Inova Loudoun Hospital

The number of people accessing the Internet for sexual purposes (cybersex) has increased dramatically over the last 10 years. However, little research has been conducted to determine how frequently clients present for treatment with cybersex-related issues. One hundred sixty-four clinical members of the American Association for Marriage and Family Therapy participated in the current study, which was conducted to identify the impacts of cybersex on MFTs' practices. Most respondents report seeing clients with cybersex-related issues, with client numbers increasing over the past 2 years. Although most respondents felt prepared to diagnose and treat adults with cybersex problems, half felt unprepared to diagnose and treat children. Lastly, most respondents reported that their required college courses were not helpful in preparing them to diagnose and treat cybersex-related problems. The implications of study findings are discussed.

A six-stage membrane bioreactor (MBR) pilot plant was operated to determine and demonstrate the capability of this process to produce a low-nutrient effluent, consistent with the nutrient reduction goals for the Chesapeake Bay. Biological nitrogen removal was accomplished using a multistage configuration with an initial anoxic zone (using the carbon in the influent wastewater), an aerobic zone (where nitrification occurred), a downstream anoxic zone (where methanol was added as a carbon source), and the aerated submerged membrane zone. The capability to reliably reduce effluent total nitrogen to less than 3 mg/L as nitrogen (N) was demonstrated. A combination of biological (using an initial anaerobic zone) and chemical (using alum) phosphorus removal was used to achieve effluent total phosphate concentrations reliably less than 0.1 mg/L as phosphorus (P) and as low as 0.03 mg/L as P. Alum addition also appeared to enhance the filtration characteristics of the MBR sludge and to reduce membrane fouling. Aeration of the submerged membranes results in thickened sludge with a high dissolved oxygen concentration (approaching saturation), which can be recycled to the main aeration zone rather than to an anoxic or anaerobic zone to optimize biological nutrient removal. Biological nutrient removal was characterized using the International Water Association Activated Sludge Model No. 2d. The stoichiometry of chemical phosphorus removal was also consistent with conventional theory and experience. The characteristics of the solids produced in the MBR were compared with those of a parallel full-scale conventional biological nitrogen removal process and were generally found to be similar. These results provide valuable insight to the design and operating characteristics of MBRs intended to produce effluents with very low nutrient concentrations.

BACKGROUND: Extremity injury is a common condition that requires pain management in an emergency department. In pediatric patients, the most frequently used method of pain control is intravenous (IV) morphine sulfate. Oral transmucosal fentanyl citrate (OTFC) is a potential alternative to morphine, which may obviate the need to place an IV before addressing pain. OBJECTIVE: To compare OTFC with IV morphine for sedation and analgesia during initial evaluation of children with deformity of an extremity and suspected fracture. DESIGN/METHODS: A randomized controlled trial of OTFC versus IV morphine in which 8- to 18-year-olds presenting to pediatric tertiary care emergency department with extremity deformity and suspected fracture were eligible. Only those with visual analog scale (VAS) (0 = no pain, 100 = worst pain imaginable) score equal to or greater than 50/100, and American Society of Anesthesia I or II qualified. Patients were excluded if history of loss of/altered level of consciousness, multiple traumatic injuries, or if patient had received prior medication for pain control. All patients enrolled were randomly assigned to receive either IV morphine (0.1 mg/kg) or OTFC (10-15 mug/kg). Patients rated pain intensity using VAS; scores were recorded before medicating and at 15-minute intervals after the medication was given. Adverse events such as emesis, pruritus, and respiratory depression were recorded. RESULTS: A total of 87 patients were enrolled in study (OTFC, 47; morphine, 40). There are no significant differences between the 2 groups when comparing sex, age, weight, and pretreatment VAS score (P > 0.05). Although the VAS scores were not significantly different before medicating the patient, an analysis of variance shows that there was a significant difference (P > 0.05) in VAS scores at 30 minutes. The differences persisted for every 15 minutes through the 75 minutes of monitoring. There was no statistically significant difference between the 2 groups when comparing the number of adverse events (P = 0.23). CONCLUSIONS: The use of OTFC can provide improved pain control when compared with IV morphine. The pain reduction starts 30 minutes after initiation of medication, and the effect is seen as far as 75 minutes after the initiation of analgesic medication. The study size was too small to make any statements concerning adverse effects; thus, further studies with larger sample sizes are needed to determine the use of OTFC.

