ABSTRACT
The recent Covid-19 pandemic has created many challenges and barriers in healthcare, which includes the treatment and management of patients with type 2 diabetes (Robson & Hosseinzadeh, 2021). The purpose of this Evidence-Based Project (EBP) project is to evaluate the effectiveness of type 2 diabetes management through telehealth and answers the following PICOT question: In patients with diabetes type 2 who have difficulties with medical visit compliance (P), will the telehealth platform (I), compared to patient's previous visit HbA1c (C) improve the Hemoglobin A1c (HbA1c) diagnostic marker (O) over a 12-week period(T)? An extensive literature search of five databases was performed, citation chasing, and a hand search yielded fourteen pieces of evidence ranging from level I to VI (Melnyk & Fineout-Overholt, 2019). The pieces of evidence selected for this project support the evidence that telehealth implementation is as effective as the "usual care" or in-person visits to treat type 2 diabetes. The John Hopkins Nursing Evidence-Based Practice (JHNEBP) model was selected. Patients with a HbA1c of greater than 6.7% have been asked to schedule two six-week telehealth visits. During the live video visit, a review of medications, and diabetes self-management education (DSME) will be conducted. Participants will be provided with education to promote lifestyle modifications. The visits will be conducted through an Electronic Medical Record (EMR) system that is Health Insurance Portability and Accountability Act (HIPAA) compliant. A paired t-Test will be used with the data collected from the pre-and post-HbA1c. Improve the management of type 2 diabetes with the incorporation of telemedicine in primary care. Research supports the need to further expand the use of telehealth in primary care, to improve patient outcomes and decrease co-morbidities related to type 2 diabetes.
ABSTRACT
Objectives: Electroconvulsive therapy (ECT) is important in the management of major, life-threating, and treatment-resistant psychiatric illness. The COVID-19 pandemic has significantly disrupted ECT services. The need for new infection control measures, staff/resource redeployment and shortages, and the perception that ECT is as an 'elective' procedure have caused changes to, and reductions in, ECT delivery. The aim of this study was to explore the impacts of COVID-19 on ECT services, staff, and patients globally. Method(s): Data were collected using an electronic, mixed-methods, cross-sectional survey. The survey was open March to November 2021. Clinical directors in ECT services, their delegates, and anaesthetists were asked to participate. Quantitative findings are reported. Result(s): One hundred and twelve participants worldwide completed the survey. The study identified significant impacts on services, staff, and patients. Based on quantitative results, most participants (57.8%, n=63) reported their services made at least one change to ECT delivery. More than three-quarters (81.0%, n=73) reported their service had identified at least one patient who could not access ECT. More than two-thirds (71.4%, n=67) reported their service identified at patients who experienced a relapse in their psychiatric illness due to lack of ECT access. Six participants (7.6%) reported their service had identified at least one patient who died, by suicide or other means, due to lack of ECT access. Participants' qualitative responses were detailed, averaging 43 words. Three qualitative themes were identified: (1) Service provision, about the importance of ECT services continuing during the pandemic, (2) Preparedness, through guidelines and environmental design, and (3) Personal protection, about strategies to increase staff safety. Conclusion(s): This is the first multi-site, international survey to explore the impacts of COVID-19 on ECT services, staff, and patients. Its findings can be used to inform evidence-based ECT practice. This supports the ongoing safe, effective operation of ECT services. Research Category and Technology and Methods Clinical Research: 2. Electroconvulsive Therapy (ECT) Keywords: Survey, Mixed Methods, COVID, Service changes;Copyright © 2023
ABSTRACT
Objective To analyze the research status and development trend of evidence-based social sciences, and to explore the synergistic relationship among branches of various fields. Methods A comprehensive search for research related to evidence-based social sciences published between the establishment of the database and September 2022 was conducted on the Web of Science, China Science Citation Database (CSCD), and Chinese Social Sciences Citation Index (CSSCI). The VOSviewer software was used to analyze the author and keywords and to perform the visualization. Results A total of 6 969 papers were included, 195 of which were in Chinese. The first paper, published in 1995, was on evidence-based management. The number of papers published on evidence-based social science research presented a trend of increasing continuously. The country with the most papers published was the United States;the institution outside China with the most papers published was McMaster University;and the institution in China with the most papers published was Sichuan University. The analysis of keywords showed that evidence-based policy, evidence-based practice, evidence-based management, and evidence-based decision-making appeared more frequently;research questions focused on evidence-based health policy development, application of big data in the context of COVID-19, evidence of climate change-induced disease, and real world research. Conclusion All the fields of evidence-based social sciences are closely related to each other in terms of research content and methods, and it presents a multi-level and multi-field crossover with evidence-based medicine. However, evidence-based social sciences in China are still in their infancy. Therefore, it is necessary to improve the methodological system of evidence-based social sciences, enrich the research content of social sciences, speed up the filling of evidence gaps in various fields, and promote the improvement and sustainable development of evidence-based social sciences.Copyright © 2023 West China University of Medical Science. All rights reserved.
