Impact of Initial eGlycemic Management System Dosing Strategy on Time to Target Blood Glucose Range

Background:Glucommander™ (GM), an electronic glycemic management system, was implemented across a multi-hospital health system as the standard of care for glycemic control. GM provides insulin dosing recommendations based on patient-specific blood glucose (BG) trends after providers select either a custom dose or weight-based multiplier as the initial dosing strategy for the first 24 hours. This study evaluated the impact of initial subcutaneous (SC) GM insulin dosing strategies on glycemic management.Methods:Non-intensive care unit patients treated with SC GM using either initial custom (based on provider discretion) or weight-based multiplier settings (0.3, 0.5, or 0.7 units/kg/day) were evaluated in this retrospective chart review. The primary endpoint was time to target BG range defined as time to first two consecutive in range point of care BG. Secondary endpoints included percentage of BG values in target range, percentage of orders following institutional recommendations, length of stay (LOS), average BG, and incidence of hypoglycemia and hyperglycemia.Results:A review of 348 patients showed time to target BG was not significantly different between custom and multiplier groups (55 vs 64 hours, P = .07). Target BG was achieved in less than half of patients in both groups (47% vs 44%, respectively). There were no differences in hospital LOS, proportion of BG in target range, rates of hypo/hyperglycemia, and average BG.Conclusions:Custom initial SC GM insulin dosing settings showed a nonsignificant decrease in time to target BG range compared to pre-defined multiplier settings. Future studies evaluating the impact of compliance with institutional recommendations on BG control are warranted.     

Transmission route of rhinovirus - the causative agent for common cold. A systematic review

BackgroundHuman rhinoviruses (RVs) are the most common cause of acute respiratory tract illness and upper respiratory tract infections, traditionally defined as ‘common colds’. Experimental transmission of RV has been studied for more than 50 years. However, there are divergent results as to whether hands and fomites or aerosols constitute the dominant route of transmission in natural settings.MethodsWe have systematically reviewed the literature according to the PRISMA 2020 statement. Searches were run in PubMed and Web of Science until August 2022. Inclusion criteria were original studies of relevance for revealing the route of transmission of rhinovirus in humans.ResultsThe search yielded 663 results, and 25 studies met the inclusion criteria and were selected for this review. These articles addressing RV transmission routes were assigned to 1 of 3 groups: (1) indirect transmission by fomites and hands, (2) direct transmission via large aerosols (droplets) or small aerosols, or (3) transmission either direct via large aerosols (droplets) or small aerosols and fomite or hands.ConclusionsWe found low evidence, that transmission via hands and fomite followed by self-inoculation is the dominant transmission route in real-life indoor settings. We found moderate evidence, that airborne transmission either via large aerosols or small aerosols is the major transmission route of rhinovirus transmission in real-life indoor settings. This suggests that the major transmission route of RVs in many indoor settings is through the air (airborne transmission).     

Trends in overall opportunistic illnesses,Pneumocystis carinii pneumonia,cerebral toxoplasmosis and Mycobacterium avium complex incidence rates over the 30 years of the HIV epidemic: a systematic review

BackgroundThe natural history of HIV infection has changed dramatically after the introduction of highly active antiretroviral therapy. Currently, opportunistic illnesses still represent a major cause of death and hospitalization in this population. In this study, we review the trends in opportunistic illnesses incidence rates and compare the results observed in high-income settings with that for low/middle-income settings, with special attention given to studies from Brazil.MethodsWe systematically searched Pubmed, Web of Science, Lilacs and Google scholar for publications on HIV associated opportunistic illness. Studies reporting rates based on person-time for all opportunistic illnesses and/or the three opportunistic infections of interest, namely, Pneumocystis carinii pneumonia, cerebral toxoplasmosis, and Mycobacterium avium complex were included.ResultsSignificant reductions in the incidence rates were demonstrated for opportunistic illnesses overall and also for the specific opportunistic infections included in the present study, both in high and low/middle-income settings. Out of the 37 studies included in the present review, almost 70% were from high-income settings. All the studies conducted in low/middle-income settings were single center studies and four were from Brazil. We found no study from Brazil reporting annual incidence rates of opportunistic illnesses.ConclusionsOpportunistic illnesses remain an important public health problem. To better guide health policies in low/middle-income settings, multicenter cohort studies should be encouraged. Studies from Brazil are urgently needed to assess the current burden of opportunistic illnesses in our population and to support the planning of HIV/AIDS health care services organization.     