In Brief In this prospective, randomized study of 102 subjects with single-lumen peripherally inserted central catheters with positive pressure Luer-activated devices, 2 flushing solution groups were compared for their effect on occlusion rates. Of the 50 subjects randomly assigned to the normal saline group, 3 (6%) experienced occlusions, all of whom were elderly women. There were no occlusions in the 52 subjects randomly assigned to the heparinized saline group. Although the occlusion rate findings were not statistically significant, the charges associated with replacing a PICC because of occlusion are economically relevant. The annualized savings attributable to heparinized saline use are $22,891. In this prospective, randomized study of 102 subjects with single-lumen peripherally inserted central catheters with positive pressure Luer-activated devices, 2 flushing solution groups were compared for their effect on occlusion rates. Of the 50 subjects randomly assigned to the normal saline group, 3 (6%) experienced occlusions, all of whom were elderly women. There were no occlusions in the 52 subjects randomly assigned to the heparinized saline group. Although the occlusion rate findings were not statistically significant, the charges associated with replacing a PICC because of occlusion are economically relevant. The annualized savings attributable to heparinized saline use are $22,891.

Professional school counselors face the challenge of delivering guidance and counseling services to students while connecting to the educational mission of schools. This article is a summary and evaluation of a small group counseling program that targets academic issues while addressing personal/social issues with elementary-aged children. Results suggest that integrating academic interventions and group counseling improved students' behavior related to school achievement. Implications for school counselors and application of the ASCA National Model® are briefly discussed.

OBJECTIVE: The purpose of this study was to determine whether implementing a program based on a clinical protocol affects breastfeeding rates within a pediatric primary care setting. Increasing breastfeeding rates is an important public health initiative identified by multiple agencies. METHODS: The Academy of Breastfeeding Medicine (ABM) clinical protocol ("The Breastfeeding-Friendly Physician's Office, Part 1: Optimizing Care for Infants and Children") was used as a template for the provision of breastfeeding services within a pediatric primary care clinic. There were 757 mother-infant pairs included in the study. A retrospective before-and-after study design was used. Data collection points included the hospital stay, the newborn visit, and the 2-, 4-, and 6-month health maintenance visits. The 2 groups were compared to estimate the protocol's effectiveness as a method of increasing breastfeeding rates. RESULTS: The results of this evaluation were positive for exclusive breastfeeding, with group comparisons showing a statistically significant increase in exclusive breastfeeding rates at all 5 time points. CONCLUSIONS: Our diverse patient population within a pediatric practice had increased initiation rates and exclusive breastfeeding rates after implementation of the ABM's breastfeeding-friendly protocol. Families who receive care in a pediatric primary care setting that has implemented the ABM clinical protocol may have increased rates of exclusive breastfeeding.

BACKGROUND: Live music therapy provided by a board-certified music therapist reduces anxiety, decreases pain, and improves the physiological response of patients in the intensive care unit (ICU). OBJECTIVES: To examine the effect of live music therapy on the physiological parameters and pain and agitation levels of adult ICU patients receiving mechanical ventilation. METHODS: A total of 118 patients were randomly assigned to live music therapy or standard care. The music therapy group received 30 minutes of live music therapy tailored to each patient's needs. The Richmond Agitation-Sedation Scale and the Critical Care Pain Observation Tool were completed by critical care nurses immediately before and after each session, and the patients' heart rates, respiratory rates, and oxygenation levels were measured. RESULTS: Patients who received live music therapy had significantly different scores on the Richmond Agitation-Sedation Scale (P < .001) and the Critical Care Pain Observation Tool (odds ratio, 6.02; P = .002) compared with the standard care group. Significant differences between groups were also reported in heart rate (P < .001). No significant differences were found in oxygen values. CONCLUSIONS: Live music therapy significantly reduced agitation and heart rate in adult patients receiving mechanical ventilation in the ICU. These findings provide further evidence for the benefits of music therapy in the ICU, including in intubated patients.