ABSTRACT
1. Introduction: Asthma causes significant morbidity and mortality worldwide. COVID-19 scenario has revealed lacks in the current model of asthma management in Primary Care (PC). 2. Aims and objectives: The aim was to build a reference framework and address patients' needs to help asthma management improvement in a COVID-19 scenario. 3. Method(s): A scientific committee from the Spanish Respiratory Group in PC (GRAP) defined an evidence-based gold standard model for asthma care pathway including: suspected asthma, confirmed asthma, asthma follow-up, asthma exacerbations and special situations in asthma. Multidisciplinary teams (family doctors, PC nurses, practice clerks, and community pharmacists) were recruited from 17 PC settings in 7 Spanish regions to characterise their local asthma care pathway and to identify room for improvement in different areas according to previously defined gold-standards. A national online Digital Innovation Laboratory was held with representatives of the local teams to prioritise areas of improvement in terms of clinical impact and to co-design action plans. 4. Result(s): 43 to-be-improved areas in asthma care pathways were identified, classified into different categories. Continuing care, collaborative work between Primary and Secondary care, availability of qualified healthcare staff, data recording and management, digital transformation and patient empowerment were some of the areas to prioritize. 5. Conclusion(s): Multidisciplinary pre-structured team work with Digital Innovation Laboratory support could help to redesign the asthma patient's pathway and to improve the effective asthma management in a COVID-19 scenario.
ABSTRACT
Background: Acute genital ulcers (AGU) are painful ulcerations of the lower vagina and vulva. Lesions typically occur in adolescents and may be preceded by a viral illness such as Epstein-barr virus, cytomegalovirus and more recently, COVID-19. AGU is a diagnosis of exclusion, with limited data to guide investigations and treatment. We aim to retrospectively review the clinical course of patients presenting to our center with suspected AGU to characterize and evaluate local practice patterns. In addition, we survey pediatric and adolescent gynecology care providers to understand the work up and management of AGU across North America. Method(s): We performed a retrospective chart review between June 1, 2016 to June 30, 2021. Medical records were reviewed to capture demographic data, diagnostic work up and management. Data is presented descriptively, and time to resolution is compared for patients managed expectantly versus with corticosteroids using a Student's T-test. A cross-sectional survey created by study authors was distributed to members of the NASPAG. Data was summarized through descriptive statistics. Management practices between care providers were compared using Fisher's Exact test. Result(s): Overall, 25 patients were diagnosed and managed as AGU at our center during the study period. On average, patients were 13.2 years old (range 11 to 17 years). The majority (92%) reported prodromal symptoms. EBV and CMV were the most ordered serologies (64%);only 3 patients showed serologic evidence of acute viral infection. Conservative measures were recommended to 84% of patients. 40% of patients were prescribed corticosteroids. Average duration to resolution was 16.3 days, with no difference between patients managed supportively versus with corticosteroids (p=0.9). In total, 100 responses from NASPAG members were included. Most care providers reported seeing fewer than 10 patients with AGU per year (62%). Common diagnostic tests performed were herpes simplex virus polymerase chain reaction (82%), Epstein-barr virus serology (56%) and cytomegalovirus serology (47%). Most care providers recommended supportive management with topical analgesia (84%), NSAIDs (83%) and acetaminophen (64%). Topical steroids were considered by 67% based on the degree of accompanying inflammation. There was no difference in corticosteroid prescribing practices between types or location of providers (p > 0.05). Conclusion(s): Our retrospective review and survey capture practice patterns of AGU management amongst pediatric and adolescent gynecology care providers. Further collaboration is needed to prospectively evaluate the effectiveness of treatment modalities, and develop evidence-based guidelines to inform practice.Copyright © 2023
ABSTRACT
Integrating mental health care in primary healthcare settings is a compelling strategy to address the mental health treatment gap in low- and middle-income countries (LMICs). Collaborative Care is the integrated care model with the most evidence supporting its effectiveness, but most research has been conducted in high-income countries. Efforts to implement this complex multi-component model at scale in LMICs will be enhanced by understanding the model components that have been effective in LMIC settings. Following Cochrane Rapid Reviews Methods Group recommendations, we conducted a rapid review to identify studies of the effectiveness of Collaborative Care for priority adult mental disorders of mhGAP (mood and anxiety disorders, psychosis, substance use disorders and epilepsy) in outpatient medical settings in LMICs. Article screening and data extraction were performed using Covidence software. Data extraction by two authors utilized a checklist of key components of effective interventions. Information was aggregated to examine how frequently the components were applied. Our search yielded 25 articles describing 20 Collaborative Care models that treated depression, anxiety, schizophrenia, alcohol use disorder or epilepsy in nine different LMICs. Fourteen of these models demonstrated statistically significantly improved clinical outcomes compared to comparison groups. Successful models shared key structural and process-of-care elements: a multi-disciplinary care team with structured communication;standardized protocols for evidence-based treatments;systematic identification of mental disorders, and a stepped-care approach to treatment intensification. There was substantial heterogeneity across studies with respect to the specifics of model components, and clear evidence of the importance of tailoring the model to the local context. This review provides evidence that Collaborative Care is effective across a range of mental disorders in LMICs. More work is needed to demonstrate population-level and longer-term outcomes, and to identify strategies that will support successful and sustained implementation in routine clinical settings. Copyright © The Author(s), 2023. Published by Cambridge University Press.
