Respiratory Muscle Training Reduces Respiratory Complications and Improves Swallowing Function After Stroke: A Systematic Review and Meta-Analysis

ObjectiveTo investigate whether respiratory muscle training is capable of reducing the occurrence of respiratory complications and improving dysphagia (swallowing or cough function) after stroke.Data SourcesCochrane Library, Excerpta Medical Database (EMBASE), PUBMED, and Web of Science were searched for studies published in English; the China Biology Medicine (CBM), China Science and Technology Journal Database (VIP), China National Knowledge Infrastructure (CNKI), and Wanfang Database were searched for studies published in Chinese up to August 10, 2021.Study SelectionEleven randomized control trials (RCTs) (N=523) met the inclusion criteria were included in this systematic review.Data ExtractionData and information were extracted by two reviewers independently and disagreements was resolved by consensus with a third coauthor. Primary outcome was the occurrence of respiratory complications, secondary outcomes would be represented by swallowing and cough function. The quality of each included RCT were assessed by Cochrane risk-of-bias criteria and the GRADE evidence profile was provided to present information about the body of evidence and judgments about the certainty of underlying evidence for each outcome.Data SynthesisRespiratory muscle training reduced the risk of respiratory complications (relative risk, 0.51; 95% confidence interval [CI], 0.28-0.93; I²=0%; P=.03; absolute risk difference, 0.068; number need to treat, 14.71) compared with no or sham respiratory intervention. It also decreased the liquid-type Penetration-Aspiration Scale scores by 0.81 (95% CI, –1.19 to –0.43; I²=39%; P<.0001). There was no significant association between respiratory muscle training and Functional Oral Intake Scale (FOIS) scores, cough function: increased FOIS scores by 0.47 (95% CI, –0.45 to 1.39; I²=55%; P=.32), decreased peak expiratory cough flow of voluntary cough by 18.70 L per minute (95% CI, –59.74 to 22.33; I²=19%; P=.37) and increased peak expiratory cough flow of reflex cough by 0.05 L per minute (95% CI, –40.78 to 40.87; I²=0%; P>.99).ConclusionThis meta-analysis provided evidence that respiratory muscle training is effective in reducing the risk of respiratory complications and improving dysphagia by reducing penetration or aspiration during swallowing liquid bolus after stroke. However, there was no sufficient evidence to determine that respiratory muscle training improves cough function. Additional multicenter studies using larger patient cohorts are required to validate and support these findings. Furthermore, long-term follow-up studies should be performed to measure outcomes, while avoiding bias due to confounding factors such as heterogeneity of the etiologies of dysphagia.     

Group Music Intervention Reduces Aggression and Improves Self-esteem in Children with Highly Aggressive Behavior: A Pilot Controlled Trial

We investigated the effects of group music intervention on aggression and self-esteem in children with highly aggressive behavior. Forty-eight children were allocated to either a music intervention group or an untreated control group. The music intervention group received 50 min of music intervention twice weekly for 15 consecutive weeks. The outcome measures were Child Behavior Checklist Aggression Problems Scale (Parents), Child Aggression Assessment Inventory (Teachers) and Rosenberg Self-esteem Scale. After 15 weeks, the music intervention group showed significant reduction of aggression and improvement of self-esteem compared with the control group. All outcome measures were significantly lower in the music intervention group than prior to treatment, while there was no change in the control group. These findings suggest that music can reduce aggressive behavior and improve self-esteem in children with highly aggressive behavior. Music intervention is an easily accessible therapy for children and as such may be an effective intervention for aggressive behavior. Further more, objective and replicable measures are required from a randomized controlled trial with a larger sample size and active comparable control.     

Intradialytic Resistance Training Improves Functional Capacity and Lean Mass Gain in Individuals on Hemodialysis: A Randomized Pilot Trial

ObjectiveTo compare the effects of high vs moderate loads of intradialytic resistance training (RT) on body composition, sarcopenia prevalence, functional capacity, inflammatory markers, and quality of life (QoL) in individuals on hemodialysis.DesignA pilot randomized clinical trial.SettingTwo hemodialysis centers.ParticipantsIndividuals on hemodialysis (N=80; 51% men, aged 30-75y) in treatment for at least 3 months, adequately dialyzed (Kt/V≥1.2, where K is dialyzer clearance in mL/min, t is time, and V is volume of water) with vascular access via arteriovenous fistula.InterventionsThe 12 weeks of intradialytic RT was performed 3 times per week. The training groups were: high-load intradialytic group (HLG, 8-10 repetitions), moderate-load intradialytic group (MLG, 16-18 repetitions), and control group (CG, stretching exercise). The total training volume was equalized among training groups.Main Outcome MeasuresLean leg mass was assessed by a dual-energy x-ray absorptiometry; functional capacity was assessed by Short Physical Performance Battery and Timed Up and Go test; and QoL was assessed by Kidney Disease QoL Instrument, inflammatory markers, and sarcopenia.ResultsAfter the training period, the HLG increased lean leg mass compared with the CG. The HLG also displayed improvements in the pain and physical function domains. The skeletal muscle index and functional capacity increased in both RT protocols. The prevalence of sarcopenia was reduced 14.3% and 25% in the MLG and HLG, respectively, while there was an increase of 10% in the CG. No differences were observed in cytokines after intervention.ConclusionsHigh-load intradialytic RT was associated with gains in lean leg mass and QoL while functional capacity, appendicular muscle mass, and sarcopenia status were improved regardless of the RT load.     