After-school programs can be implemented by school nurses to facilitate healthy lifestyle choices in children with the goal of decreasing obesity. Kids Living Fit (KLF), an after-school program designed by community hospital nurses, was implemented in elementary schools and focused on best lifestyle choices regarding foods consumed and activities chosen for children in grades 2 through 5. Study measures included comparison of body mass index (BMI) percentiles for age and gender and waist circumference between two self-selected groups composing a total sample size of 185 participants: the KLF intervention group (n = 80) and the no-intervention/ contrast group (n = 105). The 12-week intervention included a weekly fitness program and monthly dietitian presentations. Participants completed food and activity diaries and wore pedometers. In pairwise comparisons, the KLF group had a significant decrease in BMI percentile between baseline and follow-up (-2.3%) compared with the contrast group. The KLF group also demonstrated a smaller increase in waist circumference than the contrast group.

Two recent outbreaks of locally acquired, mosquito-transmitted malaria in Virginia in 1998 and 2002 demonstrate the continued risk of endemic mosquito-transmitted malaria in heavily populated areas of the eastern United States. Increasing immigration, growth in global travel, and the presence of competent anopheline vectors throughout the eastern United States contribute to the increasing risk of malaria importation and transmission. On August 23 and 25, 2002, Plasmodium vivax malaria was diagnosed in 2 teenagers in Loudoun County, Virginia. The Centers for Disease Control and Prevention (CDC) deemed these cases to be locally acquired because of the lack of risk factors for malaria, such as international travel, blood transfusion, organ transplantation, or needle sharing. The patients lived approximately 0.5 mi apart; however, 1 patient reported numerous visits to friends who lived directly across the street from the other patient. Two Anopheles quadrimaculatus s.l. female pools collected in Loudoun County, Virginia, and 1 An. punctipennis female pool collected in Fairfax County, Virginia, tested positive for P. vivax 210 with the VecTest panel assay and enzyme-linked immunosorbent assay (ELISA). In addition, 2 An. quadrimaculatus s.l. female pools collected in Montgomery, Maryland, tested positive for P. vivax 210. The CDC confirmed these initial results with the circumsporozoite ELISA. The authors believe that this is the 1st demonstration of Plasmodium-infected mosquitoes collected in association with locally acquired human malaria in the United States since the current national malaria surveillance system began in 1957.

Abstract The University of Arizona utilized wastewater-based epidemiology paired with clinical testing as a surveillance strategy to monitor COVID-19 prevalence in a dormitory community. Positive SARS-CoV-2 RNA detection in wastewater led to prompt testing of all residents and the identification and isolation of three infected individuals which averted potential disease transmission. Text Wastewater-based epidemiology (WBE) utilizes concentrations of SARS-CoV-2 in sewage to monitor population-level COVID-19 infections (1–3) . Currently, WBE is a promising indicator to support public health decisions (3,4) . In this case study, WBE was used to detect a COVID-19 outbreak in a student dormitory (henceforth Dorm A) at the University of Arizona (UArizona). The Study UArizona incorporated wastewater surveillance as a potential early-warning tool for COVID-19 outbreaks on campus. Grab samples (1L) were collected from a sewer manhole specific to Dorm A, between August 18-31 to monitor SARS-CoV-2 RNA in wastewater. Upon positive detection of viral RNA in wastewater samples, clinical testing was conducted on every individual living in the dorm. UArizona performed two clinical testing modalities, antigen (1 hour turnaround) test via anterior nasal swab and RT-PCR (48-72 hour turnaround) via nasopharyngeal swab samples. Individuals were subject to clinical testing via two routes: Campus Health Services (CHS) if experiencing symptoms or Test All Test Smart (TATS) regardless of symptoms. Refer to Appendix for method details. Article Summary Line Wastewater-based epidemiology with subsequent clinical testing identified individuals infected with COVID-19 living in a dormitory and further spread of disease was prevented with public health action.