ABSTRACT
Objective To analyze the research status and development trend of evidence-based social sciences, and to explore the synergistic relationship among branches of various fields. Methods A comprehensive search for research related to evidence-based social sciences published between the establishment of the database and September 2022 was conducted on the Web of Science, China Science Citation Database (CSCD), and Chinese Social Sciences Citation Index (CSSCI). The VOSviewer software was used to analyze the author and keywords and to perform the visualization. Results A total of 6 969 papers were included, 195 of which were in Chinese. The first paper, published in 1995, was on evidence-based management. The number of papers published on evidence-based social science research presented a trend of increasing continuously. The country with the most papers published was the United States;the institution outside China with the most papers published was McMaster University;and the institution in China with the most papers published was Sichuan University. The analysis of keywords showed that evidence-based policy, evidence-based practice, evidence-based management, and evidence-based decision-making appeared more frequently;research questions focused on evidence-based health policy development, application of big data in the context of COVID-19, evidence of climate change-induced disease, and real world research. Conclusion All the fields of evidence-based social sciences are closely related to each other in terms of research content and methods, and it presents a multi-level and multi-field crossover with evidence-based medicine. However, evidence-based social sciences in China are still in their infancy. Therefore, it is necessary to improve the methodological system of evidence-based social sciences, enrich the research content of social sciences, speed up the filling of evidence gaps in various fields, and promote the improvement and sustainable development of evidence-based social sciences.Copyright © 2023 West China University of Medical Science. All rights reserved.
ABSTRACT
OBJECTIVE: To present an established practice protocol for safe and effective hospital-setting ophthalmic practice during the coronavirus disease 2019 (COVID-19) pandemic. METHODS AND ANALYSIS: Literature was reviewed to identify articles relevant to COVID-19 pandemic and ophthalmology. The following keywords were used: COVID-19, SARS-CoV-2 and telemedicine, combined with eye, ophthalmology, conjunctivitis and tears. Data were extracted from the identified manuscripts and discussed among subspecialists to obtain consensus evidence-based practice. RESULT(S): A protocol for ophthalmic practice in the era of COVID-19 pandemic was established. The protocol covered patient screening, clinic flow, required personal protective equipment and modifications of ophthalmic equipment for improved safety. CONCLUSION(S): Important literature emerged with respect to the practice of ophthalmology in the era of COVID-19. An evidence-based ophthalmic practice protocol was established and should be modified in the future to accommodate new insights on the COVID-19 pandemic.Copyright © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
ABSTRACT
Introduction: Spasticity is a highly prevalent and complex symptom of neurological insult/disease and gaining consistency in a MDT approach at the acute, rehab and community level is challenging (RCP 2018). Across Greater Manchester (GM) (3.2million residents and 7 NHS Trusts) there is wide variation in spasticity service provision within stroke and neuro services creating inequity across the region. GMNISDN have therefore been working with regional colleagues to understand current practices and to establish a model of best practice for spasticity management across GM. Method(s): MDT working party established across stroke and neuro, inpatients and community to: * Scope current practice and patient need (2019). * Review relevant literature, guidelines, and evidence-based practice. * Scope different delivery models across the UK. * Create GM Best Practice Model for Spasticity Management (2020). * Pilot audit a representative sample of services against national standards and GM model (2020). * Host spasticity education conference (2019) and webinar series (2021) to aid education around pathophysiology, assessment and management of spasticity. Result(s): * Spasticity service provision is varied, and at times underresourced and discoordinated. * Areas of good practice, training needs and areas for improvement identified (e.g. access pathways, waiting times and follow-up). * Importance of MDT collaboration in treatment planning and evaluation highlighted. * GM Best Practice Model used to aid clinical decision-making and to educate clinicians. * Training events attended by GM and national colleagues and rated excellent. Conclusion(s): Access to appropriately resourced and coordinated spasticity services in GM is inequitable. Further work is required to understand the post-covid picture and explore pathway development/improvement across stroke and neuro services.