Ambulance transport to the emergency department: A patient-selected signal of acuity and its effect on resource provision

ObjectiveTo determine whether ambulance arrival to the emergency department has remained an unidentified signal of perceived medical acuity. Informed by economic signaling theory, does arrival via ambulance affect resource utilization given varying levels of patient acuity?MethodsThe analysis examined a nationally representative sample of de-identified emergency department patient encounters from 2011 to 2015, gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Multivariate logistic regression analysis was employed using regional and time-fixed effects. The provision of twenty diagnostic and imaging services was analyzed. Patient encounters were also categorized into five acuity-levels.ResultsDrawing from the NHAMCS dataset, 98,888 emergency department records were analyzed, weighted to represent 504.5 million estimated emergency department patient encounters. Findings suggest that patients transported to the hospital via ambulance are more likely than those who arrive by other means to receive 19 of the 20 analyzed diagnostic testing and imaging services. Furthermore, when analyzed by acuity-level, the disparity of service provision is the greatest among low-acuity patients, where medical complaints are argued to be the most subjective.ConclusionsThe results are consistent with the notion that emergency department medical providers readily accept ambulance transport as a valid signal of patient acuity, regardless of true acuity level. Consequently, patients transported to the hospital via ambulance may be receiving a disproportionate amount of medical resources in an increasingly cost-conscious environment.     

Exercise Therapy in Addition to an Orthosis Reduces Pain More Than an Orthosis Alone in Patients With Thumb Base Osteoarthritis: A Propensity Score Matching Study

ObjectiveTo compare the effect of exercises and orthotics with orthotics alone on pain and hand function in patients with first carpometacarpal joint (CMC-1) osteoarthritis (OA) and to predict outcomes on pain and hand function of exercises and orthotics.DesignProspective cohort study with propensity score matching.SettingData collection took place in 13 outpatient clinics for hand surgery and hand therapy in The Netherlands.ParticipantsA consecutive, population-based sample of patients with CMC-1 OA (N=173) was included in this study, of which 84 were matched on baseline demographics and baseline primary outcomes.InterventionsExercises and orthotics versus orthotics alone.Main Outcome MeasuresPrimary outcomes included pain and hand function at 3 months, measured using visual analog scale (VAS, 0-100) and the Michigan Hand Outcomes Questionnaire (MHQ, 0-100).ResultsA larger decrease in VAS pain at rest (11.1 points difference; 95% confidence interval, 1.9-20.3; P=.002) and during physical load (22.7 points difference; 95% confidence interval, 13.6-31.0; P<.001) was found in the exercise + orthotic group compared to the orthotic group. In addition, larger improvement was found for the MHQ subscales pain, work performance, aesthetics, and satisfaction in the exercise + orthotic group. No differences were found on other outcomes. Baseline scores of metacarpophalangeal flexion, presence of scaphotrapeziotrapezoid OA, VAS pain at rest, heavy physical labor, and MHQ total predicted primary outcomes for the total exercise + orthotic group (N=131).ConclusionsNon-surgical treatment of patients with CMC-1 OA should include exercises, since there is a relatively large treatment effect compared to using an orthosis alone. Future research should study exercises and predictors in a more standardized setting to confirm this finding.     

Ketamine Sedation and Hypoxia: A Quality Improvement Project to Reduce Respiratory Events Receiving Intervention

