Hepatitis B virus (HBV) infections continue to occur in adult hemodialysis units. A possible contributing factor is the presence of occult HBV (serum hepatitis B surface antigen [HBsAg] negative but HBV DNA positive). Two hundred forty-one adult hemodialysis patients were screened for occult HBV. HBV DNA testing was performed by real-time polymerase chain reaction (PCR) with 2 independent primer sets (core promoter and surface). Two (0.8%) of the 241 patients were HBsAg positive. Of the remaining 239 HBsAgnegative patients, 9 (3.8%) were HBV DNA positive. Viral loads in these individuals were low (10 2 -10 4 viral copies/mL). Seven of the 9 (78%) were nt 587 mutation (sG145R mutant) positive. Demographic, biochemical, and HBV serological testing did not help to identify those with occult HBV. In conclusion, the prevalence of occult HBV in adult hemodialysis patients in this North American urban center is approximately 4 to 5 times higher than standard HBsAg testing would suggest. The majority of these infections are associated with low viral loads and a high prevalence of the sG145R mutant. Finally, the demographic, biochemical, and/or serological features of HBV DNA-positive subjects do not distinguish these individuals from the remainder of the dialysis patient population. (HEPATOLOGY 2004; 40:1072-1077.) D espite the development of an effective hepatitis B virus (HBV) vaccine and extensive infection control guidelines, HBV infections continue to occur in dialysis units throughout North America and Europe. 1-3 Based on the results of hepatitis B surface antigen (HBsAg) testing, the incidence of such infections is thought to be 0.05%-1% per year. 4 However, this likely represents an underestimate of the true incidence, as the use of more sensitive monoclonal-based assays for HBsAg detection increase positive findings in dialysis patients by 120%. 5 The relatively low acceptance and response rates to the HBV vaccine among dialysis patients likely contributes to ongoing transmission, as does the need for vaccine boosts to maintain antibody to HBsAg (anti-HBs) at protective levels. 4,6 -8 Additional contributing factors include "breakdowns" in the application of universal and/or dialysis-specific infection control measures. 4,7,9 With the development of specific and sensitive polymerase chain reaction (PCR)-based testing for HBV DNA, the presence of occult HBV infection (HBV DNA positivity in the setting of negative serum HBsAg) represents yet another possible explanation for ongoing transmission.To date, few studies have documented the prevalence of occult HBV infection in renal dialysis patients. In 3 small studies of 33, 5, and 67 HBsAg-negative dialysis patients, 50%, 40%, and 0%, respectively, were HBV DNA positive. 10 -12 Of note, the majority of HBV DNApositive individuals in these studies had serological evidence of previous HBV infection (HBV seropositive), but as many as 39% were HBV seronegative.The present study documents the prevalence of HBV DNA positivity in a large, North American renal dialys...

TRIAD showed that training nurses to assess for depression using an approach developed in partnership with home healthcare agencies led to appropriate referral and care for depressed patients.

No abstract

IMPORTANCE Among older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression.OBJECTIVE To determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study. INTERVENTIONS The Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses' training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week. MAIN OUTCOMES AND MEASURES Depression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D). RESULTSThe 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect (P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, <10), the intervention had no effect (P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness (P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005). CONCLUSION AND RELEVANCEHome health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01979302

Background Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress. Objectives We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience. Research design An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers. Participants Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital. Research context This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies. Ethical considerations The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project. Findings Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports. Discussion Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting. Conclusion This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice.

Objectives:Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada.Methods:We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners.Results:We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report.Conclusions:This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.

Results suggest that factors collected during routine HH patient assessments can provide important information to predict risk of earlier hospitalization and re-hospitalization among Medicare HH patients. Identified factors can help identify patients at greatest risk of early hospitalization and may be important targets for agencies and care providers to prevent avoidable hospitalizations.

High rates of controlled prescription drugs are associated with cognitive impairment, falls, and misuse and dependence. Little is known about the prevalence of these medications among older adults receiving home healthcare. The purpose of this study was to determine the frequency of, and the factors related to, opioid analgesics, benzodiazepines (BNZ), and non-benzodiazepine (NBNZH) hypnotics among a large sample of older adults entering home health services. The data came from administrative records of 133 Certified Home health Agencies located across 32 states. Patients (age ≥ 65) receiving Medicare home health services and who received a start-of-care Medicare OASIS assessment between Jan. 1, 2013 and Dec. 31, 2014 were included in the study (n= 87,780). Rates of controlled medication use were compared across patient-level sociodemographic, clinical, functional, and environmental variables. The prevalence of controlled medication was high, with 58% prescribed at least one class of controlled drug, 44% were prescribed an opioid, 19% were prescribed a BNZ, and almost 7% were prescribed a NBZDH. Factors independently associated with higher levels of controlled medication usage include younger-old age, white race, post-surgical status, injuries, referral from inpatient settings and rural location. Home health clinicians are well-positioned to review and reconcile medication, oversee referrals and follow-up care, and provide ongoing assessment of risk regarding the use of opioids, BNZ, and hypnotics among home health patients.