ABSTRACT
Purpose: An interdisciplinary team approach is recommended by numerous practice guidelines for management of eating disorder (ED) care in pediatric populations. Registered dietitians (RDs), with their unique clinical nutrition knowledge and skill play a valuable role in treating adolescents with eating disorders and their inclusion on an interdisciplinary team is integral to the team approach. Despite this, there is little guidance on standards of care for RDs working in this setting, as well as limited research on outcomes of RD managed nutrition support which may result in inconsistent and inequitable care. During the COVID-19 pandemic, cases of youth presenting with eating disorders have increased causing unprecedented demands on healthcare resources. The pandemic has also resulted in the rapid evolution of care delivery models, including the wide adoption of telemedicine services. This study fills a considerable gap in the evidence base by seeking to understand RD practices across institutional pediatric outpatient eating disorder care settings. This is a vital step to inform the development of care standards and pave the way for future research to assess outcomes of RD involvement in eating disorder care. Methods: We surveyed 18 dietitians at tertiary care institutions across all regions of the United States using a 24-question web-based questionnaire. Participants were recruited by purposeful sampling of institutional program RDs following email referral by medical leadership in affiliated eating disorder programs. Our survey addressed topics such as frequency and duration of nutrition appointments, individuals present for nutrition appointments, use of family-based treatment (FBT), content and approaches included in nutrition appointments, and disciplines with whom RDs coordinated care. Results: Most RDs surveyed practiced within interdisciplinary teams utilizing a Family Based Treatment (FBT) approach. A majority of respondents used telemedicine for at least a portion of their eating disorder appointments;nearly half of respondents (47%) reported using telemedicine for 50-100% of their eating disorder appointments. Survey responses regarding care delivery topics, such as visit frequency and duration, nutrition education content, and approach were highly variable among participants. Conclusions: This study maintains that RDs prioritize individualized care, however it highlights a gap in guidance and practice standards for their role in outpatient eating disorder care. Furthermore, our results emphasize the importance of addressing variability in nutrition practice when interpreting outcomes of RD involvement in eating disorder care. With recent changes in health care delivery as a result of the COVID-19 pandemic, there is value in understanding how nutrition care is evolving in order to meet all patient's needs. Sources of Support: Seattle Children's Hospital provided statistics support. No funding was provided.
ABSTRACT
PURPOSE/HYPOTHESIS: Individuals with Long COVID experience a variety of symptoms (cardiopulmonary, neurological, musculoskeletal, and psychological) for 12 weeks or more after being infected with COVID-19. Preliminary evidence suggests exercise to be beneficial in alleviating short-term COVID-19 symptoms. The purpose of this investigation is to assess the impact of a progressive therapeutic exercise program on individuals with Long COVID. NUMBER OF SUBJECTS: Ten participants (8 females, 2 males) with Long COVID (age=49 +/- 5 yrs, mass = 89 +/- 6 kg, BMI = 30.2 +/- 1.9 kg/m2) were enrolled in the study. MATERIALS AND METHODS: Before and after the intervention participants were assessed for 6-minute walk distance (6MWD), 5-times sit to stand (5XSTS), gait speed, grip strength, perceived quality of life (SF-12), and general fatigue (visual analog fatigue scale, VAFS). Participants then completed a progressive, individualized exercise program (;8 weeks) designed to improve cardiovascular fitness, muscle strength, and endurance. Modes of exercise used to facilitate improvement in cardiorespiratory fitness included the treadmill, NuStep, semirecumbent bike, semi-recumbent elliptical, and standup elliptical. Heart rate (HR), blood pressure (BP), O2saturation, and rating of perceived exertion (RPE) were regularly monitored during aerobic exercise. Dumbbell exercises targeted at large muscle groups were used to challenge muscular strength and endurance. Progression of exercise intensity and duration was based on symptom response to exercise. Paired t-tests were used to evaluate changes in outcome measures following the intervention. RESULT(S): 6MWD (pre = 469 +/- 19 m, post=529 +/- 18 m, P = .001), 5XSTS (pre=11.4 +/- 1.1 s, post=9.4 +/- 0.9 s, P = .012), gait speed (pre=1.24 +/- 0.05m/s, post=1.35 +/- 0.07m/s, P = .029), and right (pre=69.8 +/- 4.2lbs, post=73.6 +/- 4.4lbs;P = .041) and left (pre=64.7 +/- 3.5lbs, post=68.8 +/- 3.1lbs;P = .041) grip strength improved following the intervention. Similarly, both the physical component (pre=44.4 +/- 3.1, post=50.76 2.4, P = .006) and mental component (pre=43.9 +/- 2.9, post=51.4 +/- 2.0, P = .007) of SF-12 improved, while VAFS (pre54.86 0.5, post52.86 0.6, P5.005) was reduced following the intervention. CONCLUSION(S): A progressive individualized exercise program can be effective at improving physical function and perceived quality of life in Long COVID patients. CLINICAL RELEVANCE: Many physicians are referring patients out to be treated for Physical Therapy, but there is currently limited reference of evidence-based practice to treat these individuals and some concern that exercise may exacerbate symptoms. The majority of APTA clinical guidelines for COVID-19 focus on short-term COVID-19 symptoms and do not address treatment methods for Long COVID symptoms. While functional status has been demonstrated to be negatively impacted in Long COVID patients, little guidance is available for treatment strategies in this population. This investigation provides physical therapists with a generalized strategy to improve physical function and quality of life in Long COVID patients.
