Disparities in the Diagnosis and Management of Infants Hospitalized With Inadequate Weight Gain

OBJECTIVES

To evaluate the association between race and the named etiology for inadequate weight gain among hospitalized infants and assess the differences in management.

METHODS

This single-center retrospective cohort study of infants hospitalized for the workup and management of inadequate weight gain used infant race and neighborhood-level socioeconomic deprivation as exposures. The etiology of inadequate weight gain was categorized as nonorganic, subjective organic (ie, gastroesophageal reflux and cow's milk protein intolerance), or objective organic (eg, hypothyroidism). The management of inadequate weight gain was examined in secondary outcomes.

RESULTS

Among 380 infants, most were white and had a nonorganic etiology of inadequate weight gain. Black infants had 2.3 times higher unadjusted odds (95% credible interval [CI] 1.17-4.76) of a nonorganic etiology of inadequate weight gain compared with white infants. After adjustment, there was no association between race and etiology (adjusted odds ratio 0.8, 95% CI [0.44-2.08]); however, each 0.1 increase in neighborhood-level deprivation was associated with 80% increased adjusted odds of a nonorganic etiology of inadequate weight gain (95% CI [1.37-2.4]). Infants with a nonorganic etiology of inadequate weight gain were more likely to have social work and child protective service involvement and less likely to have nasogastric tube placement, gastroenterology consults, and speech therapy consults.

CONCLUSIONS

Infants from neighborhoods with greater socioeconomic deprivation were more likely to have nonorganic causes of inadequate weight gain, disproportionately affecting infants of Black race. A nonorganic etiology was associated with a higher likelihood of social interventions and a lower likelihood of medical interventions.

Development of Scholarship Core Competencies for Pediatric Hospital Medicine Fellowship Programs

The Pediatric Hospital Medicine (PHM) Fellowship Directors, recent fellowship graduates, and senior leaders in PHM have long identified training in scholarly activities as a key educational priority for fellowship training programs. We led a 2-day conference funded by the Agency for Healthcare Research and Quality to develop scholarship core competencies for PHM fellows. Participants included fellowship directors, national experts in PHM research, and representatives from key stakeholder organizations. Through engagement in large group presentations and small group iterative feedback and editing, participants created and refined a set of scholarship core competencies. After the conference, goals and objectives were edited and harmonized by conference leaders incorporating feedback from conference participants. Core competency development included 7 domains: (1) study design and execution, (2) data management, (3) principles of analytics, (4) critical appraisal of the medical literature, (5) ethics and responsible conduct of research, (6) peer review, dissemination, and funding, and (7) professionalism and leadership. Specific objectives for each goal were further organized into 3 levels to indicate core skills for all fellowship trainees (level 1), specialized and specific skills determined by fellow scholarly focus (level 2), and advanced skills for fellows interested in a clinical investigator career path (level 3). These newly developed scholarship core competencies provide a foundation for curricular development and implementation to ensure that the field continues to expand academically, given the 2-year training period and variable infrastructure across programs.

Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial

BACKGROUND

Children and young adults with medical complexity (CMC) experience high rates of healthcare reutilization following hospital discharge. Prior studies have identified common hospital-to-home transition failures that may increase the risk for reutilization, including medication, technology and equipment issues, financial concerns, and confusion about which providers can help with posthospitalization needs. Few interventions have been developed and evaluated for CMC during this transition period.

OBJECTIVE

We will compare the effectiveness of the garnering effective telehealth 2 help optimize multidisciplinary team engagement (GET2HOME) transition bundle intervention to the standard hospital-based care coordination discharge process by assessing healthcare reutilization and patient- and family-centered outcomes.

DESIGNS, SETTINGS, AND PARTICIPANTS

We will conduct a pragmatic 2-arm randomized controlled trial (RCT) comparing the GET2HOME bundle intervention to the standard hospital-based care discharge process on CMC hospitalized and discharged from hospital medicine at two sites of our pediatric medical center between November 2022 and February 2025. CMC of any age will be identified as having complex chronic disease using the Pediatric Medical Complexity Algorithm tool. We will exclude CMC who live independently, live in skilled nursing facilities, are in custody of the county, or are hospitalized for suicidal ideation or end-of-life care.

INTERVENTION

We will randomize participants to the bundle intervention or standard hospital-based care coordination discharge process. The bundle intervention includes (1) predischarge telehealth huddle with inpatient providers, outpatient providers, patients, and their families; (2) care management discharge task tracker; and (3) postdischarge telehealth huddle with similar participants within 7 days of discharge. As part of the pragmatic design, families will choose if they want to complete the postdischarge huddle. The standard hospital-based discharge process includes a pharmacist, social worker, and care management support when consulted by the inpatient team but does not include huddles between providers and families.

MAIN OUTCOME AND MEASURES

Primary outcome will be 30-day urgent healthcare reutilization (unplanned readmission, emergency department, and urgent care visits). Secondary outcomes include 7-day urgent healthcare reutilization, patient- and family-reported transition quality, quality of life, and time to return to baseline using electronic health record and surveys at 7, 30, 60, and 90 days following discharge. We will also evaluate heterogeneity of treatment effect for the intervention across levels of financial strain and for CMC with high-intensity neurologic impairment. The primary analysis will follow the intention-to-treat principle with logistic regression used to study reutilization outcomes and generalized linear mixed modeling to study repeated measures of patient- and family-reported outcomes over time.

RESULTS

This pragmatic RCT is designed to evaluate the effectiveness of enhanced discharge transition support, including telehealth huddles and a care management discharge tool, for CMC and their families. Enrollment began in November 2022 and is projected to complete in February 2025. Primary analysis completion is anticipated in July 2025 with reporting of results following.

Child Opportunity Index 2.0 and acute care utilization among children with medical complexity

BACKGROUND

Disproportionately high acute care utilization among children with medical complexity (CMC) is influenced by patient-level social complexity.

OBJECTIVE

The objective of this study was to determine associations between ZIP code-level opportunity and acute care utilization among CMC.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, multicenter study used the Pediatric Health Information Systems database, identifying encounters between 2016-2019. CMC aged 28 days to <16 years with an initial emergency department (ED) encounter or inpatient/observation admission in 2016 were included in primary analyses.