Practice Context Affects Efforts to Improve Diabetes Care for Primary Care Patients: A Pragmatic Cluster Randomized Trial

BackgroundEfforts to improve primary care diabetes management have assessed strategies across heterogeneous groups of patients and practices. However, there is substantial variability in how well practices implement interventions and achieve desired outcomes.ObjectiveTo examine practice contextual features that moderate intervention effectiveness.DesignSecondary analysis of data from a cluster randomized trial of three approaches for implementing the Chronic Care Model to improve diabetes care.ParticipantsForty small to mid-sized primary care practices participated, with 522 clinician and staff member surveys. Outcomes were assessed for 822 established patients with a diagnosis of type 2 diabetes who had at least one visit to the practice in the 18 months following enrollment.ConclusionsThis study supports the need for broader use of methodological approaches to better examine contextual effects on implementation and effectiveness of quality improvement interventions in primary care settings.KEY WORDS: Diabetes, Contextual effects, Multilevel modeling     

Dignity and autonomy in the care for patients with dementia: Differences among formal caretakers of varied cultural backgrounds and their meaning

BackgroundA key message in the World Health Organization report on dementia (2012) emphasizes this disease as a top priority in public health and the need to improve professional attitudes to patients with dementia, while acknowledging that the workforce in dementia care is becoming increasingly diverse culturally.AimsTo trace whether there are substantial gaps between formal caretakers from different cultural groups (Israeli born Jews [Sabras], Israeli Arabs [Arabs] and migrants from Russia [Russians]) regarding their stances on the human dignity and autonomy of patients with dementia, as well as understand the meaning of these gaps.Design & methodquantitative analysis utilizing questionnaires that were filled-out by approximately 200 caretakers from the different cultural groups, working in a nursing home or a hospital.ResultsIn nursing homes, substantial differences were found in the attitudes to human dignity and autonomy of patients with dementia between Russian and Arab as well as Sabra caretakers. In the hospital, there was no influence for the ethno-culture variable on dignity or autonomy.ConclusionContrary to past research, in nursing homes, significant differences were found between certain ethno-cultural groups (Arabs and Russians) regarding their stance towards the dignity of patients with dementia. Arab caretakers hold a conception of dignity and autonomy that resonates strongly with person-centered care and outweighs institutional settings as well as may be related to the fostering of virtues.     

Improved response to cardiac resynchronization therapy through optimization of atrioventricular and interventricular delays using acoustic cardiography: a pilot study

BackgroundThe purpose of this pilot study was to determine the utility of acoustic cardiography for the optimization of atrioventricular (AV) and interventricular (VV) delays in cardiac resynchronization therapy (CRT).Methods and ResultsWe evaluated 14 patients (86% male, mean age 64 ± 9 years, mean time since implant 15 ± 18 months). Subjects were enrolled >10 weeks after CRT implant. Spiroergometry and 2-dimensional/3-dimensional echocardiography were used to assess cardiac performance for “out-of-the-box” settings (baseline settings: AV 120 ms, VV 0 ms) versus optimal settings (determined by acoustic cardiography). Cardiac performance measurements were performed 6 weeks after settings were modified. Optimal AV/VV settings were determined based on the lowest electromechanical activation time (EMAT, the time from the onset of QRS to the mitral valve component of the first heart sound). Statistical analysis was performed using a paired 2-tailed Student's t-test. In comparison to “out-of-the-box” settings, AV/VV delay optimization with acoustic cardiography improved cardiac performance as indicated by significant changes in work capacity, maximum oxygen uptake, oxygen pulse, ejection fraction, end-systolic volume, and velocity-time integral in left ventricular outflow tract.ConclusionsAV and VV optimization by acoustic cardiography produces significant improvements in objective clinical and hemodynamic parameters in comparison to typical “out-of-the-box” settings.     