Over a four-month period, 113 consecutive admissions to a general psychiatric ward of a Veterans Affairs hospital were evaluated for the presence of a substance use diagnosis as well as type of discharge (regular or irregular). Of the patients studied, 61 percent had a substance use diagnosis and 57 percent received an irregular discharge. Although there was some increase in the rate of irregular discharges among substance users, logistic regression analysis showed the increase was not significant. There was no difference between substance users and nonusers in length of stay. However, younger age and axis II pathology were associated with irregular discharge, and younger age was associated with shorter length of stay. Because an irregular discharge implies an undesirable treatment outcome, future studies should focus on identifying and providing optimal treatment of those patients at risk for irregular discharge.

BACKGROUND: The effect of obesity on outcomes in critically ill patients requiring invasive mechanical ventilation in a medical intensive care unit (ICU) is uncertain. OBJECTIVES: This study was intended to further explore the relationship between outcomes and obesity in patients admitted to a medical ICU who required invasive mechanical ventilation. METHODS: All adult patients admitted to the medical ICU at Washington Hospital Center requiring intubation and invasive mechanical ventilation for at least 24 h between January 1 and December 31, 2009, were retrospectively studied. Patients were categorized as nonobese (BMI <30) and obese (BMI ≥30). The primary outcome measure was 30-day mortality following intubation. Secondary outcomes included ICU length of stay (LOS), hospital LOS and duration of mechanical ventilation. RESULTS: There were 504 eligible patients: 306 nonobese and 198 (39%) obese. Obese patients had significantly higher rates of diabetes (43 vs. 30%, p = 0.004), hyperlipidemia (32 vs. 24%, p = 0.04), asthma (16 vs. 8%, p = 0.004) and obstructive sleep apnea requiring continuous positive airway pressure treatment (12 vs. 1%, p < 0.001). Nonobese patients had a significantly higher rate of HIV infection (10 vs. 5%, p = 0.05) and malignancy (21 vs. 13%, p = 0.03). There were no significant differences in mortality up to 30 days following intubation and secondary outcomes between obese and nonobese patients. Multivariate analysis using logistic regression showed no significant relationship between mortality rate at 30 days following intubation and obesity. Outcomes were similar for the black obese (n = 153) and nonobese (n = 228) patients and the obese (n = 85) and very obese (n = 113) patients. CONCLUSIONS: Obesity did not influence outcomes in critically ill patients requiring invasive mechanical ventilation in a medical ICU. Black obese patients had similar outcomes to black nonobese patients, and very obese patients also had similar outcomes to obese patients.

This article describes a quality improvement project that examined postoperative infection rates for 100 surgical procedures in which a total of 121 flash sterilizations were performed and determined the costs of treating the postoperative infections compared to the cost of purchasing additional instruments. The post operative infection rate on physical examination was 3%, and the overall cost of diagnosing and treating the postoperative infections was found to be lower than the cost of purchasing additional instruments. To minimize use of flash sterilization, the hospital has added additional surgical instrument inventory and expanded flash sterilization education requirements for staff members.