MAIN OUTCOME AND MEASURES

We assessed associations between the nationally-normed, multi-dimensional, ZIP code-level Child Opportunity Index 2.0 (COI) (high COI = greater opportunity), and total utilization days (hospital bed-days + ED discharge encounters). Analyses were conducted using negative binomial generalized estimating equations, adjusting for age and distance from hospital and clustered by hospital. Secondary outcomes included intensive care unit (ICU) days and cost of care.

RESULTS

A total of 23,197 CMC were included in primary analyses. In unadjusted analyses, utilization days decreased in a stepwise fashion from 47.1 (95% confidence interval: 45.5, 48.7) days in the lowest COI quintile to 38.6 (36.9, 40.4) days in the highest quintile (p < .001). The same trend was present across all outcome measures, though was not significant for ICU days. In adjusted analyses, patients from the lowest COI quintile utilized care at 1.22-times the rate of those from the highest COI quintile (1.17, 1.27).

CONCLUSIONS

CMC from low opportunity ZIP codes utilize more acute care. They may benefit from hospital and community-based interventions aimed at equitably improving child health outcomes.

Predictors of Invasive Herpes Simplex Virus Infection in Young Infants

OBJECTIVES

To identify independent predictors of and derive a risk score for invasive herpes simplex virus (HSV) infection.

METHODS

In this 23-center nested case-control study, we matched 149 infants with HSV to 1340 controls; all were ≤60 days old and had cerebrospinal fluid obtained within 24 hours of presentation or had HSV detected. The primary and secondary outcomes were invasive (disseminated or central nervous system) or any HSV infection, respectively.

RESULTS

Of all infants included, 90 (60.4%) had invasive and 59 (39.6%) had skin, eyes, and mouth disease. Predictors independently associated with invasive HSV included younger age (adjusted odds ratio [aOR]: 9.1 [95% confidence interval (CI): 3.4-24.5] <14 and 6.4 [95% CI: 2.3 to 17.8] 14-28 days, respectively, compared with >28 days), prematurity (aOR: 2.3, 95% CI: 1.1 to 5.1), seizure at home (aOR: 6.1, 95% CI: 2.3 to 16.4), ill appearance (aOR: 4.2, 95% CI: 2.0 to 8.4), abnormal triage temperature (aOR: 2.9, 95% CI: 1.6 to 5.3), vesicular rash (aOR: 54.8, (95% CI: 16.6 to 180.9), thrombocytopenia (aOR: 4.4, 95% CI: 1.6 to 12.4), and cerebrospinal fluid pleocytosis (aOR: 3.5, 95% CI: 1.2 to 10.0). These variables were transformed to derive the HSV risk score (point range 0-17). Infants with invasive HSV had a higher median score (6, interquartile range: 4-8) than those without invasive HSV (3, interquartile range: 1.5-4), with an area under the curve for invasive HSV disease of 0.85 (95% CI: 0.80-0.91). When using a cut-point of ≥3, the HSV risk score had a sensitivity of 95.6% (95% CI: 84.9% to 99.5%), specificity of 40.1% (95% CI: 36.8% to 43.6%), and positive likelihood ratio 1.60 (95% CI: 1.5 to 1.7) and negative likelihood ratio 0.11 (95% CI: 0.03 to 0.43).

CONCLUSIONS

A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.

Disparity in Nurse Discharge Communication for Hospitalized Families Based on English Proficiency

OBJECTIVES

Effective communication is critical for safely discharging hospitalized children, including those with limited English proficiency (LEP), who are at high risk of reuse. Our objective was to describe and compare the safety and family centeredness of nurse communication at hospital discharge for English-proficient (EP) and LEP families.

METHODS

In this single-center, cross-sectional study, we used direct observation of hospital discharges for EP and LEP children. Observers recorded quantitative and qualitative details of nurse-family communication, focusing on 3 domains: safe discharge, family centeredness, and family engagement. Patient characteristics and percentages of encounters in which all components were discussed within each domain were compared between EP and LEP encounters by using Fisher's exact tests. We used field notes to supplement quantitative findings.

RESULTS

We observed 140 discharge encounters; 49% were with LEP families. Nurses discussed all safe discharge components in 31% of all encounters, most frequently omitting emergency department return precautions. Nurses used all family-centered communication components in 11% and family-engagement components in 89% of all encounters. Nurses were more likely to discuss all components of safe discharge in EP encounters when compared with LEP encounters (53% vs 9%; P < .001; odds ratio: 11.5 [95% confidence interval 4.4-30.1]). There were no differences in family centeredness or family engagement between LEP and EP encounters.

CONCLUSIONS

Discharge encounters of LEP patients were less likely to include all safe discharge communication components, compared with EP encounters. Opportunities to improve nurse-family discharge communication include providing written discharge instructions in families' primary language, ensuring discussion of return precautions, and using teach-back to optimize family engagement and understanding.

Association Between Statewide School Closure and COVID-19 Incidence and Mortality in the US

Importance

In the US, states enacted nonpharmaceutical interventions, including school closure, to reduce the spread of coronavirus disease 2019 (COVID-19). All 50 states closed schools in March 2020 despite uncertainty if school closure would be effective.

Objective

To determine if school closure and its timing were associated with decreased COVID-19 incidence and mortality.

Design, Setting, and Participants

US population-based observational study conducted between March 9, 2020, and May 7, 2020, using interrupted time series analyses incorporating a lag period to allow for potential policy-associated changes to occur. To isolate the association of school closure with outcomes, state-level nonpharmaceutical interventions and attributes were included in negative binomial regression models. States were examined in quartiles based on state-level COVID-19 cumulative incidence per 100 000 residents at the time of school closure. Models were used to derive the estimated absolute differences between schools that closed and schools that remained open as well as the number of cases and deaths if states had closed schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile.

Exposures

Closure of primary and secondary schools.

Main Outcomes and Measures

COVID-19 daily incidence and mortality per 100 000 residents.