Compared efficacy of University of Wisconsin and histidine-tryptophan-ketoglutarate solutions in ex-situ liver resection and autotransplantation for end-stage hepatic alveolar echinococcosis patients

BackgroundThe University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) solutions are the two most frequently used liver graft preservation fluids. The present study aimed to compare their efficacy in end-stage hepatic alveolar echinococcosis patients who underwent ex-situ liver resection and autotransplantation (ELRA).MethodsA total of 81 patients received ELRA from August 2010 to March 2018. They were allocated into UW (n = 48) and HTK groups (n = 33) based on the type of solutions used. Demographic and operational data were retrospectively analyzed. Primary outcomes included 90-day mortality, incidence of early graft loss, primary dysfunction, and postoperative complications.ResultsDemographic and operational characteristics were similarly distributed in the two groups. No statistically significant differences were observed with regard to 90-day mortality (12.77% vs. 12.12%) and early graft loss rate (8.51% vs. 9.09%) between the two groups. Patients in the UW and HTK groups showed a primary dysfunction rate of 27.66% and 27.27%, respectively. The UW group exhibited a higher incidence tendency of biliary complications, albeit with no statistical significance.ConclusionsThis is the largest cohort study comparing the efficacy of the UW and HTK organ-preserving solutions in end-stage hepatic alveolar echinococcosis patients in ELRA settings. UW and HTK solutions presented similar efficacy and safety. A randomized clinical trial with larger scale is needed for further investigation in future clinical applications.     

What Nurses in Primary Care Practices Know About Asthma Care: Results from a National Survey

Objectives: The purpose of this study was to characterize what nurses working in primary care settings know about asthma care. Current views on the care of persons with asthma suggest the need for sound knowledge of guideline-based care and a health care team that includes both physicians, nurses, and other providers. While there are reports of physician-related asthma care practices in the United States, there are few, if any, reports of nursing knowledge, attitudes, or beliefs about asthma care.

Methods: A national, randomly selected, representative sample of nurses working in ambulatory primary care settings was interviewed by telephone using a structured interview format.

Results: Of a sample of 80 nurses, less than 10% identified inflammation of the airways as the underlying condition that causes asthma symptoms. Fifty-one percent believed the underlying condition could be treated, while 44% believed only the symptoms could be treated, and 5% didn't know. Only 35% said they were aware of the National Heart, Lung, and Blood (NHLBI) asthma guidelines.

Conclusions: Nurses working in ambulatory primary care settings may lack sufficient knowledge to effectively teach and participate in asthma care.     

Provider Perspectives on Essential Functions for Care Management in the Collaborative Treatment of Hypertension: The P.A.R.T.N.E.R. Framework

BACKGROUNDCare management has become a widespread strategy for improving chronic illness care. However, primary care provider (PCP) participation in programs has been poor. Because the success of care management relies on provider engagement, understanding provider perspectives is necessary.OBJECTIVEOur goal was to identify care management functions most valuable to PCPs in hypertension treatment.DESIGNSix focus groups were conducted to discuss current challenges in hypertension care and identify specific functions of care management that would improve care.PARTICIPANTSThe study included 39 PCPs (participation rate: 83 %) representing six clinics, two of which care for large African American populations and four that are in underserved locations, in the greater Baltimore metropolitan area.APPROACHThis was a qualitative analysis of focus groups, using grounded theory and iterative coding.CONCLUSIONSThe P.A.R.T.N.E.R. framework is the first to offer a checklist of care management functions that may promote successful collaboration with PCPs. Future research should examine the validity of this framework in various settings and for diverse patient populations affected by chronic diseases.KEY WORDS: care management, chronic disease, implementation research, primary care, qualitative research     

Guidelines of the Italian societies of gastroenterology on the diagnosis and management of coeliac disease and dermatitis herpetiformis

IntroductionCoeliac disease and dermatitis herpetiformis are immune-mediated diseases triggered by the consumption of gluten in genetically predisposed individuals. These guidelines were developed to provide general practitioners, paediatricians, gastroenterologists, and other clinicians with an overview on the diagnosis, management and follow-up of coeliac patients and those with dermatitis herpetiformis.MethodsGuidelines were developed by the Italian Societies of Gastroenterology. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists and a paediatrician with expertise in this field.ResultsThese guidelines provide a practical guidance for the diagnosis, management and follow-up of coeliac patients and dermatitis herpetiformis in children and adults, both in primary care and in specialist settings. We developed four sections on diagnosis, gluten-free diet, follow-up and risk of complications in adults, one section focused on diagnosis and follow-up in children and one on the diagnosis and management of dermatitis herpetiformis.ConclusionsThese guidelines may support clinicians to improve the diagnosis and management of patients with coeliac disease.     