ABSTRACT
PURPOSE/HYPOTHESIS: Individuals with Long COVID experience a variety of symptoms (cardiopulmonary, neurological, musculoskeletal, and psychological) for 12 weeks or more after being infected with COVID-19. Preliminary evidence suggests exercise to be beneficial in alleviating short-term COVID-19 symptoms. The purpose of this investigation is to assess the impact of a progressive therapeutic exercise program on individuals with Long COVID. NUMBER OF SUBJECTS: Ten participants (8 females, 2 males) with Long COVID (age=49 +/- 5 yrs, mass = 89 +/- 6 kg, BMI = 30.2 +/- 1.9 kg/m2) were enrolled in the study. MATERIALS AND METHODS: Before and after the intervention participants were assessed for 6-minute walk distance (6MWD), 5-times sit to stand (5XSTS), gait speed, grip strength, perceived quality of life (SF-12), and general fatigue (visual analog fatigue scale, VAFS). Participants then completed a progressive, individualized exercise program (;8 weeks) designed to improve cardiovascular fitness, muscle strength, and endurance. Modes of exercise used to facilitate improvement in cardiorespiratory fitness included the treadmill, NuStep, semirecumbent bike, semi-recumbent elliptical, and standup elliptical. Heart rate (HR), blood pressure (BP), O2saturation, and rating of perceived exertion (RPE) were regularly monitored during aerobic exercise. Dumbbell exercises targeted at large muscle groups were used to challenge muscular strength and endurance. Progression of exercise intensity and duration was based on symptom response to exercise. Paired t-tests were used to evaluate changes in outcome measures following the intervention. RESULT(S): 6MWD (pre = 469 +/- 19 m, post=529 +/- 18 m, P = .001), 5XSTS (pre=11.4 +/- 1.1 s, post=9.4 +/- 0.9 s, P = .012), gait speed (pre=1.24 +/- 0.05m/s, post=1.35 +/- 0.07m/s, P = .029), and right (pre=69.8 +/- 4.2lbs, post=73.6 +/- 4.4lbs;P = .041) and left (pre=64.7 +/- 3.5lbs, post=68.8 +/- 3.1lbs;P = .041) grip strength improved following the intervention. Similarly, both the physical component (pre=44.4 +/- 3.1, post=50.76 2.4, P = .006) and mental component (pre=43.9 +/- 2.9, post=51.4 +/- 2.0, P = .007) of SF-12 improved, while VAFS (pre54.86 0.5, post52.86 0.6, P5.005) was reduced following the intervention. CONCLUSION(S): A progressive individualized exercise program can be effective at improving physical function and perceived quality of life in Long COVID patients. CLINICAL RELEVANCE: Many physicians are referring patients out to be treated for Physical Therapy, but there is currently limited reference of evidence-based practice to treat these individuals and some concern that exercise may exacerbate symptoms. The majority of APTA clinical guidelines for COVID-19 focus on short-term COVID-19 symptoms and do not address treatment methods for Long COVID symptoms. While functional status has been demonstrated to be negatively impacted in Long COVID patients, little guidance is available for treatment strategies in this population. This investigation provides physical therapists with a generalized strategy to improve physical function and quality of life in Long COVID patients.
ABSTRACT
Introduction: Consultation of minor ailments and direct product request are frequent in community pharmacy in Spain, although every pharmacy offers the service following their own criteria. Standard Operational Procedures (SOP) and referral criteria agreed between community pharmacists (CPs) and general practitioners (GPs) are needed to deliver a safer service. Referral criteria set the limits of action for each healthcare professional (CPs and GPs) when managing patients. Following the positive findings of an impact study, a roll out was required to translate the evidence-based approach into usual practice. Objective(s): The aim was to characterise the referrals between CPs and GPs through a Minor Ailment Service (MAS, service offered in community pharmacy following the SOP). Method(s): A 12-month pragmatic study with hybrid effectiveness-implementation design was planned from October 2020 in Spain. The co-designed MAS service had several components: agreed SOP with GP scientific organisations, protocols for ailments divided into five groups (dermatological, digestive, related to pain, upper respiratory tract related and others) including referral criteria, information technology (IT) based consultation protocol and training before and during the study. Patients were followed up by pharmacists after ten days of the service. All data were collected through an IT system (SEFAC eXPERT) as a by-product of service delivery and implementation. Outcomes for the first fifteen months (up to December 2021) are shown. Result(s): 1246 pharmacists from 24 provinces in Spain were trained having a reach of 14083 consultations. 1858 (13.2%) patients were referred to the GP. 2193 referral criteria were detected, most patients referred had one single referral criteria (n = 965, 80.8%). Referral criteria detected were red flags such as temperature over 38degreeC, dyspnoea, etc. (n = 846, 39.5%);patients' age (n = 398, 18.6%), symptom duration (n = 361, 16.9%);patients' treatments for other health problems different than the minor ailment consulted (n = 263, 12.3%);other patients' health problems (n = 186, 8.7%) and others (n = 85, 4.0%). Minor ailments more frequently referred were joint pain (n = 190, 10.2%), cough (n = 106, 5.7%), dermatitis (n = 104, 5.6%) and heartburn (n = 63, 3.4%). Conclusion(s): High-risk patients (patients with symptoms/condition that do not appear to be minor ailments) can be assessed by CPs and referred to be evaluated and diagnosed by GPs. The use of co-designed management protocols strengthened the identification of red flags in patients suffering minor ailments to be referred when necessary. Joint pain and cough were two of the minor ailments more frequently referred, which could be a result of the study being undertaken during COVID19 pandemic. CPs can perform clinically, referring patients and acting as a triage point through MAS to increase patients' safety.
