Healthcare acquired infections (HAIs) are a complex and multi-factorial problem associated with high morbidity, mortality, and cost. Toothbrushes (TBs) may be at risk for contamination with potential pathogenic microorganisms (PPMs) from the patient care environment or autoinnoculation from the patient. We focused on three PPMs: multiply resistant Staphylococcus aureus (MRSA), vancomycin resistant Enterococcus (VRE), and Acinetobacter. Specific aims were to (1) describe environmental factors associated with TB contamination in the ICU; (2) describe the relationship between TB contamination and oral colonization in critically ill adults.

Examining older adults’ experiences with and response toward hurricanes within the context of the community of residence is key to both understanding their experiences and planning for future hurricanes. Specific to this research, the objective was to understand the current social network of older adults, or who provides care for whom under what circumstances, using the social constructionist perspective. Grounded theory combined with action research was the theoretical orientation guiding the study. Sources of data included the collection of household disaster plans, semi-structured interviews with older adult residents of housing authority neighborhoods, semi-structured interviews with community planners, and observation of community planning meetings. Data were gathered from older adults living in housing authority communities in Southeastern North Carolina using guidelines established by the North Carolina Department of Health and Human Services to develop individual disaster plans. The individual disaster plans were completed during face to face meetings with the older adults, as were semi-structured interviews. Semi-structured interviews were also completed with area planners. Agendas, minutes, and observational notes from disaster planning meetings were collected. The content of the individual disaster plans, semi-structured interviews, and observation notes were then analyzed to determine gaps that must be addressed in order to meet the overall needs of the community. Working with participants, the housing authority disaster response committee, and county planners, a neighborhood plan will be developed that reflects the social construction of all concerned for use in response to future hurricanes. The impact of the multiple levels of communities was apparent in this research. While common thematic processes emerged in data analysis, planners, housing authority personnel and residents of housing communities define community differently. There is discordance when they identify needed resources, and when they reflect on past experience. A power differential which resulted in stifling was also observed.

ABSTRACT HOSPITALS WITH PHYSICIAN CEOS: AN INSTITUTIONAL THEORY PERSPECTIVE By: Jeremy S. Zoch, Ph.D. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Health Related Sciences at Virginia Commonwealth University. Virginia Commonwealth University, 2011 Major Director: Kenneth R. White, Ph.D. Professor Department of Health Administration The complexities of the healthcare industry at the beginning of the 21st century continue to challenge hospitals to optimize their operations. A key leadership position in the overall success of a hospital is the role of the Chief Executive Officer. The purpose of this study was to determine the kind of leader that hospitals have in place and to analyze more closely those specific organizations that have physician CEOs. This study had three distinct objectives. The first was to describe the organizational variables for American Hospital Association (AHA) hospitals with CEOs who are physicians. The second objective was to analyze the organizational and market characteristics of hospitals with physician CEOs. The final objective was to examine the similarities and differences between hospitals that have a CEO who is a physician and those headed by a CEO who is not a physician. Institutional theory was utilized to form a theoretical model and to develop the relevant hypotheses. The study was a retrospective, cross-sectional study of over 5600 American Hospital Association (AHA) short-term, acute care hospitals located in the United States. Data sources utilized were the AHA’s Annual Survey of Hospitals, the Area Resource File, Centers for Medicaid and Medicare Services, HealthLeaders-Interstudy, and SK&A from 2007-2008. There were 118 hospitals out of 5,671 with a physician CEO in 2008. The descriptive statistics and multivariate logistic regression analyses revealed that although hospitals with physician CEOs are located in many different locations and types of hospitals, they are some attributes that indicate a greater likelihood. Hospitals with physician CEOs are most prevalent in the northeast. The multivariate logistic regression analyses revealed there is a greater likelihood that hospitals with physician CEOs are more likely to be larger, specialty, not-for-profit and non-church operated, teaching, and be in a market with higher physicians per capita. The study also found that there wasn’t more likelihood for a hospital to have a physician CEO when comparing with US News top hospitals, based on affluence of a market, based on the competition in the market, or the managed care penetration. The study identified several of the components and how they positively relate to the institutional theory model that was developed. The study also identified several limitations that could further be improved using additional research approaches and obtaining more data. Overall, the study has furthered the information available about hospitals with CEOs who are also physicians and their corresponding organizational and market characteristics.