Older people's participation and engagement in falls prevention interventions: Comparing rates and settings

ObjectiveFalls among older people remain a major public health issue. The purpose of this article was to facilitate accurate interpretation of the existing evidence-base and facilitate robust planning of future fall prevention randomised controlled trials (RCTs).MethodTwo systematic reviews were further developed that evaluated older people's participation and engagement in RCTs to prevent falls in both community and institutional settings. It is argued that there is a need to differentiate between: firstly, acceptance rates versus recruitment rates, i.e. respectively the proportion of older people willing to participate in the RCTs versus those willing and included; secondly, rates of recruitment and participation in institutional settings distinguishing between nursing care facilities versus hospitals.ResultsFor community settings (n = 78), the median rates were 41.3% (22.0–63.5%) for recruitment and 70.7% (64.2–81.7%) for acceptance. For institutional settings (n = 25), the median rates were 48.5% (38.9–84.5%) for recruitment and 88.7% (81.2–95.4%) for acceptance. In comparing trials from nursing care facilities and hospitals, recruitment and acceptance rates were remarkably similar, though the remaining data – attrition, adherence, and whether adherence acted as a moderator on the effectiveness of the intervention on trial outcomes – was only available from trials from nursing care facilities.ConclusionResearchers are encouraged to be more inclusive in trials and to conduct more RCTs in hospitals to prevent falls. A consensus on how to define successful engagement with trials and uptake and adherence to trial interventions remains desired.     

The use of nature – based activities for the well-being of older people: An integrative literature review

BackgroundDuring the last decades scientific literature has focused on the positive relationships between Nature - Based Activities (NBA) and health. The aging of the population and the increasing costs of health services make it important to investigate the benefits for older people.ObjectiveThe purpose of this study was to systematically review the existing literature regarding Nature – Based Activities addressed to older people.MethodsA systematic search of the literature was made in PubMed, Web of Science and Scopus from 2005 till December 2018.ResultsWe identified 42 articles that satisfied the inclusion criteria. The results highlighted the multidisciplinary use of nature in many settings as well as a variety of different research designs, both quantitative and qualitative. The majority of experimental assessments were carried out in the setting of nursing homes and residential facilities. A variety of treatments, e.g. horticultural therapy, gardening, green visiting, green exercise and of settings, e.g. residential facilities or adult day services, participants’ homes, outdoor settings, and green care farms were examined.ConclusionsThe examined studies offered numerous examples of the healing power of nature for the health and well-being of older people. Occupational therapists could gain substantial insight from earlier experiences of NBA for application in their practices.     

Impacts of the COVID-19 pandemic on the infection prevention and control field: Findings from focus groups conducted with association for professionals in infection control & epidemiology (APIC) members in fall 2021

IntroductionEmergence of the Delta variant in 2021 changed the pandemic landscape and led to healthcare surges across the US, despite availability of COVID-19 vaccine. Anecdotal information indicated that the infection prevention and control (IPC) field was changing, but formal assessment was needed.MethodsFocus groups (6) were conducted with APIC members in November and December, 2021 to elicit infection preventionists' (IP) opinions changes to the IPC field due to the pandemic. Focus groups were audio recorded via Zoom and transcribed. Content analysis was used to identify major themes.ResultsNinety IPs participated. IPs described multiple changes to the IPC field during the pandemic, including being more involved in policy development, the challenge of transitioning back to routine IPC while still responding to COVID-19, increased need for IPs across practice settings, difficulties in recruiting and retaining IPs, presenteeism in healthcare, and extensive burnout. Participants suggested approaches to improve IPs' wellbeing.ConclusionsThe ongoing pandemic has brought significant changes to the IPC field, including a shortage of IPs just as the field is expanding rapidly. The continued overwhelming workload and stress due to the pandemic has resulted in burnout among IPs and the need for initiatives to improve their wellbeing.     

Training program in resuscitation maneuvers delivered by teachers in a school setting: An economic argument

IntroductionTraining school children may help to increase the rate of citizen-initiated resuscitation. However, training in school settings exclusively by healthcare professionals would lead to high costs for the Portuguese National Health Service. The aim of this study was to assess the costs and effectiveness of training by school teachers, in comparison with training provided by healthcare professionals.MethodsA quasi-experimental study was performed, with assessments before, immediately after, and two and a half months after the intervention. The costs and effectiveness of the training were compared in a sample of 362 students from the 10th, 11th and 12th grades, when performed by school teachers (experimental) versus health professionals (control).ResultsRegarding knowledge retention and chest compressions, there was no significant difference between the groups two and a half months later. Regarding practical skills, the experimental group had improved more at two and a half months than the control group. However, no statistically significant differences were observed between the groups using multivariate analysis. The implementation and annual maintenance costs were 4043 and 862 euros, respectively, in the experimental group, and 8561 and 6430 euros in the control group.Discussion and ConclusionsThe training provided by school teachers presented similar levels of effectiveness obtained at a lower cost, compared to the same training led by health professionals. This result suggests that generalizing training performed by school teachers could be valuable.     