Results

COVID-19 cumulative incidence in states at the time of school closure ranged from 0 to 14.75 cases per 100 000 population. School closure was associated with a significant decline in the incidence of COVID-19 (adjusted relative change per week, -62% [95% CI, -71% to -49%]) and mortality (adjusted relative change per week, -58% [95% CI, -68% to -46%]). Both of these associations were largest in states with low cumulative incidence of COVID-19 at the time of school closure. For example, states with the lowest incidence of COVID-19 had a -72% (95% CI, -79% to -62%) relative change in incidence compared with -49% (95% CI, -62% to -33%) for those states with the highest cumulative incidence. In a model derived from this analysis, it was estimated that closing schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile was associated with 128.7 fewer cases per 100 000 population over 26 days and with 1.5 fewer deaths per 100 000 population over 16 days.

Conclusions and Relevance

Between March 9, 2020, and May 7, 2020, school closure in the US was temporally associated with decreased COVID-19 incidence and mortality; states that closed schools earlier, when cumulative incidence of COVID-19 was low, had the largest relative reduction in incidence and mortality. However, it remains possible that some of the reduction may have been related to other concurrent nonpharmaceutical interventions.

Imaging Strategies and Outcomes in Children Hospitalized with Cervical Lymphadenitis

OBJECTIVES

This study aimed to describe variation in imaging practices and examine the association between early imaging and outcomes in children hospitalized with cervical lymphadenitis.

METHODS

This multicenter cross-sectional study included children between two months and 18 years hospitalized with cervical lymphadenitis between 2013 and 2017. Children with complex chronic conditions, transferred from another institution, and with prior hospitalizations for lymphadenitis were excluded. To examine hospital-level variation, we calculated the proportion of children at each hospital who received any imaging study, early imaging (conducted on day 0 of hospitalization), multiple imaging studies, and CT imaging. Generalized linear or logistic mixed effects models examined the association between early imaging and outcomes (ie, multiple imaging studies, surgical drainage, 30-day readmission, and length of stay) while accounting for patient demographics, markers of illness duration and severity, and clustering by hospital.

RESULTS

Among 10,014 children with cervical lymphadenitis, 61% received early imaging. There was hospital-level variation in imaging practices. Compared with children who did not receive early imaging, children who received early imaging presented increased odds of having multiple imaging studies (adjusted odds ratio [aOR] 3.0; 95% CI: 2.6-3.6), surgical drainage (aOR 1.3, 95%CI: 1.1-1.4), and 30-day readmission for lymphadenitis (aOR 1.5, 95%CI: 1.2-1.9), as well as longer lengths of stay (adjusted rate ratio 1.2, 95%CI: 1.1-1.2).

CONCLUSIONS

Children receiving early imaging had more resource utilization and intervention than those without early imaging. Our findings may represent a cascade effect, in which routinely conducted early imaging prompts clinicians to pursue additional testing and interventions in this population.

Identification of Children With High-Intensity Neurological Impairment

This cross-sectional study describes and evaluates the effectiveness of a refined coding system for distinguishing children with high-intensity neurological impairment from those with lower-intensity neurological conditions.

Inpatient Communication Barriers and Drivers When Caring for Limited English Proficiency Children

BACKGROUND

Achieving effective communication between medical providers and families with limited English proficiency (LEP) in the hospital is difficult.

OBJECTIVE

Our objective was to identify barriers to and drivers of effective interpreter service use when caring for hospitalized LEP children from the perspectives of pediatric medical providers and interpreters.

DESIGN/PARTICIPANTS/SETTING

We used Group Level Assessment (GLA), a structured qualitative participatory method that allows participants to directly produce and analyze data in an interactive group session. Participants from a single academic children's hospital generated individual responses to prompts and identified themes and relevant action items. Themes were further consolidated by our research team and verified by stakeholder groups.

RESULTS

Four GLA sessions were conducted including 64 participants: hospital medicine physicians and pediatric residents (56%), inpatient nursing staff (16%), and interpreter services staff (28%). Barriers identified included: (1) difficulties accessing interpreter services; (2) uncertainty in communication with LEP families; (3) unclear and inconsistent expectations and roles of team members; and (4) unmet family engagement expectations. Drivers of effective communication were: (1) utilizing a team-based approach between medical providers and interpreters; (2) understanding the role of cultural context in providing culturally effective care; (3) practicing empathy for patients and families; and (4) using effective family-centered communication strategies.

CONCLUSIONS

Participants identified unique barriers and drivers that impact communication with LEP patients and their families during hospitalization. Future directions include exploring the perspective of LEP families and utilizing team-based and family-centered communication strategies to standardize and improve communication practices.

Herpes Simplex Virus Infection in Infants Undergoing Meningitis Evaluation

BACKGROUND

Although neonatal herpes simplex virus (HSV) is a potentially devastating infection requiring prompt evaluation and treatment, large-scale assessments of the frequency in potentially infected infants have not been performed.

METHODS

We performed a retrospective cross-sectional study of infants ≤60 days old who had cerebrospinal fluid culture testing performed in 1 of 23 participating North American emergency departments. HSV infection was defined by a positive HSV polymerase chain reaction or viral culture. The primary outcome was the proportion of encounters in which HSV infection was identified. Secondary outcomes included frequency of central nervous system (CNS) and disseminated HSV, and HSV testing and treatment patterns.

RESULTS

Of 26 533 eligible encounters, 112 infants had HSV identified (0.42%, 95% confidence interval [CI]: 0.35%-0.51%). Of these, 90 (80.4%) occurred in weeks 1 to 4, 10 (8.9%) in weeks 5 to 6, and 12 (10.7%) in weeks 7 to 9. The median age of HSV-infected infants was 14 days (interquartile range: 9-24 days). HSV infection was more common in 0 to 28-day-old infants compared with 29- to 60-day-old infants (odds ratio 3.9; 95% CI: 2.4-6.2). Sixty-eight (0.26%, 95% CI: 0.21%-0.33%) had CNS or disseminated HSV. The proportion of infants tested for HSV (35%; range 14%-72%) and to whom acyclovir was administered (23%; range 4%-53%) varied widely across sites.

CONCLUSIONS

An HSV infection was uncommon in young infants evaluated for CNS infection, particularly in the second month of life. Evidence-based approaches to the evaluation for HSV in young infants are needed.