Neonatal Intensive Care Units have experienced profound advances in technology and treatment modalities over the last two decades. Infants born at the edge of viability are now surviving despite prolonged hospitalizations. These infants born preterm are prone to a high degree of stress from life sustaining and routine interventions. Much focus has been directed toward addressing noxious environmental factors such as noise, light, and infectious disease; however, little has been done to examine the stress experienced by the professional caregiver who work in these environments. Environmental press theory, which focuses on the interplay between human beings and their surroundings, is explored as a way to provide insight into understanding and mitigating the stress experienced by health care providers working in the newborn intensive care. A proposal for a research study with a cross-over design was approved to study the effect of “four handed care” on infants’ physiologic responses (oxygenation, heart rate, and stress) and behavioral responses (state, stress and defense, self-regulatory and approach behaviors) to and recovery from endotracheal suctioning when compared to routine care. Results of this study demonstrated no significant differences were noted when heart rate (HR) or oxygen saturation (SpO2) taken at baseline were compared to HR and SpO2 obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO2 increased from pre-observation 95.49 to during observation saturation 97.75 (p = 0.001). Salivary cortisol did not differ between groups at baseline or post-suctioning. There was no significant difference in behavior state between the two conditions at any time point. More stress and defense behaviors were seen post-suctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory behaviors were exhibited by infants during (p = .019) and after suctioning (p = .016) when receiving four-handed care as opposed to routine care. There was no statistical difference in the number of monitor call-backs post-suctioning. In conclusion, four-handed care during suctioning was associated with a decrease in stress and defense behaviors and an increase in self-regulatory behaviors. These findings, while based on a small sample, provide modest evidence that the four-handed care intervention for suctioning should receive further testing. Interventions such as four-handed care that are theoretically developmentally supportive of the sick preterm infant, need further research attention before recommending widespread adoption.

Delta9-tetrahydrocannbinol (THC), the primary active constituent of Cannabis sativa, has long been known to reduce opioid withdrawal symptoms. Although THC produces most of its pharmacological actions through the activation of CB1 and CB2 cannabinoid receptors, the role these receptors play in reducing opioid withdrawal symptoms remains unknown. The endogenous cannabinoids, N-arachidonoylethanolamine (anandamide; AEA) and 2-arachidonylglycerol (2-AG), activate both cannabinoid receptors, but are rapidly metabolized by fatty acid amide hydrolase (FAAH) and monoacylglycerol lipase (MAGL), respectively. The objective of this dissertation was to test whether increasing AEA or 2-AG, via inhibition of their respective hydrolytic enzymes, reduces morphine withdrawal symptoms in in vivo and in vitro models of opiate dependence. Morphine-dependent ICR mice subjected to acute naloxone challenge or abrupt withdrawal (via pellet removal) reliably displayed a profound withdrawal syndrome, consisting of jumping, paw tremors, head shakes, diarrhea, and weight loss. THC and the MAGL inhibitor, JZL184 dose-dependently reduced the intensity of precipitated withdrawal measures through the activation of CB1 receptors. The FAAH inhibitor, PF-3845, reduced the intensity of a subset of precipitated signs through the activation of CB1 receptors, but did not ameliorate the incidence of diarrhea or weight loss. In the next set of experiments, MAGL inhibition dose-dependently reduced the intensity of all spontaneous withdrawal signs (i.e jumps, paw flutters, head shakes, weight loss and diarrhea) in a CB1 receptor dependent manner. However, FAAH inhibition reduced the intensity of head shakes and paw flutters, but did not affect other signs. Strikingly, a combination of low-dose JZL184 and high-dose PF-3845 reduced abrupt withdrawal signs in a manner similar to complete MAGL inhibition, which suggests potential therapeutic advantages of dual enzyme inhibition. This combination elevated appropriate eCB levels and caused moderate CB1 receptor desensitization, but did not affect receptor number in whole brain. Since MAGL, but not FAAH inhibition, blocked diarrhea during opioid withdrawal in vivo, we investigated whether inhibitors of each enzyme would differentially attenuate naloxone-precipitated contractions and secretion in morphine-dependent ilea in vitro. Both enzyme inhibitors attenuated the intensity of naloxone-induced contractions, and blocked naloxone-precipitated hypersecretion. Thus, these models offer useful tools for investigating in vitro end-ponts of withdrawal, but not for elucidating anti-diarrheal mechanism of these inhibitors.If targeting endocannabinoid catabolic enzymes is indeed a viable approach to treat other abuse disorders, it is important to know whether these inhibitors would themselves have abuse or dependence liability. In the final series of experiments we tested whether prolonged elevation of endocannabinoid leads to the development of cannabinoid dependence, based on the occurrence of somatic withdrawal signs upon challenge with rimonabant, a CB1 receptor antagonist. Repeated treatment with high doses, but not low doses, of JZL184 led to cannabinoid dependnece. These results indicate that the strategy of increasing endogenous cannabinoids through the inhibition of their catabolic enzymes represents a promising approach to ameliorate opioid withdrawal symptoms.