ABSTRACT
Background. During the COVID-19 pandemic, evolving literature and emerging therapies have led to significant controversies on what constitutes optimal therapy for hospitalized patients with COVID-19. In addition, multiple guidelines emerged exhibiting variable recommendations in key areas of therapeutic management. Thus, interpreting emerging data and deploying novel therapeutics during the pandemic has been challenging. Antimicrobial stewardship programs (ASP) have been proven to help promote evidence-based practices and are now common the United States (US). We seek to further understand the role of ASP during the COVID-19 pandemic. Methods. A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, hospital size, facility type, and existence of active ASP. COVID-19 therapeutic restrictions and type of provider who decides on treatment allocation was surveyed. Results. A total of 92 surveys were completed, representing wide geographic reach within the United States (Figure 1). Hospital size by beds were 14% less than 200 (13), 18.5% 201-300 beds (17), 15.2% 301-400 beds (14), and 52.2% over 400 beds (48). Community hospitals accounted for 31.5% (29), county/public hospital 3.3% (3, 3.3%), University-affiliated Community-Based Teaching Hospitals 10.9% (10), University-based Teaching Hospital 45.7% (42), and 8.7% selected other. ASP were present in 97.2% of hospitals. COVID-19 therapeutic restrictions were common (Figure 2). Infectious diseases (ID) approval was required in 87.9% of facilities (Figure 3). Figure 1 Geographic distribution of hospitals represented in the survey Figure 2. Restricted COVID-19 therapies by medication type (%) Figure 3 Specialties or providers that are able to order or approve restricted COVID-19 therapies (%) Conclusion. COVID-19 therapeutics were commonly restricted during the COVID-19 pandemic. Approval by ID clinicians was required almost universally (87.9%). The role of other specialties was significantly lower, representing less than 45% of hospitals. ID clinicians have played a vital role in guiding therapy and supporting ASP during the COVID-19 pandemic. This survey highlights the value of ID clinicians to healthcare systems in allocating resources and promoting evidence-based practices through ASP.
ABSTRACT
The proceedings contain 13 papers. The topics discussed include: are citizens involved in vascular access research? a scoping review protocol;nursing care to prevent peripherally inserted central catheter (PICC) related complications: a systematic review;clothing constraints in maintaining vascular access;supporting Portuguese nurses' evidence-based practice related to peripheral intravenous catheterization: a Delphi consensus study;aseptic techniques for peripherally inserted central catheters: a scoping review protocol;unusual placement of a fully implantable catheter into the internal thoracic vein;relationship between nutritional status and catheter-related infection in COVID-19 patients;comparison of two methods for evaluation of the tip position in totally implantable venous access device (TIVAD);and best practice in the insertion and maintenance of removal of peripheral intravenous catheters (PIVC): contributions to nursing care.
ABSTRACT
Introduction: Two fundamental supportive invasive interventions in the intensive care unit (ICU) are ventilation and intravenous therapy. Ventilation research has dominated the literature since the pandemic began, with little research on vascular access devices (VADs), despite these interventions existing almost co-dependently. This scoping review aimed to identify the types of evidence available, knowledge gaps and key concepts on vascular access (VA) approaches in patients with Covid-19 in ICU. The main objective was to conduct a systematic search to examine the types of research conducted on VADs during the pandemic. Method(s): Design: scoping review. The Joanna Briggs Institute (JBI) three-step approach was followed to undertake a systematic search using databases and search engines EMBASE, Medline, CINAHL, PubMed and clinical trials registries. Study designs were searched from 2019 to March 2022 limited to the English language. Our data extraction instrument was developed using a template from JBI (Table 1). The PRISMA-ScR checklist was used to report findings. Result(s): A total of 5107 results were identified (Figure 1). From this number data was extracted from 67 papers. Among the study designs were: retrospective studies (20), editorials and commentaries (17), case reports (14), prospective cohort studies;observational studies;cross sectional studies (8), conference s (2), quality improvement initiative (2), one survey (1), study protocol (1). Two clinical guidelines from expert groups were identified. No randomised controlled trials were identified. No clinical trials, registered or ongoing, were identified. Discussion(s): This review identified that Covid-19 patients are requiring more VADs, over longer periods with an increased risk of mortality. These patients are proned for up to 18 hours a day, reducing access for regular VAD assessment. Well-designed VA research is lacking in COVID 19 cohorts. Conclusion(s): The foundation of evidence-based practice depends on the integration of valid research alongside clinical expertise. Despite VA recommendations being in existence, no randomised controlled trials, systematic reviews or meta-analysis exist to support these recommendations. Future research needs to focus on high quality randomised controlled trials. A systematic review and meta-analysis is, at present, unnecessary.
