"Now I Am Walking Toward Health": A Qualitative Study About the Outcomes of Physical Activity Participation That Matter to Older Adults.

BACKGROUND/OBJECTIVES: Randomized controlled trials that deliver physical activity interventions have demonstrated benefits for older adults across numerous health outcomes. However, too little attention has been directed to ensuring that such trials are measuring patient-relevant outcomes. To support outcome selection for future trials, the objective of this study was to understand what outcomes related to their physical activity participation older adults find important. METHODS: We conducted 12 semistructured interviews with adults aged 65 years and older and analyzed interview transcripts with a reflexive thematic analysis. RESULTS: Older adults desired diverse outcomes from their physical activity participation, ranging from generic (e.g., quality of life) to specific (e.g., leg strength). Relevant outcomes were classified under five themes: physical, clinical, social, psychological, and overarching, each with respective subthemes. CONCLUSIONS: The outcomes that older adults found important were plentiful and rooted in a desire to improve their quality of life. Some of the outcome themes have been reported frequently in past trials (e.g., physical), but others have not (e.g., social). Future researchers should be aware of, and responsive to, the priorities of older adults when designing trials and defining outcomes. Significance/Implications: This study will help to improve outcome selection for future trials of physical activity with older adults. In alignment with a patient-oriented research philosophy, this study will also ground future outcome selection in the priorities of older adults.

WireSafeTM - A pilot study of a novel safety engineered device designed to prevent guidewire retention and reduce sharps injuries during central venous catheter insertion.

Background: Guidewire retention and sharps injury during central venous catheter insertion are errors that cause patient and healthcare professional harm. The WireSafeTM is a novel procedure safety pack engineered to prevent guidewire retention and sharps injury during central venous catheter insertion. This is a pilot study aimed to determine its acceptability, usability and safety during clinical practice. Methods: An observational time and motion study was conducted comparing central venous catheter insertion and sharps disposal practice using standard versus WireSafeTM techniques. One-year following implementation, a structured survey was conducted to determine clinician opinion and experiences of using the WireSafeTM. Results: 15 procedures were observed using standard practice and 16 using the WireSafeTM technique. The WireSafeTM technique decreased the time taken from removal of the guidewire to disposal of sharps (standard 11.4 ± 5.6 min vs WireSafeTM 8.7 ± 1.4 min, p = 0.035), as well as total procedure time (standard 16 ± 7 min vs WireSafeTM 14.2 ± 2 min, p = 0.17), although this latter trend did not reach significance. Clinicians frequently practiced unsafe behaviour during sharps disposal in the standard group (53%), but when using the WireSafeTM technique, 100% exhibited safe practice by transferring sharps to the bin inside the sealed WireSafeTM box. One-year following implementation, 20 clinicians participated in the structured survey. Clinicians across three different departments used the WireSafeTM in varying clinical situations and reported that its use for central line insertion was either easier (10/20) or no different (10/20) compared to standard practice. All clinicians (20/20) felt that the WireSafeTM reduced the risk of guidewire retention and all stated that they approved of the WireSafeTM technique, and supported its use for convenience and safety benefits. Conclusion: Utilising the WireSafeTM for central line insertion facilitated earlier and safer sharps disposal, and the device was well supported by clinicians for its convenience and safety benefits.

Outcome domains measured in randomized controlled trials of physical activity for older adults: a rapid review.

BACKGROUND: Toward development of a core outcome set for randomized controlled trials (RCTs) of physical activity (PA) interventions for older adults, the purpose of this study was to identify outcome domains and subdomains ('what' was measured) in previously published RCTs of PA for older adults. METHODS: We conducted a rapid review and searched Ovid MEDLINE for recently- published (2015-2021), English-language, RCTs of PA interventions for older adults (mean age 60+ yrs). We limited to articles published in Web of Science top-10 journals in general and internal medicine, geriatrics and gerontology, rehabilitation, and sports science. Two reviewers independently completed eligibility screening; two other reviewers abstracted trial descriptors and study outcomes. We classified study outcomes according to the standard outcome classification taxonomy endorsed by the Core Outcome Measures in Effectiveness Trials Initiative. RESULTS: Our search yielded 548 articles; 67 articles were eligible to be included. Of these, 82% were efficacy/effectiveness trials, 85% included both male and female participants, and 84% recruited community-dwelling older adults. Forty percent of articles reported on interventions that involved a combination of group and individual PAs, and 60% involved a combination of PA modes (e.g., aerobic, resistance). Trial sample size ranged from 14 to 2157 participants, with median (IQR) of 94 (57-517); 28,649 participants were included across all trials. We identified 21 unique outcome domains, spanning 4/5 possible core areas (physiological/clinical; life impact; resource use; adverse events). The five most commonly reported outcome domains were physical functioning (included in n=51 articles), musculoskeletal and connective tissue (n=30), general (n=26), cognitive functioning (n=16), and emotional functioning/wellbeing (n=14). Under these five outcome domains, we further identified 10 unique outcome subdomains (e.g., fall-related; body composition; quality of life). No outcome domains or subdomains were reported consistently in all RCTs. CONCLUSIONS: We found extensive variability in outcome domains and subdomains used in RCTs of PA for older adults, reflecting the broad range of potential health benefits derived from PA and also investigator interest to monitor a range of safety parameters related to adverse events. This study will inform development of a core outcome set to improve outcome reporting consistency and evidence quality.