This study examined the cytotoxic effects of STERIPLEX™ HC (sBioMed, Orem, UT) and sodium hypochlorite (NaOCl) on human fibroblast cells in vitro. Fibroblasts exposed to various concentrations of NaOCl or STERIPLEX™ HC were visualized via light microscopy. Dilutions of either NaOCl or STERIPLEX™ HC that did not appear to disrupt the integrity of the cells were recorded for further analysis. Cells were then cultured and grown to confluence in five separate plates. A void was created down the middle of each plate. If the cells were viable, cellular confluence was seen. If nonviable, confluence of the cells did not occur. Both disinfectants showed absolute kill at all concentrations above 1%. The cells treated with 0.1% NaOCl were found to be nonviable. However, at 0.1% STERIPLEX™ HC, the cells were viable and able to replicate, filling the void and returning to confluence.

Background: While efficacy of the Forsus appliance has been shown, there are disagreements on its mechanism for Class II correction. Class II studies have been criticized for ignoring potential differences in results based on differing vertical facial phenotypes. The purpose of this study was to better understand the effects of Class II correction using the Forsus appliance and relate changes during and at the completion of treatment to initial MP-SN angles. Materials and Methods: Records of 59 patients obtained at 4 different time points were examined retrospectively. ANOVA was used to describe the cephalometric changes and Pearson’s correlation tested for any relationship between patients’ pretreatment MP-SN angle and other selected measures. Results/Conclusions: Class II correction was achieved by mesial movement of the mandibular dentition, differential mandibular growth, and clockwise rotation of the occlusal plane. There was no correlation between pre-treatment MP-SN angles and any selected cephalometric measure.

Purpose: To determine which method of anesthesia risk presentation parents understand and prefer across their demographic variables Methods: As a cross-sectional study, questionnaires were distributed to 50 parents of patients (<7 years of age) in the VCU Pediatric Dental Clinic. Parents were asked of their own and their children’s demographics, previous dental and anesthesia experiences, and anesthesia understanding. Parents were then asked to rate the level of risk of several risk presentations and finally asked which method of risk presentation they most understood or preferred. Data analysis was performed using descriptive statistics, correlation coefficients, likelihood chi square tests, and repeated measures logistic regression. Results: There was no evidence of a differential preference due to gender (P = 0.28), age (P > .9), education (P = 0.39) or whether they incorrectly answered any risk question (P > 0.7). There was some evidence that the three types were not equally preferred (likelihood ratio chi- square = 5.31, df =2, P-value = 0.0703). The best estimate is that 60% prefer charts, 34% prefer numbers, and 36% prefer activity comparisons. There was a relationship between the average relative risk of general anesthesia and age (r = –0.38, P = 0.0070). Younger individuals indicate High risk more often and older individuals indicate Low risk more often. Conclusion: There was no preference of risk presentation type due to gender, age, or education, but there was evidence that each was not equally preferred. Healthcare providers must be able to present the risk of anesthesia in multiple ways to allow for full patient understanding.