Development of a New Care Model for Hospitalized Children With Medical Complexity

Children with medical complexity are a rapidly growing inpatient population with frequent, lengthy, and costly hospitalizations. During hospitalization, these patients require care coordination among multiple subspecialties and their outpatient medical homes. At a large freestanding children's hospital, a new inpatient model of care was developed in an effort to consistently provide coordinated, family-centered, and efficient care. In addition to expanding the multidisciplinary team to include a pharmacist, dietician, and social worker, the team redesign included: (1) medication reconciliation rounds, (2) care coordination rounds, and (3) multidisciplinary weekly handoff with outpatient providers. During weekly medication reconciliation rounds, the team pharmacist reviews each patient's current medications with the team. In care coordination rounds, the team collaborates with unit care managers to identify discharge needs and complete discharge tasks. Finally, at the end of the week, the outgoing hospital medicine attending physician hands off patient care to the incoming attending with input from the team's pharmacist, dietician, and social worker. Families and providers noted improvements in care coordination with the new care model. Remaining challenges include balancing resident autonomy and attending supervision, as well as supporting providers in delivering care that can be emotionally challenging. Aspects of this care model could be tested and adapted at other hospitals that care for children with medical complexity. Additionally, future work should study the impact of inpatient complex care models on patient health outcomes and experience.

Interpretation of Cerebrospinal Fluid White Blood Cell Counts in Young Infants With a Traumatic Lumbar Puncture

STUDY OBJECTIVE

We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures.

METHODS

We performed a secondary analysis of a retrospective cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm³) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm³ for infants aged 28 days or younger and greater than or equal to 10 cells/mm³ for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis.

RESULTS

Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval [CI] 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days.

CONCLUSION

Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.

Effects of dietary fiber on the ideal standardized ileal digestible threonine:lysine ratio for twenty-five to fifty kilogram growing gilts

Four experiments were conducted to determine effects of fiber on the ideal Thr:Lys ratio for 25- to 50-kg gilts. In Exp. 1, the objective was to determine the requirement for standardized ileal digestible Lys for gilts from 25 to 50 kg BW. Seventy gilts (24.54 ± 3.28 kg BW) were used in a growth assay with 2 pigs per pen, 5 diets, and 7 replicate pens per diet. The 5 diets were based on corn and soybean meal and contained between 0.80 and 1.32% SID Lys. Results indicated that 1.09% SID Lys was needed to optimize ADG and G:F. In Exp. 2, the objective was to determine the standardized ileal digestibility of AA in corn, soybean meal, field peas, fish meal, and soybean hulls. Six ileal-cannulated gilts (26.5 ± 0.74 kg BW) were allotted to a 6 × 6 Latin square design with 6 diets and 6 periods. Values for standardized ileal digestibility of AA were calculated for all ingredients. In Exp. 3, the objective was to determine the effect of fiber on the ideal SID Thr:Lys ratio for gilts from 25 to 50 kg BW. A total of 192 gilts (26.29 ± 4.64 kg BW) were used in a growth assay with 2 pigs per pen and 8 replicate pens per treatment. Six low-fiber diets and 6 high-fiber diets were formulated using the same batches of ingredients as in Exp. 2. Within each level of fiber, diets with SID Thr:Lys ratios ranging from 45:100 to 90:100 were formulated using the SID values calculated in Exp. 2. In both types of diets, ADG and G:F linearly and quadratically ( < 0.05) increased as the Thr:Lys ratio increased. Regression analysis estimated the ideal SID Thr:Lys ratio at 0.66 and 0.63 for ADG and G:F, respectively, for pigs fed low-fiber diets and at 0.71 and 0.63, respectively, for pigs fed high-fiber diets. In Exp. 4, the objective was to determine the N balance in pigs fed low-fiber or high-fiber diets that were formulated to have SID Thr:Lys ratios of 45:100 or 60:100. The 4 diets were formulated using the same batches of ingredients as in Exp. 2, and the SID values determined in Exp. 2 were used in diet formulations. Thirty-six gilts (29.0 ± 0.74 kg BW) were individually housed in metabolism crates with 9 replicate pigs per diet. Retention of N (% of intake) was greater (P < 0.05) for pigs fed the low-fiber diets compared with pigs fed the high-fiber diets regardless of the Thr:Lys ratio. Results of these experiments indicate that increased fiber levels in diets fed to growing gilts increase the requirement for Thr and that diets with higher fiber levels should be formulated to a greater SID Thr:Lys ratio.

Improving Discharge Efficiency in Medically Complex Pediatric Patients

BACKGROUND AND OBJECTIVE

Children with medical complexity have unique needs when facilitating transitions from hospital to home. Defining readiness for discharge is challenging, and preparation requires coordination of family, education, equipment, and medications. Our multidisciplinary team aimed to increase the percentage of medically complex hospital medicine patients discharged within 2 hours of meeting medical discharge goals from 50% to 80%.

METHODS

We used quality improvement methods to identify key drivers and inform interventions. Medical discharge goals were defined on admission for each patient. Interventions included implementation of a complex care inpatient team with electronic admission order set, weekly care coordination rounds, needs assessment tool, and medication pathway. The primary measure, percentage of patients discharged within 2 hours of meeting medical discharge goals, was followed on a run chart. The secondary measures, pre- and post-intervention length of stay and 30-day readmission rate, were compared by using Wilcoxon rank-sum and χ(2) tests, respectively.

RESULTS

The percentage of medically complex patients discharged within 2 hours of meeting medical discharge goals improved from 50% to 88% over 17 months and sustained for 6 months. In preintervention-postintervention comparison, median length of stay did not change (3.1 days [interquartile range, 1.8-7.0] vs 2.9 days [interquartile range, 1.7-6.1]; P = .67) and 30-day readmission rate was not impacted (30.7% vs 26.4%; P = .51).

CONCLUSIONS

Efficient discharge for medically complex patients requires support of a multidisciplinary team to proactively address discharge needs, ensuring patients are ready for discharge when medical goals are met.

Implementation of an Innovative Pediatric Hospital Medicine Education Series

OBJECTIVE

Limitations on resident duty hours require formal education programs to be high-yield and impactful. Hospital medicine (HM) topics provide the foundation for inpatient pediatric knowledge pertinent to pediatric residents and medical students. Our primary objective was to describe the creation of an innovative pediatric HM curriculum designed to increase learners’ medical knowledge and their confidence in communicating with patients and families about these topics; our secondary objective was to evaluate the level of innovation of the conference sessions perceived by the learners.