Assessment of functional capacity in fibromyalgia. Comparative analysis of construct validity of three functional scales

ObjectiveTo compare the construct validity of three functional capacity questionnaires in patients with fibromyalgia.Patients and methodsTransversal multicentric study of 301 patients from fifteen rheumatology outpatient clinics in Spain. Scores of Health Assessment Questionnaire (HAQ), Fibromyalgia Health Assessment Questionnaire (FHAQ) and the physical function scale of the Fibromyalgia Impact Questionnaire (PF-FIQ) were compared with extreme groups of patients defined by four external indirect measures: 6 Min Walk Test, a modified Borg Fatigue Scale, Lumbar Spine Flexion Test and Patient Global Passive Mobility Assessment. Standardized differences were determined and correlation coefficients were calculated between the three questionnaires scores.ResultsAll three questionnaires showed good construct validity, but the results obtained with the PF-FIQ were poorer. Correlations between HAQ and FHAQ were very high (0.92), but correlations between these two questionnaires and PF-FIQ were only moderate (0.59).ConclusionsHAQ and FHAQ are more valid measures of functional capacity than the PF-FIQ. HAQ could be substituted by FHAQ in some settings because of its shorter format (only 8 items).     

Toilet plume bioaerosols in health care and hospitality settings: A systematic review

BackgroundThe spread of some respiratory and gastro-intestinal infections has been linked to the exposure to infectious bioaerosols released after toilet flushing. This represents a health hazard and infection risk for immunocompromised patients, health workers and the public, particularly within the health care and hospitality settings. This systematic review provides current knowledge and identifies gaps in the evidence regarding toilet plume bioaerosols and the potential contributory role in spreading infections in health care and hospitality settings.MethodsThe PRISMA guidelines were used. Searches were run in PubMed, Scopus, and Google Scholar from 1950 to 30th June 2021. Searches of global and regional reports and updates from relevant international and governmental organizations were also conducted.Results and ConclusionThe search yielded 712 results, and 37 studies were finally selected for this review. There is a lack of national and international bioaerosol sampling and exposure standards for health care and hospitality settings. Toilet plume bioaerosols are complex in nature, thus, measured bioaerosol concentrations in these settings depend on many variables and may differ for every pathogen responsible for a particular infectious disease. The contact and airborne transmission risks posed by toilet plume bioaerosols also remain unquantified. They are an important pathway that can increase the exposure to enteric and airborne pathogens. Hence, quantitative risk assessment and related research are needed to investigate these transmission risks.     

Predictors of CPAP compliance in different clinical settings: primary care versus sleep unit

Background

Good adherence to continuous positive airway pressure (CPAP) treatment improves the patient’s quality of life and decreases the risk of cardiovascular disease. Previous studies that have analyzed the adherence to CPAP were performed in a sleep unit (SU) setting. The involvement of primary care (PC) in the management of obstructive sleep apnea (OSA) patients receiving CPAP treatment could introduce factors related to the adherence to treatment.

Objectives

The objective was to compare the baseline predictors of CPAP compliance in SU and PC settings.

Methods

OSA patients treated with CPAP were followed for 6 months in SU or PC setting. We included baseline clinical and anthropometrical variables, the Epworth Sleep Scale (ESS) score, the quality of life index, and the Charlson index. A logistic regression was performed for each group to determine the CPAP compliance predictors. Discrimination and calibration were performed using the area under the curve and Hosmer-Lemeshow tests.

Results

We included 191 patients: 91 in the PC group and 100 in the SU group. In 74.9% of the patients, the compliance was ≥ 4 h per day, with 80% compliance in the SU setting and 69.2% compliance in the PC setting (p = 0.087). The predictors of CPAP compliance were different between SU and PC settings. Body mass index, ESS, and CPAP pressure were predictors in the SU setting, and ESS, gender, and waist circumference were predictors in the PC setting.

Conclusions

The predictors of adequate CPAP compliance vary between SU and PC settings. Detecting compliance predictors could help in the planning of early interventions to improve CPAP adherence.