ABSTRACT
SESSION TITLE: Close Critical Care Calls SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Heparin is the preferred anticoagulant for use in pregnancy while on extracorporeal membrane oxygenation (ECMO) (1). Alternatives to heparin in this patient population are not well studied as heparin-induced thrombocytopenia is rare in pregnancy. Parenteral non-heparin anticoagulants available in the United States include the direct thrombin inhibitors argatroban and bivalirudin, both of which are utilized in ECMO. Guidelines recommend avoidance of these agents in pregnancy if at all possible (2). Whereas case reports support the safe use of argatroban in pregnancy, to our knowledge, there are no known documented reports of bivalirudin use in this patient population (3). Here we describe the successful use of bivalirudin during pregnancy. CASE PRESENTATION: A 25 year old G2P1 was transferred to our institution at 28 weeks gestation for further management of acute hypoxic respiratory failure secondary to COVID-19. On hospital day 2 the patient was urgently placed on venovenous (VV) ECMO for refractory hypoxemia, high dead space with acidosis, and the inability to provide adequate gas exchange and lung protection with mechanical ventilation alone. Following ECMO cannulation with a 25f cannula in the right femoral vein and a 21f cannula in the right internal jugular vein, she was anticoagulated with heparin at a rate of 12 units/kg/hr. This was titrated to target a PTT goal of 60-80 seconds. On ECMO day 2, the TEG demonstrated a markedly hypocoagulable state, and the heparin nomogram called for increasing heparin dosing based on PTT. Given the already high dose of heparin that the patient was on (32.9 units/kg/hr), the decision was made to switch from heparin to bivalirudin to prevent over anticoagulation and reduce bleeding risk. Bivalirudin was titrated to a goal PTT of 50-60 seconds, with an initial rate of 0.15 mg/kg/hr (dose range 0.15-0.22 mg/kg/hr). Therapy was continued and on ECMO day 11, at 29w6d the patient delivered via cesarean section. Bivalirudin was discontinued 2.5 hours prior to the surgical procedure which resulted with no fetal bleeding complications. The patient was decannulated from ECMO on day 20 and was later discharged from the hospital. The newborn is developing well and meeting age adjusted milestones. DISCUSSION: Bivalirudin was selected based on institutional experience and the pharmacokinetic properties of the drug (half-life of 25 minutes) as we considered a situation where an emergent delivery may be indicated. Bivalirudin successfully prevented clotting of the circuit with no maternal or fetal bleeding complications during its use. CONCLUSIONS: Our case report describes a multidisciplinary approach to managing a pregnant patient on ECMO requiring anticoagulation using an alternative medication to heparin. This is the first documented use of bivalirudin in pregnancy. Reference #1: ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support Extracorporeal Life Support Organization, Version 1.4 August 2017. Ann Arbor, MI, USA www.elso.org. Reference #2: Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(Suppl): e691S–736S Reference #3: Young SK, Al-Mondhiry HA, Vaida SJ, et al. Successful use of argatroban during the third trimester of pregnancy: case report and review of the literature. Pharmacotherapy 2008;28: 1531–6. DISCLOSURES: No relevant relationships by Jacqueline Finger No relevant relationships by Caitlin Gluck No relevant relationships by Cameron Hypes No relevant relationships by John Rathbun
ABSTRACT
SESSION TITLE: Rare Pulmonary Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Castleman's Disease (CD) includes a group of rare and heterogenous lymphoproliferative disorders that share characteristic histopathological features. The etiology of CD is unknown. The condition results in episodic regional lymphadenopathy. Symptoms are driven by episodic cytokine excess. Clinical presentation can include fevers, night sweats, weight loss and fatigue. Life expectancy is not affected, however patients are at risk of developing various other conditions including amyloidosis, cryptogenic organizing pneumonia and lymphoma. COVID-19 is known to have periods of cytokine excess. In severe instances in can lead to cytokine storm, characterized by bilateral pulmonary infiltrates, worsening hypoxemia, and organ failure. We present the case of a 48 year-old female with CD who endured prolonged COVID-19 and cytokine storm. CASE PRESENTATION: A 48-year-old female with CD presented to the emergency department for shortness of breath. Six months prior to admission she had received one dose of the mRNA-1273 (Moderna) vaccine against SARS-CoV-2. Unfortunately, she contracted COVID-19 prior to the second dose. At that time she was hospitalized at a separate institution for COVID-19 and hypoxemia. The patient was treated with systemic glucocorticoids and remdesivir, and subsequently discharged home on supplemental oxygen via nasal cannula at 2 l/min. Unfortunately her respiratory status progressively declined over the following two months. During this time PCR testing for SARS-CoV-2 was positive on multiple occasions. She subsequently presented to our ER for dyspnea and hypoxemia. She once again tested positive by PCR. Inflammatory markers including fibrin degradation products, c-reactive protein and fibrinogen were severely elevated. Chest radiograph revealed bilateral infiltrates. The patient was placed on high flow oxygen and admitted to the ICU. Treatment was initiated with remdesivir, systemic glucocorticoids, and tocilizumab. Unfortunately, she continued to decline and was eventually placed on mechanical ventilation. The patient was then transferred to another institution for evaluation of extracorporeal membrane oxygenation. DISCUSSION: Both CD and COVID-19 are characterized by cytokine excess. Our patient with CD presented with persistent COVID-19. She remained