The effect of nurse prescribers on glycaemic control in type 2 diabetes: A systematic review and meta-analysis

BackgroundThe creation of advanced nursing roles in diabetes management, with specific skills such as nurse prescribing, has resulted in nurses taking on roles that have traditionally been associated with doctors.ObjectivesWe aimed to examine the effectiveness of nurse-led clinics, in which nurses were involved in prescribing, on haemoglobin A1c (HbA1c) among people with type 2 diabetes.MethodsWe systematically searched the literature, Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE and Allied Health Literature database guide (CINAHL) databases, to identify randomised controlled trials (RCTs) assessing the effect of nurse prescribers on HbA1c. We focused on randomised controlled trials which compared nurse prescriber interventions with usual care in adults aged 18 years or over with a diagnosis of type 2 diabetes. The main outcome measure was change in HbA1c levels. We performed a random effects model meta-analysis to assess the pooled effect size of the intervention. Studies were divided into two groups according to the role of nurses in the intervention. In one group, the nurses supplemented a team, as an add-on to usual care; in the other group, they worked independently, and were compared directly to a doctor.ResultsNine RCTs were identified and included in this study. All studies were from developed countries, with a medium risk of bias and a moderate heterogeneity between studies. In the five RCTs in which nurse prescribers supplemented a team, there was no significant difference in change of HbA1c compared to usual care (-0.34 percentage points; 95% CI: −0.71, 0.02). In the four RCTs in which nurses replaced doctors, the outcomes of nurse prescribers were comparable to those of doctors. No data on adverse events were available.ConclusionThere was no clear evidence of benefit on glycaemic control, when nurses who undertake prescribing work alongside a doctor and other practitioners. However, in those studies in which nurses replaced physicians, the glycaemic control was comparable between nurses and doctors. Therefore, there may be value in providing nurse-led prescribing services where there is limited access to doctor-led services.     

Bone mineral density in primary care patients related to serum calcium concentrations: a longitudinal cohort study from Sweden

Objective: Elevated calcium concentration is a commonly used measure in screening analyses for primary hyperparathyroidism (pHPT) and cancer. Low bone mineral density (BMD) and osteoporosis are common features of pHPT and strengthen the indication for parathyroidectomy. It is not known whether an elevated calcium concentration could be a marker of low BMD in suspected pHPT patients with a normal parathyroid hormone concentration.

Purpose: To study if low BMD and osteoporosis are more common after ten years in patients with elevated compared with normal calcium concentrations at baseline.

Design: Prospective case control study.

Setting: Primary care, southern Sweden.

Subjects: One hundred twenty-seven patients (28 men) with baseline elevated, and 254 patients (56 men) with baseline normal calcium concentrations, mean age 61 years, were recruited. After ten years, 77% of those still alive (74 with elevated and 154 with normal calcium concentrations at baseline) participated in a dual energy x-ray absorptiometry measurement for BMD assessment and analysis of calcium and parathyroid hormone concentrations.

Main outcome measures: Association between elevated and normal calcium concentration at base-line and BMD at follow-up. Correlation between calcium and parathyroid hormone concentrations and BMD at follow-up.

Results: A larger proportion of the patients with elevated baseline calcium concentrations who participated in the follow-up had osteoporosis (p value?=?0.036), compared with the patients with normal concentrations. In contrast, no correlation was found between calcium or parathyroid hormone concentrations and BMD at follow-up.

Conclusions: In this study, patients with elevated calcium concentrations at baseline had osteoporosis ten years later more often than controls (45% vs. 29%), which highlights the importance of examining these patients further using absorptiometry, even when their parathyroid hormone level is normal.

• Key Points

• Osteoporosis is common, difficult to detect and usually untreated. It is not known whether elevated calcium concentrations, irrespective of the PTH level, could be a marker of low bone mineral density.

• No correlation was found between calcium or parathyroid hormone concentrations and bone mineral density at follow-up.

• In this study, patients with elevated calcium concentrations at baseline had osteoporosis ten years later more often than controls (45% vs. 29%).

     

The Treatment of Acute Pain in the Emergency Department: A White Paper Position Statement Prepared for the American Academy of Emergency Medicine

Background

Pain is one of the most common reasons patients present to the emergency department (ED). Emergency physicians should be aware of the numerous opioid and nonopioid alternatives available for the treatment of pain.