METHODS

A systematic approach was used to develop a curriculum framework incorporating a variety of interactive and engaging educational strategies. Six sessions were studied over the 2012–2013 academic year. The bimonthly sessions were presented during the resident daily conference schedule as a recurring pediatric HM series. Change in learners’ medical knowledge and confidence in communicating with families were analyzed presession to postsession by using McNemar’s test and the Wilcoxon signed rank test, respectively. Learners rated the level of innovation for each session on a 5-point Likert scale.

RESULTS

Content covered during the 6 sessions included bronchiolitis, child abuse, health care systems, meningitis/fever, urinary tract infection, and wheezing. Medical knowledge increased presession to postsession (P < .001), as did confidence in communicating about each topic with families (P < .01). The average rating score for all sessions was highly innovative.

CONCLUSIONS

A systematic approach is useful for developing new curricula for pediatric learners. Focusing on high-yield topics and established competencies allows impactful education sessions within the confines of pediatric learners’ schedule constraints.

The Greenock medical martyrs of 1864-65

In the nineteenth century it was not uncommon for doctors to die from infectious diseases, but the death of five young physicians in Greenock--one third of the medical profession in a medium-sized Scottish town--from epidemic typhus, during four consecutive months in 1864-65, was an unusual event. This paper describes the lives and backgrounds of these five doctors, whose deaths in the line of duty earned them the description 'medical martyrs'.

The place of spiritual well-being in hospice patients' overall quality of life

There is an increasing awareness of, and interest in the relationship between spirituality and health. This research examines spiritual well-being as one of six components of hospice patients' overall quality of life. Patients admitted over a four-month period were surveyed, using the Functional Assessment of Cancer Therapy scale (FACT-G), at admission, one month later, three months later, and six months later. Data showed spiritual well-being to be an important contributor to overall quality of life. The article concludes by advocating that providing spiritual care to hospice patients makes good business sense.

The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): an analysis of 500 consecutive evaluations

We assessed the safety of a new office or bedside method of evaluating both the motor and sensory components of swallowing called flexible endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal sensory discrimination thresholds by endoscopically delivering air-pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of laryngopharyngeal sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 500 times in 253 patients with dysphagia over a 2.5-year period in a tertiary care center. The patients had a variety of underlying diagnoses, with stroke and chronic neurological disease predominating (n = 155). To determine the safety of FEESST, the presence of epistaxis, airway compromise, and significant changes in heart rate before and after the evaluation were assessed. Patients were also asked to rate the level of discomfort of the examination; 498 evaluations were completed. There were three instances of epistaxis that were self-limited. There were no cases of airway compromise. There were no significant differences in heart rate between pre- and posttest measurements (p > 0.05). Eighty-one percent of patients noted either no discomfort or mild discomfort as a result of the examination. In conclusion, FEESST is a safe method of evaluating dysphagia in the tertiary care setting and may also have application for the chronic care setting.

Laryngopharyngeal sensory discrimination testing and the laryngeal adductor reflex

Laryngopharyngeal sensory capacity has been determined by endoscopically administering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve and asking the patient if he or she feels the stimulus. A potential shortcoming of this psychophysical testing (PT) procedure is that it is a subjective test, and patients with impaired cognition may not be able to perform the required task. In the search for an objective measure of laryngeal sensory function, we have observed that the laryngeal adductor reflex (LAR) is evoked at stimulus intensities similar to those capable of eliciting the psychophysical, or perceptual, response. The purpose of this study is to determine if the threshold for eliciting the LAR is the same as that of the sensory threshold. A specially designed endoscope was used to present air pulse stimuli (range 0.0 to 10 mm Hg) to the laryngopharynx in 20 healthy subjects and in 80 patients with dysphagia, using both PT and the LAR. The patients had a variety of underlying diagnoses, with stroke and chronic neurologic disease predominating (n = 65). In the control group and in the group of patients with dysphagia, there was no statistically significant difference between the median laryngopharyngeal sensory thresholds whether we used PT or the LAR (p>.05, Wilcoxon signed-rank test). The intraclass correlation for the total sample was .999 (U = .999, L = .998). Since psychophysical and sensorimotor reflex thresholds were not statistically significantly different and the intraclass correlation was close to a perfect correlation, we conclude that the LAR can be used as an objective and accurate clinical method of endoscopically assessing laryngopharyngeal sensory capacity.

Pastoral counseling in a hospice: have you considered it?

Claims that hospices provide a challenging setting for pastoral counselors but one in which they do not appear to be practicing. Offers some personal experiences of working in a hospice and urges counselors to become more involved in this form of specialized ministry.

A twist on Tarasoff: is there a duty to warn one's client?

Describes a famous legal case in which the court's decision obligates a therapist to protect potential victims from harm that may be done to them by the therapist's client and relates it to the issue of confidentiality as frequently understood by pastoral counseling specialists.

Fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in healthy controls

The purpose of this study was to introduce a new method of bedside assessment of both the motor and sensory components of swallowing called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). This approach combines the established bedside endoscopic swallowing evaluation with a more recently described technique that allows objective determination of laryngopharyngeal (LP) sensory discrimination thresholds by delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a flexible endoscope. A prospective study was conducted of FEESST in 20 healthy control subjects, mean age of 34 +/- 11 years. LP sensory thresholds were defined as either normal (< 4.0 mmHg air pulse pressure [APP]), moderate deficit (4.0-6.0 mmHg APP), or severe deficits (> 6.0 mmHg APP). Subsequent to LP sensory testing, food of varying consistencies, mixed with green food coloring, was given and attention was paid to spillage, laryngeal penetration, pharyngeal residue, aspiration, and reflux. Therapeutic maneuvers such as postural changes and airway protection techniques were performed on each subject to determine if the assessed swallowing parameters were affected by maneuvers. All patients completed the study; all had normal LP sensory discrimination thresholds (2.9 +/- 0.7 mmHg APP). There were no instances of spillage, laryngeal penetration, or aspiration. Two of 20 subjects had pharyngeal residue and 2 of 20 had reflux. Institution of therapeutic maneuvers resulted in a predictable change in the endoscopic view of the laryngopharyngeal anatomy. FEESST provides comprehensive, objective sensory and motor information about deglutition in the bedside setting and might have implications for the bedside diagnosis and management of patients with dysphagia.

