nocturia when age controlled. The degree of bother by LUTS as determined by the IPSS quality of life question was also correlated with SHIM scores; however, this correlation was not significant when age or risk factor for ED was controlled. The presence of LUTS especially storage symptoms is strongly associated with erectile dysfunction independent of age and comorbidities.

Basiliximab: A Comparative Study Between the Use of the Recommended Two Doses Versus a Single Dose in Living Donor Kidney Transplantation

Basiliximab (Simulect) is a high-affinity chimeric and humanized monoclonal antibody, directed against the alpha chain of human interleukin-2 receptor (CD25). The administration of two doses (20 mg intravenously per dose), one given 2 hours before transplantation and the second on day 4 posttransplant, provides suppression of the interleukin-2 receptor for up to 45 days, reducing the rate of acute rejection in kidney transplantation. This study was designed to compare the efficacy of a single dose of Simulect to the recommended two doses. The other objective was the reduction of the costs related to the standard two dose protocol. Fifty-two patients were included: group I (32 patients) received two doses of Simulect; group II (20 patients) received one dose. There were 39 living related donors and 13 living unrelated. All patients were followed for 1 year. Maintenance immunosuppression consisted of tacrolimus or cyclosporine, mycophenolate mofetil, and steroids. The diagnosis of rejection was made clinically. All episodes were treated with intravenous steroids. The incidence of rejection was similar in both groups; there was no graft loss to rejection. There were two deaths in group I, and one death in group II, yielding graft and patient actual survival rates at 1 year of 93% and 95%, respectively. These results suggest that Simulect is equally effective when administered in two doses or in a single dose in kidney transplantation. The reduction of cost by giving a single dose is significant, especially in developing countries without national health insurance.

Cutaneous protothecosis: report of the second Brazilian case

The present report describes a case of cutaneous protothecosis caused by Prototheca wickerhamii in a non-immunocompromised female from the state of Bahia, Brazil. This is the second case described in Brazil. Dermatological examination revealed diffusely infiltrated erythematous plaques on the flexor aspect of the right arm and forearm. The authors emphasize the pathological aspects that can lead to misdiagnosis this condition. The patient was successfully treated with fluconazole.

Percutaneous transluminal angioplasty of the symptomatic atherosclerotic carotid arteries. Results, complications, and follow-up

BACKGROUND AND PURPOSE

Carotid endarterectomy reduces stroke risk in patients with > 70% symptomatic stenosis. We present our results of percutaneous transluminal angioplasty (PTA) as an alternative treatment.

METHODS

Ninety-eight patients with symptomatic > 70% stenosis of the internal carotid artery were considered for PTA. Details of the procedure, complications, and 4-year follow-up were registered.

RESULTS

Eighty-five PTAs were performed in a 4-year period. Transient cardiovascular effects were frequent: hypotension (54.1%), bradycardia (67.1%), asystole (25.9%), and syncope (16.5%). Transient ischemic attack occurred in 3 of 82 patients (3.7%), and disabling stroke occurred in 4 (4.9%); mortality was 0%. After a mean follow-up period of 18.7 months, 4 patients died, 1 due to fatal stroke. The overall probability of surviving any stroke or death was 86.7%. Restenosis (> 70%) was seen in 6 cases (7.4%).

CONCLUSIONS

PTA may be a reasonable treatment for symptomatic atherosclerotic stenosis, at least in patients at high risk for carotid endarterectomy.

[Tracheoesophageal fistula secondary to endoscopic sclerotherapy of esophageal varices]

Over the past 15 years, endoscopic variceal sclerotherapy (EVS) has become the main therapy for patients with bleeding esophageal varices. EVS has the advantage of a low associated mortality and morbidity, but may lead to serious complications. We report a case of esophagotracheal fistula complicating sclerotherapy that resolved with nonsurgical management.

The plasmatic 11-hydroxy-corticosteroid response in the human to a synthetic octadecapeptide corticotrophin (C-41795-Ba)

The adrenal response as measured by the plasmatic changes in 11-hydroxy-corticosteroid (11-OHCS) concentration following the administration of a synthetic octadecapeptide (C-41795-Ba) was compared in 17 normal young males with that obtained with the commercially available tetracosactrin. C-41795-Ba polypeptide shows a higher potency than tetracosactrin. Its effects are longer lasting when administered intravenously which indicates a significant local inactivation of the polypeptide.

Inhibition of antibody formation during continual stimulation with a strong immunogen

Long persisting antigenic stimulation at immunogenic levels leads to a profound inhibition of antibody formation. With Brucellus abortus, there is first a brief and high IgM response. IgG antibody titres remain at a low level for some days, and then begin a slow and progressive increase, leading to a rather persistent maximum, and finally after about 300 days, to the state of inhibition. When the same total dose is given with monthly intervals, the effect is quite different, with similar IgM and IgG peaks being observed after each dose. The inhibited animals respond moderately to a ten-fold higher antigen dose, and only with IgG. Six months after interruption of the persistent antigenic stimulus, a strong response can be obtained after a new antigenic stimulation, with a substantial proportion of IgM. It is concluded that persistent antigenic stimulation plays a major role in the change from IgM to IgG synthesis.