A recent outbreak of rabies in raccoons, Procyon lotor (L.), in Loudoun County, Virginia (1981-82), prompted a study of the epidemiology of the disease. Parameters studied included the occurrence and movement of the disease over time, sex and age relationships, and behavior patterns of raccoons. During the 18 mo, 427 raccoons were tested, of which 75% were infected with rabies virus. Interpretation of rainfall data and the subsequent spatial occurrence of infected raccoons within the county indicated a cause and effect relationship. The submission rate of female raccoons was greater than that of males. The female raccoons (adult and juvenile) were also found to be infected with the virus more often than the males. Behavior of infected raccoons in a rural environment was similar to those observed in the southeastern United States during earlier epizootics of rabies. The presence of a skunky odor on infected raccoons may be a characteristic of raccoon rabies.

Abstract The momentum and thermal boundary layer equations are solved numerically to assess the effects of filament drawdown on aerodynamic drag and heat transfer in melt fiber spinning. It is found that, relative to the case without drawdown (constant filament velocity and diameter), the aerodynamic drag on the filament increases substantially, but the heat transfer rate is suppressed. Moreover, the air velocity profile eventually becomes fully developed (unlike the zero drawdown case), and the (velocity) boundary layer thickness, rather than continuing to grow with distance beneath the spinneret, eventually becomes proportional to the filament diameter, and thus decreases with increasing axial distance. Quantitative results are presented for the dimensionless drag force per unit length along the filament (the Drag number) and the Nusselt number as functions of the dimensionless axial distance and a new dimensionless parameter, the Drawdown Reynolds number. © 2004 American Institute of Chemical Engineers AIChE J, 50: 898–905, 2004

BACKGROUND: More than half of United States nurses are estimated to be overweight or obese. Interventions are needed that help nurses live healthier lifestyles. With most registered nurses being female and with an average age of 45.5 years in the category most likely to be obese, it is not promising that US nurses will become healthier over time without intervention. The Nurses Living Fit (NLF) program, an exercise- and nutrition-based intervention innovated by nurses, was developed to decrease body mass index in nurse participants and to help nurse's care for themselves and their families and patients. SUBJECTS: A total of 217 nurses self-selected to the NLF intervention (n = 108) or contrast (no intervention; n = 109) groups. METHODS: The NLF program included exercise (12 once-weekly sessions, 1 hour each), yoga (4 once-monthly sessions, 1 hour each), nutrition education (4 once-monthly sessions, 1 hour each taught by registered dietitians), diary completion (completed daily for 4 weeks specifying time spent on exercise/yoga, types and amount of food consumed, amount of water consumed, and hours slept), and healthy lifestyle principles education. Evaluation of the NLF program components was also completed. RESULTS: The NLF participants had significant decreases in body mass index (NLF = -0.5 kg/m; contrast = -0.2 kg/m) and waist circumference (NLF = -0.9 in; contrast = -0.2 in). Overall, program component evaluation demonstrated that participants wanted more personalized exercise, more nutrition education, and year-round program provision. As a result of the NLF program, nurses specified they exercised more and improved nutrition. CONCLUSIONS: Evidence-based intervention or programs are needed to educate nurses on healthy lifestyles. Nurse leaders need to promote healthy workplace environments, which can be done in part through the facilitation of exercise- and nutrition-based programs, such as NLF, to help nurses better care for themselves and their families and patients.

PURPOSE: The purpose of this study was to describe the relationships between adolescent girls and older male sexual partners in urban Kingston, Jamaica, and identify the human immunodeficiency virus (HIV)-related sexual risks that occur within these relationships. DESIGN: The study employed a descriptive qualitative design. METHODS: Data were collected through focus groups and individual interviews conducted with 43 late adolescent girls (18-21 years old). An age-discordant relationship was defined as a sexual relationship between a Jamaican adolescent female and a man who was 2 or more years older. Data were analyzed using qualitative content analysis. FINDINGS: Age-discordant relationships were common and often began when girls were early adolescents. Both adolescent girls and older men tended to have multiple partners, and transactions of gifts, money, or resources from an older partner were expected and common. Older partners were highly influential in HIV-related risk behaviors. CONCLUSIONS: Age-discordant relationships need to be explicitly addressed in HIV prevention programs for adolescent girls in Jamaica. Further, the implications of gift-giving, informal sexual transactions, and intradyadic power must be incorporated into strategies for reducing HIV-related sexual risk with older partners. Future studies should examine the perspectives of Jamaican men. CLINICAL RELEVANCE: This study found that many Jamaican adolescent girls engage in sexual relationships with older men and that the unique characteristics of these relationships may increase girls' risks for HIV and other sexually transmitted diseases. HIV risk reduction interventions for adolescent girls should address sexual risks associated with older male partners.