Restoration of laryngopharyngeal sensation by neural anastomosis

OBJECTIVE

To demonstrate that sensory nerve transposition may be used to reestablish sensation of the laryngopharynx after central nervous system injury and vagal deficit.

DESIGN

Prospective preliminary report of 2 patients following brain-stem stroke with aspiration pneumonia confirmed on chest radiography, severe dysphagia and inability to tolerate oral alimentation, and modified barium swallow that demonstrated cricopharyngeal spasm and impaired laryngeal elevation. Both patients also had severe, bilateral laryngopharyngeal sensory deficits as determined by delivery of air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a fiberoptic telescope. Each patient underwent surgery as part of management of dysphagia after failure of aggressive nonsurgical treatment.

INTERVENTION

During a cricopharyngeal myotomy and laryngeal suspension, a unilateral microneurorrhaphy between the greater auricular nerve and the superior laryngeal nerve was performed.

OUTCOME MEASURES

Ability to tolerate oral diet without development of aspiration pneumonia and postoperative laryngopharyngeal sensory capacity.

RESULTS

By 12 months after surgery, both patients had ipsilateral restoration of laryngopharyngeal sensation, with no further episodes of aspiration pneumonia.

CONCLUSIONS

In select cases of severe dysphagia after central nervous system injury, sensory nerve transposition may be a useful adjunct to the surgical rehabilitation of the patient with dysphagia.

Effects of spray-dried porcine plasma protein on growth traits and nitrogen and energy balance in mice

Energy and nitrogen balances of mice receiving a dried skim milk-based control diet were compared to a similar group of mice receiving a diet containing 8% spray-dried plasma protein (SDPP). Mice were housed in pairs in metabolism cages with feed and water available for ad libitum intake. Five cages were assigned to each diet for a 21-d feeding period. Mice fed SDPP gained more weight (P < .01), consumed more feed (P < .01), and had higher gain: feed ratios (G:F) (P < .01) than mice fed the control diet during wk 1. No significant differences in growth, feed intake, or G:F were detected during wk 2. During wk 3, mice receiving the control diet tended to gain more (P < .10) and had a higher G:F (P < .01). Nitrogen intake and retention were greater for mice fed SDPP (P < .02). Energy intake was greater for mice fed SDPP (P < .01); however, energy retention was not different between treatment groups due to greater (P < .01) metabolic energy losses (urinary energy+heat production). Empty gut weight was greater for control mice on an absolute basis (P < .05) and when expressed as a percentage of BW (P < .02). Liver weights of mice fed SDPP were greater on an absolute basis (P < .02) and as a percentage of BW (P < .01). Feed intake, growth rate, and G:F were increased by dietary addition of SDPP.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of spray-dried porcine plasma protein on feed intake, growth rate, and efficiency of gain in mice

One hundred eight mice were weaned at 21 +/- 1 d and allotted to four dietary treatments: 1) control, 2) control + 4% spray-dried porcine plasma protein (SDPP), 3) control + 8% SDPP, and 4) control + 12% SDPP. Daily gain for males increased with increasing SDPP during wk 1 (P < .01), wk 2 (P < .01), and for the entire 3 wk (P < .01). Daily gain increased quadratically with increasing SDPP for females during wk 1 (P < .05). During the 3rd wk, ADG decreased for females with increasing SDPP (P < .05). Daily feed intake increased linearly (P < .01) with increasing SDPP in all periods. Gain-to-feed ratio (G/F) increased with increasing SDPP during wk 1 (P < .01) and for the first 2 wk (P < .05). During wk 3, G/F decreased with increasing SDPP level (P < .01). Gain-to-feed ratio of females responded quadratically to increasing SDPP during wk 1 (P < .05), whereas G/F of males increased linearly with increasing SDPP level. Gain-to-feed ratio for the entire trial was unaffected by treatment among females (P = .82) but increased linearly with increasing SDPP levels among males (P < .01). Liver weight increased quadratically with increasing SDPP levels for males (P < .05) and females (P < .05). Treatment effect on liver weight per kilogram BW.75 approached significance (P < .10) in females. Male liver weight/100 g BW and liver weight per kilogram BW.75 responded quadratically to increasing SDPP levels (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Antitachycardia pacing with cardioverter-defibrillator backup for malignant ventricular dysrhythmias

This article provides a summary of the history of antitachydysrhythmic devices and their current application in patients with ventricular dysrhythmias. Future trends are also discussed, followed by a case study illustrating the nursing care required for a patient with a combination antitachycardia pacemaker and automatic implantable cardioverter-defibrillator for slow ventricular tachycardia. The basic principles provided can be incorporated into the teaching plans of patients with antidysrhythmic devices for malignant ventricular dysrhythmias.

Myasthenia gravis and Schmidt syndrome

We describe a 47 year old woman with a 30-year history of generalized myasthenia gravis whose condition had been stable and well controlled on a combination of pyridostigmine and ephedrine until she presented. At this time she gave a 2 month history of weakness, nausea, vomiting and more recently intermittent confusion. Investigations confirmed both primary hypothyroidism and primary adrenal failure (Schmidt syndrome). The autoimmune aetiology of these three conditions was confirmed by positive acetylcholine receptor, adrenal and thyroid microsomal antibodies.

Recovery of inoculated Salmonella from poultry feed containing furazolidone

It was determined that the presence of furazolidone, a common feed additive, prevented detection of Salmonella in feed samples. Artificially inoculated Salmonella were not recovered from feed samples containing furazolidone when buffered peptone broth (BP) was used as an enrichment medium, but Salmonella were recovered from all feed samples containing furazolidone when thiol broth was used as a substitute for BP.

Identification of Enterobacteriaceae in Foods with the AutoMicrobic System

Stock cultures (136) and fresh isolates (163) of Enterobacteriaceae from ground beef, processed chickens, frozen pot pies and commercial poultry feeds were identified to species with the AutoMicrobic System (AMS). All stock cultures and fresh isolates were also concurrently tested with two other identification systems (Micro-ID and API), previously evaluated and proven accurate for identification of Enterobacteriaceae . The AMS correctly identified to species 135/136 (99.3%) of the stock cultures and 160/163 (98.2%) of the fresh isolates. All Salmonella cultures tested (74) were correctly identified by AMS.