symptomatic for close to six months. Her course was waxing and waning for the first few months and then progressively declined. Multiple PCR tests for SARS-CoV-2 were positive during this interval. We postulate that the proclivity of CD to cytokine excess had a synergistic effect on the inflammatory components of COVID-19 infection. This may have contributed to the protracted infection. CONCLUSIONS: More research is needed in patients with lymphoproliferative disorders and the impact of COVID-19 infection on their outcomes. Reference #1: Van Rhee, Frits, et al. "International, Evidence-Based Consensus Treatment Guidelines for Idiopathic Multicentric Castleman Disease.” American Society of Hematology, American Society of Hematology, 15 Nov. 2018, https://ashpublications.org/blood/article/132/20/2115/39506/International-evidence-based-consensus-treatment. Reference #2: "Castleman Disease: Symptoms, Causes, Treatments and Tests.” Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/17920-castleman-disease. Reference #3: "Castleman Disease.” NORD (National Organization for Rare Disorders), 10 July 2017, https://rarediseases.org/rare-diseases/castlemans-disease/. DISCLOSURES: No relevant relationships by Wajahat Khan No relevant relationships by Nashwa Yosry
ABSTRACT
Background The widespread use of medical software applications and internet for browsing health related topics have become a novel way to improve health and health care delivery system. Especially, in these days when covid 19 pandemic have struck the world so badly that people have less access to hospitals for their routine medical care, mHealth have shortened the distance between a patient and doctor. Advancements in mobile technologies and better reach of mobile networks have accelerated the usage of mobile apps and other electronic devices for planning,programming and executing various health care services round the globe. Even in India during the covid pandemic, use of mobile apps like Arogya Setu have made a great impact in planning and provision of health care. This study aims at assessment of awareness on mHealth among undergraduate medical students in a tertiary centre at Maharashtra, India. Methodology A cross sectional study was conducted among undergraduate medical students of Government Medical College, Aurangabad, Maharashtra. A pretested semi structured questionnaire was used to collect data from the medical students. About 400 students studying in first year and second year were included in the study. An informed consent was attached along with the questionnaire. Collected data was entered in MS Excel and analyzed using SPSS 26 trial version. Quantitative data was expressed in terms of mean and standard deviation, categorical data was expressed as frequencies and percentages. Chi-square test was used to check the association between the parameters. Data was represented in tabular and graphical form. Result Among the 379 participants,226(59.63%) were males and 153(40.36 %) were females.55.4% belonged to age group above 20 years,85.22% were Hindus. 82.32% belonged to Class I socioeconomic class according to modified B G Prasad's classification. Among the respondents,47.75% only had adequate knowledge, 54.8% had appropriate attitude and 64.3% followed appropriate practice regarding mHealth. About 70% thought that usage of health related apps is not a wastage of time.87.07 % browse internet for health related queries and 76.78% of them spend only less than 30 minutes for that. 67.8% do not prefer to recommend health related apps to their colleagues. About 57% are expecting more health related apps in future, after solving the glitches in the currently available ones. Among the respondents, 95 (55.8%)of those belonging to age group less than 20 years have adequate knowledge regarding m-health, while only 40.6% of those belonging to age group more than 20 years had adequate knowledge in this regard (p value= 0.0015). Males had more knowledge about mHealth than females (p=0.0015).102 respondents belonging to 1st year MBBS(54.5%) had adequate knowledge as compared to 79 belonging to 2nd year MBBS(41.4%) (p=0.004). Males had a better attitude regarding mHealth than females(p= 0.016).Also, respondents aged less than 20 years had better appropriate practice of mHealth than others (p=<0.00). Conclusion In this study,it has been found that more awareness must be created among health care professionals regarding use of mHealth in healthcare delivery. Majority of the respondents agreed upon the utility of health related apps in easy access to national guidelines and lab reference, faster medical score and dose calculations and for acquiring knowledge, developing skills and for evidence based practice. Hence in this context, developing an e-platform for the same can save time,money and manpower to a great extend. Therefore, focus must be on creating apps which are user friendly and which provides maximum data in short span of time. Periodic quality checks on apps must be given to ensure accurate content delivery. Copyright © 2022 Ubiquity Press. All rights reserved.
ABSTRACT
The proceedings contain 245 papers. The topics discussed include: application of the lantern model to stories from the pandemic: its use in enhancing MDT working;hidden work and hidden workers in hospice care;carrying the torch for physician associates (PAS) working in UK hospices;'going against the grain of all we do': hospice staff experiences of moral distress during COVID-19;transformation of death and bereavement support processes across children and adult hospice services;development of a journal club to improve care in a hospice through evidence based practice;no barriers here! advance care planning and people with intellectual disabilities;online community of practice development - palliative care and homelessness;enhancing bereavement group support - changing from a social to a psycho-educational model;and hospice heritage stories: making every memory matter.