一种抗CPS控制层欺骗攻击的算法

信息物理系统(CPS)在原本的工控系统中加入了计算单元,使攻击者能够通过对该网络进行攻击。本文考虑攻击者通过恶意篡改信道中传输的传感器测量数据,使计算单元无法根据测量值对物理环境做出正确决策。通过改进针对CPS控制层欺骗攻击的卡尔曼滤波器算法,使改进后的算法对多种类型的欺骗攻击都有较好的检测性能,并能在一定程度上恢复被篡改的数据。本文使用改进算法对田纳西伊斯曼过程中反应釜内的压强测量值进行攻击检测,并与原算法进行比较,通过实验可以验证改进后算法对偏差型和几何型攻击的检测和恢复效果明显优于原算法。     

Results of a Double-Blind,Randomized, Placebo-Controlled Study of Nabiximols Oromucosal Spray as an Adjunctive Therapy in Advanced Cancer Patients with Chronic Uncontrolled Pain

Context

Prior Phase 2/3 studies found that cannabinoids might provide adjunctive analgesia in advanced cancer patients with uncontrolled pain.

4CH8模式下社区脑卒中管控效果评价

目的 对社区卫生服务中心实施4CH8健康管理模式后社区脑卒中患者的管控效果明显提高的情况进行分析和评价.方法 在上海市某社区卫生服务中心随机抽取100名脑卒中患者分为实验组和对照组,每组50人,在脑卒中临床治疗的基础上,实验组参照4CH8健康管理模式对患者进行疾病的综合管控,对照组则采用一般的健康宣教对患者进行健康教育,比较2组患者干预前后疾病认知情况和危险行为变化情况,对比2组患者的疾病复发率.结果 实验组患者在综合管控后脑卒中确诊标准知晓率,高血压、糖尿病、房颤、高脂血症导致脑卒中,成人每日食盐摄入标准的知晓率明显优于对照组(P＜0.05).实验组在食盐控制、饮食规律、吸烟、饮酒、滥用药物、适量运动等方面明显优于对照组(P＜0.05).实验组脑卒中复发率由68％降低到4％,明显优于对照组的复发率由70％降低到32％ (P ＜0.05).结论 “4CH8”模式对社区脑卒中患者的初步临床效果是积极的,可以降低脑卒中的复发率、致残率、病死率,值得在社区进行全面推广.     

Specific balance training included in an endurance-resistance exercise program improves postural balance in elderly patients undergoing haemodialysis

Purpose: The purpose of this study was to evaluate the effects of 6 months of specific balance training included in endurance-resistance program on postural balance in haemodialysis (HD) patients.

Methods: Forty-nine male patients undergoing HD were randomly assigned to an intervention group (balance training included in an endurance-resistance training, n?=?26) or a control group (resistance-endurance training only, n?=?23). Postural control was assessed using six clinical tests; Timed Up and Go test, Tinetti Mobility Test, Berg Balance Scale, Unipodal Stance test, Mini-Balance Evaluation Systems Test and Activities Balance Confidence scale.

Results: All balance measures increased significantly after the period of rehabilitation training in the intervention group. Only the Timed Up and Go, Berg Balance Scale, Mini-Balance Evaluation Systems Test and Activities Balance Confidence scores were improved in the control group. The ranges of change in these tests were greater in the balance training group.

Conclusions: In HD patients, specific balance training included in a usual endurance-resistance training program improves static and dynamic balance better than endurance-resistance training only.

• Implications for rehabilitation

• Rehabilitation using exercise in haemodialysis patients improved global mobility and functional abilities.

• Specific balance training included in usual endurance resistance training program could lead to improved static and dynamic balance.

     

Benefits and risks of immediately sequential bilateral cataract surgery: a literature review

Immediately sequential bilateral cataract surgery (ISBCS) is a highly contended issue in ophthalmology, mainly due to the risk of bilateral endophthalmitis and financial penalties that many ophthalmologists face when performing simultaneous cataract surgeries. The purpose of this review is to understand the current status of the knowledge of ISBCS, mainly its benefits and risks and how they compare with the standard of care, delayed sequential bilateral cataract surgery. Evidence, although limited, increasingly supports ISBCS for providing faster rehabilitation, improved visual outcomes, and cost and time savings. Evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure. However, stronger and greater evidence is needed before ISBCSs can be considered the standard of care. Where ISBCS can potentially create the most beneficial impact is in public eye health programmes in developing countries, but this has not yet been explored.