Abstract Bias‐based bullying focused on sexual orientation or gender identity in schools has significant negative implications for the academic, social, and emotional well‐being of students who identify as lesbian, gay, or bisexual, or who are perceived to behave in gender nonconforming ways. Despite empirical support for the influence of bystander behavior can have on school bullying, information about bystander behavior during bias‐based bullying remains limited. Using a thematic narrative analysis, this study analyzed high school students’ perceptions of bystander behavior in their school. Results suggest bystanders are observed to enact a range of responses that fall into three categories: (a) passive avoidance, (b) victim support, or (c) joining the bullying situation. Furthermore, the motivation of bystanders was described within the themes of (a) fear, (b) individual characteristics, (c) relationships, and (d) personal experience. By drawing from the daily lived experiences of adolescents, the current study offers greater insight into youth perspective on how future strategies could address bias‐based bullying in schools. This study is foundational to increase the ecological validity of efforts to quantify bias‐based bullying.

PURPOSE: Evaluate the effect of the Kids Living Fit hospital-based intervention on body mass index (BMI) percentile, adjusted for age (months) and gender in children ages 8-12 years with BMI percentiles > or = 85. DESIGN AND METHODS: Twelve weekly exercise sessions and three nutrition presentations were held. Nurses recorded BMI and waist circumference at baseline, week 12, and week 24. Participants completed food and activity diaries. RESULTS: Of the 32 participants enrolled, 16 completed all outcome measures and experienced a decrease in average BMI, BMI percentile, and waist circumference between baseline and weeks 12 and 24. PRACTICE IMPLICATIONS: Hospitals can offer exercise and nutrition programs to decrease childhood obesity in their communities.

Purpose The objectives of this study were to determine how many hospitals have active programs for converting patients from intravenous (IV) to oral (PO) therapy and obtain details of their conversion policies and documented cost savings and clinical impact from the IV to PO programs. In addition, the perceived benefits of these types of pharmacy programs will be highlighted. Methods Surveys were sent via e-mail to approximately 7,905 pharmacy managers and clinical pharmacists throughout the United States, which were obtained from American Society of Health-System Pharmacists (ASHP) and American College of Clinical Pharmacy (ACCP) by working through various list-serves that target this group of practitioners. The survey questioned participants regarding their hospital's policies for IV to PO conversion programs, including demographics, criteria, process, medications involved in the switches, clinical outcomes, and cost savings of such programs. Results Of 276 surveys completed and returned, 42% of responders were from the south; 81% had an active IV to PO program (larger hospital systems were more likely to have a program in existence for a longer period of time); and 82% identified patients via a computer-generated list of target patients and drugs for pharmacists to intervene. The majority of medications involved in IV to PO switches included antibiotics, GI, and antifungal drug classes. Fifty-four percent of responders indicated pharmacy manpower was the largest barrier to implementation and continuation of IV to PO conversion programs. Sixty-seven percent of responders documented cost savings and 47% of the 81 facilities that specified savings had saved at least $50,000 annually. Conclusion There was no change in the percent of facilities with IV to PO conversion programs (81%). There were minimal differences in the types of medications involved in conversion programs between 1996 and 2007. The policy and procedures supporting these type of programs have become more defined in the 11 years between surveys. In addition, methods of conversions have become more automatic since the first survey. Financial impact of IV to PO conversion programs were documented in both surveys.