Identification of Enterobacteriaceae from Foods with the Spectrum-10

Spectrum-10, a newly developed miniaturized identification system, was analyzed for its ability to accurately and rapidly identify members of the Enterobacteriaceae family. This study, conducted at two separate laboratories, tested freshly isolated organisms from raw and frozen foods (180) and stock cultures (144). For comparison purposes, the Micro-ID and API-20E identification systems were concurrently inoculated with the test organisms. In comparison to the Micro-ID and the API-20E systems, the Spectrum-10 identified 95 to 96% of the stock cultures to genus and species, whereas 93% of the fresh isolates were identified to genus and 82% to species.

Comparison of Aerobic and Anaerobic Incubation Conditions for Optimal Recovery of Salmonella

Effects of aerobic and anaerobic incubation of selenite-cystine and TT enrichment broth incubated at 37 and 34°C on the growth of Salmonella were determined. Pure cultures of four serotypes of Salmonella were enumerated at 0, 4, 8 and 24 h of incubation and no significant differences related to incubation conditions were found. The effect of microflora other than Salmonella , in pure and mixed cultures and from chicken and feed samples, on the recovery rate of Salmonella after incubation in enrichment media was evaluated and no significant effects were found; however, aerobic incubation usually gave higher Salmonella counts. Greater recovery of Salmonella was obtained by incubating selective plating media aerobically rather than anaerobically. Aerobic incubation of liquid enrichment media and differential plating media is therefore recommended for optimal recovery of Salmonella .

Survival of Salmonella in Dry Food and Feed

The survival of Salmonella Montevideo and Salmonella heidelberg in dry milk, cocoa powder, poultry feed, and meat and bone meal was studied at three water activities (a_w) in the range of 0.4 to 0.75. S. montevideo was more resistant to the various dry environments than S. heidelberg . Salmonellae were enumerated immediately after inoculation, after 2 d, and after 1, 3, 7 and 14 wk. Survival was greater at a_w of 0.43 and 0.52 than at 0.75 a_w. Based on these findings and due to the marked differences in survival observed in the different products equilibrated at a specific a_w value, it is concluded that the survival of salmonellae in a dry product cannot be predicted on the basis of the a_w alone.

Comparison of Brands of Media for Isolating Bacteria from Poultry, Beef and Shrimp

Five brands of media (BBL, Difco, Gibco, Oxoid and Scott) were evaluated for enumerating microorganisms by the aerobic plate count and by Enterobacteriaceae , Escherichia coli , and coliform counts, and for determining Salmonella incidence. Microbiological evaluations were done on raw chickens, raw beef and raw shrimp, except that Salmonella incidence was not determined on shrimp samples. There were statistically significant differences in total plate counts (with chicken, beef and shrimp), Enterobacteriaceae counts (with shrimp) coliforms (with chicken) and E. coli counts (with chicken) by the five brands of media, but these differences were too small to be of practical significance. It was concluded that no differences of practical significance were found among the five brands of media.

Recovery of Salmonella from Artificially Contaminated Poultry Feeds in Non-Selective and Selective Broth Media

The efficacy of four preenrichment media (lactose broth, lactose broth with Tergitol, buffered peptone and M-9) and of direct enrichment in selenite cystine and modified tetrathionate broths for recovering two Salmonella serotypes from dry poultry feed was determined. The salmonellae, artificially inoculated and stored for 7 wk in the dry feed (1.5 to 2.2 cells of salmonellae/g of feed analyzed), were recovered from significantly more samples after preenrichment with M-9 or buffered peptone than with any of the other procedures tested.

Effect of Reduced Processing on Recovery of Foodborne Pathogens from Hot-Boned Broiler Meat and Skin

Recovery of pathogens from breast meat, thigh meat and skin from scalded, defeathered but uneviscerated broiler carcasses with and without spray washing was compared to recovery from breast meat, thigh meat and skin from fully processed, chilled carcasses (controls). The incidence of coagulase-positive staphylococci was not significantly different on meat and skin from both uneviscerated carcasses with and without a spray washing compared to meat and skin from fully processed carcasses. The incidence of Clostridium perfringens was not significantly different on skin, breast and thigh meat for any of the sampling sources except that incidence on meat from control breasts was lower than on breast meat from uneviscerated carcasses without spray-washing; and incidence on meat from control thighs was lower than on meat from spray-washed, uneviscerated carcasses. Salmonella incidence was higher on both breast and thigh meat from fully processed control carcasses than from uneviscerated unwashed carcasses. When uneviscerated carcasses were spray-washed after defeathering, the incidence of Salmonella was not significantly different on breast meat, and significantly lower on thigh meat than on these meats from fully processed control carcasses. Skin from fully processed control carcasses had a higher incidence of Salmonella than did skin from uneviscerated, unwashed carcasses, but not skin from uneviscerated, spray-washed carcasses. Reducing the number of stages of processing significantly reduced the incidence of Salmonella but not of coagulase-positive staphylococci or Clostridium perfringens .

Selecting a Miniaturized System for Identification of Enterobacteriaceae

The most commonly used commercial diagnostic kits for identification of Enterobacteriaceae are API, Enteric-Tek, Enterotube II, Micro-ID, Minitek and Spectrum-10. The accuracy of identification by all systems does not vary significantly, and falls within the acceptable range. Therefore, a bacteriologist who is considering the use of these products should evaluate factors other than accuracy when making a choice. Twenty-three professional microbiologists who had previous experience with these systems listed advantages and disadvantages of each system, and evaluated the conventional procedure for identification. The comments were summarized and presented in tabular form. The current cost per isolate of each system and the cost of the identification manual, reagents and incidental costs were also determined. These data provide the potential user with comparative information on price, shelf-life, versatility, time required for inoculation, incubation and manipulation after incubation, possible difficulties in determining positive and negative reactions, and potential safety factors for laboratory personnel.

Salmonella and other Enterobacteriaceae found in commercial poultry feed

Poultry feed (mash and pelleted) and meat and bone meal samples were collected from commercial mills. All samples were analyzed for Enterobacteriaceae count (ENT) and Salmonella. The genus and species of the various Enterobacteriaceae present were also determined. The average ENT for mash, pelleted, and meal samples was log 4.1, .8, and 1.8/g, respectively. Enterobacteriaceae were present in 100, 60, and 92% and Salmonella in 58, 0, and 92% of the mash, pelleted, and meal samples, respectively. Overall, the Enterobacteriaceae most frequently isolated from all samples were Enterobacter agglomerans, Enterobacter cloacae, and Klebsiella pneumoniae. Although no Salmonella were found in the pelleted samples, the presence of other Enterobacteriaceae suggests that commercial pelleting may not totally destroy Salmonella since their heat resistance is similar to the other organisms found.