Purpose: to assess the retentive strengths of passive fit esthetic anterior restorations using three commercially available cements. Methods: Three resin dies were fabricated from the intaglio surface of each restoration type. Each die was prepared following the current accepted guidelines on primary anterior tooth crown preparation. The three prepared teeth were replicated to produce 30 dies for each of the three restoration types. The prepared teeth were further separated into nine groups of 10 teeth each. Thirty EZ Pedo Crowns, 30 NuSmile Primary Crowns and 30 Unitek crowns were cemented using hand pressure employing the luting cement assigned to the corresponding group. The units were allowed to cure for 7 days. The force required to dislodge the restoration was tested using the Instron Universal Testing Machine. The data was statistically analyzed using a two-way ANOVA to analyze the force required to dislodge the restorations. A two-way logistic regression was used to analyze the failure types. Results: There were no significant differences in restoration retention rates between restoration types (P = 0.4412) but there were significant differences between types of cements used. (P < .0001). The differences with regard to cement types were consistent across the restoration groups (P = 0.7682). Tukey’s HSD multiple comparison procedure indicated FujiCem was significantly more retentive than either Fuji I or Ketac Cem cements and there were no significant differences in restoration retention rates between the Fuji I and Ketac Cem cements. Conclusion: The type of restoration did not matter between cements but cement type did matter with FujiCem cement being more retentive than the other types of cements tested.

Infections in patients with acute liver failure (ALF) and acute liver injury (ALI) are a frequent occurrence. Because ALF and ALI patients share many of the same clinical features as patients with severe sepsis and septic shock, identifying an infection based upon clinical manifestations is extremely difficult. Bacterial culture and sensitivity reports require 24 to 72 hours to be finalized after the need for a culture is suspected and obtained. During this time period, ALF and ALI patients are either not receiving required antibiotic therapy, receiving antibiotic therapy that is not required or not appropriate for the infecting bacterial pathogen, or receiving the correct antibiotic prophylaxis. Receiving an antibiotic that is not needed or inappropriate adds another level of complexity to the ALF and ALI patients because antibiotics may exacerbate liver dysfunction. The purpose of this study was to determine the utility of serum procalcitonin concentrations (SPCTC) as a biomarker of bacterial infections in patients with acute liver failure (ALF) and acute liver injury (ALI). This three part study measured SPCTC retrospectively on samples from ALF and ALI patients who were prospectively enrolled in the United States Acute Liver Failure Study Group (USALFSG) ALF and ALI studies. In the first part of the study, subjects were categorized according to how many SIRS continuum components they had and whether there was a documented infection. In the second part, serial samples on subjects who developed infections were identified. And, in the third part, serial samples on subjects diagnosed with infection on day one of the study and categorized based upon transplant free survival (TFS) or death and/or liver transplant (DoT) were identified. Procalcitonin was not found to be useful in identifying infection in the ALF and ALI patient populations. A cut-off for indication of infection was calculated to be 1.62 ng/mL using receiver operator curve (ROC) analysis. Despite the fact that there was an overall increase in SPCTC as the severity of illness increased in patients with a documented infection, there were confounding variables including antibiotic use, missing data, and small sample size that may have contributed to the poor sensitivity and specificity (0.643 and 0.620 respectively) calculated as part of the ROC analysis. SPCTC values appeared to be increased in subject with acetaminophen (APAP) toxicity and may have affected the cut-off, sensitivity, and specificity results. Increased SPCTC values were seen in APAP subjects who did not have a documented infection. It is unknown at this time if the SPCTC were increase due to liver damage, an undiagnosed infection, or as a result of increase cytokine production due to the APAP toxicity. Serial PCT concentrations in patients who achieved TFS showed a greater decrease over time than those of patients who died or received a liver transplant, however, the TFS group contained a large portion of APAP subjects. Further prospective studies are needed to determine the extent of interference with SPCTC in patients with APAP toxicity and to better define the PCT concentration cut-off between infection and no infection in the ALF and ALI populations.