BackgroundKetamine is a well-studied and safe medication used for procedural sedation in the pediatric emergency department (ED). However, in our ED and urgent care (UC), we had higher rates of respiratory events receiving intervention (REs) than has been reported nationally.ObjectiveA quality improvement (QI) project was initiated to address this problem with the following aim: during a 24-month period, we aimed to decrease REs during i.v. ketamine sedation from > 10% to < 6% in our network of EDs and UCs.MethodsInclusion criteria included patients in our EDs and UCs who received i.v. ketamine for procedural sedation. We organized a multidisciplinary team to identify key drivers for the primary outcome (i.e., REs) and establish interventions. We based process measures on key interventions and utilized 2 Plan-Do-Study-Act (PDSA) cycles, which we evaluated with Shewhart P (provost) charts. Balancing measures included length of sedation, success of sedation, and length of stay.ResultsREs decreased from 11.4% to 4.9%; this rate was maintained for 12 months, starting 1 month after PDSA cycle 2 implementation. There was no difference in REs for length of stay, length of sedation, or success of sedation.ConclusionsUsing QI methodology, we reduced and maintained rates of RE to < 6%. Due to the nature of the project, it is difficult to link one intervention to the reduction in REs; however, a significant shift occurred just after PDSA cycle 2 interventions. This project can give a guideline for interventions to improve the safety of pediatric ketamine sedations.     

Outcomes for Patients Who Contact the Emergency Ambulance Service and Are Not Transported to the Emergency Department: A Data Linkage Study

Objectives: Emergency ambulance services do not transport all patients to hospital. International literature reports non-transport rates ranging from 3.7–93.7%. In 2017, 38% of the 11 million calls received by ambulance services in England were attended by ambulance but not transported to an Emergency Department (ED). A further 10% received clinical advice over the telephone. Little is known about what happens to patients following a non-transport decision. We aimed to investigate what happens to patients following an emergency ambulance telephone call that resulted in a non-transport decision, using a linked routine data-set. Methods: Six-months individual patient level data from one ambulance service in England, linked with Hospital Episode Statistics and national mortality data, were used to identify subsequent health events (ambulance re-contact, ED attendance, hospital admission, death) within 3 days (primary analysis) and 7 days (secondary analysis) of an ambulance call ending in non-transport to hospital. Non-clinical staff used a priority dispatch system e.g. Medical Priority Dispatch System to prioritize calls for ambulance dispatch. Non-transport to ED was determined by ambulance crew members at scene or clinicians at the emergency operating center when an ambulance was not dispatched (telephone advice). Results: The data linkage rate was 85% for patients who were discharged at scene (43,108/50,894). After removal of deaths associated with end of life care (N?=?312), 9% (3,861/42,796) re-contacted the ambulance service, 12.6% (5,412/42,796) attended ED, 6.3% (2,694/42,796) were admitted to hospital, and 0.3% (129/42,796) died within 3 days of the call. Rates were higher for events occurring within 7 days. For example, 12% re-contacted the ambulance service, 16.1% attended ED, 9.3% were admitted to hospital, and 0.5% died. The linkage rate for telephone advice calls was low because ambulance services record less information about these patients (24% 2,514/10,634). A sensitivity analysis identified a range of subsequent event rates: 2.5–10.5% of patients were admitted to hospital and 0.06–0.24% of patient died within 3 days of the call. Conclusions: Most non-transported patients did not have subsequent health events. Deaths after non-transport are an infrequent event that could be selected for more detailed review of individual cases, to facilitate learning and improvement.     

陕西省25所基层医院护士法律知识掌握程度及学习需求现状调查

目的了解《医疗事故处理条例》、《最高人民法院关于民事诉讼的若干规定》和《病案书写基本规范》颁布和实施两年半之后,基层医院护士相关法律知识的掌握状况及学习需求。方法采用问卷调查法,对陕西省25所县（市）、区及厂矿医院,护龄在5年及以上的100名护士进行调查。结果基层医院护士的法律意识亟待加强,相关法律知识匮乏,难以适应新的医疗卫生法律法规实施后对护理的要求。结论要使基层医院护士尽快适应现代法律社会下的医疗新形势,必须对其加强法制教育,强化法律意识,掌握法律知识,规范护理行为。     

Ten Years and Counting: A Successful Academic-Practice Partnership to Develop Nursing Research Capacity

Achieving a decade long successful academic-practice partnership between a university-based school of nursing and a large private healthcare organization during a time of healthcare payment transformation is a significant accomplishment. Goals of the partnership are to provide evidence that 1. research collaboration and mentoring are instrumental in improving patient care by shaping nursing infrastructure and capacity and 2. consultation and mentoring activities will effectively engage faculty and staff nurses in an academic-practice research partnership. Nursing faculty and practicing clinicians collaborate on organizational priorities to improve patient care outcomes. Of the 28 approved studies, 17 are completed, five are in progress, and six were not completed. Dissemination products directly related to this partnership include: three publications, 23 podium presentations, and eight poster presentations delivered at local, national, and/or international conferences. Findings from seven of the 17 completed projects have been translated to improve practice. Several partnership participants have continued their academic progression and continue to conduct studies. This innovative partnership is a successful endeavor that bridges education and practice in our community, while developing research capacity in both institutions. This article adds to the emerging literature on models of academic-practice partnership to develop nursing research.