Evaluation of Five Miniaturized Systems for Identifying Enterobacteriaceae from Stock Cultures and Raw Foods

Five miniaturized systems (API, Enteric-Tek, Enterotube II, Micro-ID and Minitek) were compared to conventional procedures for identification of Enterobacteriaceae from stock cultures and freshly isolated from food sources, The accuracy of identification to genus was 98% for Micro-ID; 95%, Minitek; 94%, Enteric-Tek; 93%, API; and 86%, Enterotube II, Accuracy of identification to species was 97% for Micro-ID; 94%, Minitek; 93%, Enteric-Tek; 91 %, API; and 79%, Enterotube II, The 124 organisms tested in this study were from 11 genera of the Enterobacteriaceae family. All systems accurately identified to species the most pathogenic members of the family ( Arizona hinshawii , Salmonella typhi , Salmonella typhimurium and Shigella flexneri ). Most of the inaccuracies in identification occurred with Enterobacter and Serratia species.

Heating by microwave, hot air, and flowing steam to eliminate inoculated Salmonella from poultry feed

Poultry feed samples (mash) obtained from a commercial mill were inoculated with either 100 or 5,000 cells/g of a marker strain of Salmonella montevideo. Samples (125 g) were then placed in a microwave oven at power settings of 1.5 or 2.0 kW for 60, 90, or 120 sec; a hot air oven at 99 C (210 F) or 110 C (230 F) for 15, 30, 45, or 60 min; or a flowing steam chamber for 1, 5, 10, or 20 min. Temperature, moisture, and presence of the inoculated S. montevideo were determined in all samples before and after treatment. Feed samples placed in the microwave oven reached a maximum temperature of 186 C (367 F) and had a final moisture content as low as .8%. About 25% of the samples inoculated with 100 cells/g and about 40% of those inoculated with 5,000 cells/g remained positive after treatment. In the hot air oven, feed reached a maximum temperature of 93 C (200 F) with a moisture level after heating of about 4%. Salmonellae were recovered from 35 and 60% of the low and high inoculum level samples, respectively. In flowing steam, maximum feed temperature was 90 C (194 F) with a final moisture level of 15%. After 1, 5, 10, and 20 min of flowing steam, 100, 90, 60, and 0% of the samples were found to contain salmonellae, respectively. All treatments occasionally eliminated salmonellae from the samples, but results were inconsistent and unpredictable.

Rapid Procedure for Biochemical Characterization and Serological Confirmation of Suspect Salmonella Isolates

Fifty-two freshly processed broiler carcasses were examined for the presence of Salmonella by using a rinse method. Three selective plating media (bismuth sulfite, brilliant green sulfa and Hektoen enteric) were compared. After 24 h of incubation, typical colonies were picked from each selective plate. An 8-h procedure to biochemically characterize (Micro ID) and serologically (poly O and poly H) confirm Salmonella was then compared with a conventional procedure. Suspect Salmonella isolates were correctly classified from 63% of the carcasses with both the 8-h and conventional procedures. Of the 244 isolates confirmed to be Salmonella by conventional testing, 236 (97%) were also confirmed by the 8-h procedure. Brilliant green sulfa and Hektoen enteric agar were superior to bismuth sulfite agar for Salmonella recovery. The 8-h procedure required less incubation time (8 h vs. 48 h) after colony formation, less incubation space, and less media preparation and cleanup than the conventional procedure.

Effect of various media and incubation conditions on recovery of inoculated Salmonella from poultry feed

Samples of commercially pelleted poultry feed (30 g) were inoculated with nalidixic acid-resistant marker strains of Salmonella heidelberg or S. montevideo at levels of 1 (low), 20 (medium), or 40 (high) cells/g of feed, then 100 ml of either a nonselective preenrichment medium (lactose broth) or a selective enrichment medium [selenite cystine (SC) or tetrathionate brilliant green (TT) broth] was added and incubated at either 37 or 43 C for 24 or 48 hr in different experiments. Four selective plating media [MacConkey with 100 ppm nalidixic acid, brilliant green (BG) sulfa, modified BG, bismuth sulfite] were then streaked. MacConkey agar with nalidixic acid served as a control to which the other three plating media were compared. After 24 hr incubation at 37 C, colonies with characteristics typical of Salmonella were selected from the plates and examined biochemically and serologically to determine if they were the marker organism. In this study, preenrichment was counterproductive, because the marker organisms were recovered much more often with direct enrichment in SC or TT broth than with reenrichment in lactose broth. The TT broth produced 135 positive recoveries, whereas only 88 positive recoveries were made with SC. No differences were observed between 37 and 43 C or 24 and 48 hr incubation of the selective enrichment media. Overall efficiency of the plating media for Salmonella recovery from feed, when compared to the control (MacConkey), was BG sulfa, 65%;modified BG, 64%; and bismuth sulfite, 40%. The most effective enrichment broth-plating medium combination was TT-BG sulfa, yielding 86% positive recoveries when compared to the control.

Minimizing Salmonella Contamination on Broiler Carcasses with Poly (Hexamethylenebiguanide Hydrochloride)

Broiler carcasses, each inoculated with 30 cells of marker Salmonella heidelberg , were prechilled and chilled together with uninoculated carcasses in a simulated commercial chilling system. When either 10 or 25 ppm of PHMB [poly(hexamethylenebiguanide hydrochloride)] was added to the prechill water, cross-contamination (uninoculated carcasses showing contamination with marker Salmonella after chilling) was prevented, and no viable Salmonella were found on the inoculated carcasses. When carcasses, each inoculated with 60,000 cells of marker Salmonella , were similarly chilled, and 10 ppm of PHMB was added to the prechill water, cross-contamination was not prevented, and viable Salmonella were found on the inoculated carcasses. With 60,000 cells, and 25 ppm PHMB, cross-contamination was prevented, but viable Salmonella remained on the inoculated carcasses.