Central Venous Catheter Guidewire Retention: Lessons From England's Never Event Database.

OBJECTIVES: Guidewire retention during central venous catheter (CVC) insertion is considered a "never event." We analyzed the National Health Service England Never Event database (2004-2015) to explore the process of guidewire retention and identify potential preventative measures. METHODS: We performed a systematic analysis of reported retained guidewire incidents by 3 independent reviewers. RESULTS: There was a rising frequency of reported retained CVC guidewires, with an average of 2 never events per month. Only 11% of retained guidewires are identified during the procedure itself, with the remainder identified during equipment clear-up (6%), after the procedure (4%), at the first check radiograph (23%), or after the first radiograph (55%). In 59 cases, the grade of the operator was reported, and among these, 88% were inserted by trainee doctors. Analysis of causative factors was only possible for 38 cases, and of these, operator's mistake (32%), operator/human error (16%), and distraction (16%) were the most common. Of 163 reported cases, preventative measures instigated were actions taken against the individual clinician (36%), departmental actions such as investigations, additional teaching or reminders (37%), and additional checklists (27%). CONCLUSIONS: Most retained guidewires are discovered after the procedure. Despite the introduction of safety measures, guidewire retention still occurs because the checks, alerts, reminders, and additional checklists all solely rely on the operator remembering not to make the mistake. System changes or design modifications to the CVC equipment are needed to prevent guidewire retention, this being at the top of the hierarchy of intervention effectiveness.

Why are rhizobial symbiosis genes mobile?

Rhizobia are one of the most important and best studied groups of bacterial symbionts. They are defined by their ability to establish nitrogen-fixing intracellular infections within plant hosts. One surprising feature of this symbiosis is that the bacterial genes required for this complex trait are not fixed within the chromosome, but are encoded on mobile genetic elements (MGEs), namely plasmids or integrative and conjugative elements. Evidence suggests that many of these elements are actively mobilizing within rhizobial populations, suggesting that regular symbiosis gene transfer is part of the ecology of rhizobial symbionts. At first glance, this is counterintuitive. The symbiosis trait is highly complex, multipartite and tightly coevolved with the legume hosts, while transfer of genes can be costly and disrupt coadaptation between the chromosome and the symbiosis genes. However, horizontal gene transfer is a process driven not only by the interests of the host bacterium, but also, and perhaps predominantly, by the interests of the MGEs that facilitate it. Thus understanding the role of horizontal gene transfer in the rhizobium-legume symbiosis requires a 'mobile genetic element's-eye view' on the ecology and evolution of this important symbiosis. This article is part of the theme issue 'The secret lives of microbial mobile genetic elements'.

Humidicare - an implementation study of a novel HME safety device designed to prevent ventilator circuit occlusion due to inadvertent dual humidification.

Mechanical ventilation bypasses the protective mechanisms of the upper respiratory tract which are designed to heat and humidify inspired air to 37 °C and 44 mg H2O/L respectively. Artificial humidification systems are therefore incorporated into ventilation circuits to condition cold and dry medical gases before they reach the lower respiratory tract and cause patient harm. Commonly either a heat and moisture exchanger (HME) or a heated humidifier (HH) are utilised for this purpose, however the inadvertent simultaneous use of both devices within the same circuit can cause critical airway occlusion within 24 h. The Humidicare HME (Medovate, Cambridge, UK) is a safety engineered temperature-dependent warning system designed to activate when inadvertently placed into a warm circuit containing a HH. This study aimed to determine the efficacy of the Humidicare HME warning system in simulated clinical conditions. The threshold temperature for activation of the device was determined in a digital incubator, and the device was tested for efficacy with a HH present or absent from the breathing circuit. The device performed reliably and activated rapidly when required across all simulations. The Humidicare HME warning system is a simple and unobtrusive device which can effectively alert the operator to the error of dual humidification.

The glucose error in arterial sampling: assessing staff awareness and the effect of sampling technique.

BACKGROUND: Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. METHODS: Following a near-miss and subsequent educational and training efforts at our institution, we conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient's refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. RESULTS: (1) Only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. CONCLUSION: Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.

A bedside rescue method for retrieving retained guidewires: The 'Suck Out' technique.

BACKGROUND: Central venous catheter guidewire retention is classed as a 'never event' in the United Kingdom, with the potential for significant patient harm. If the retained guidewire remains within the central venous catheter lumen, bedside techniques may facilitate guidewire retrieval. However, these techniques may be ineffective if the guidewire has already passed below skin level. We investigated a novel 'suck out' technique for bedside guidewire retrieval and compared this against traditional retrieval methods. METHODS: Simulation 1: in a benchtop model, seven different central venous catheters had their corresponding guidewire placed in the last 2 cm of the catheter tip which was immersed horizontally in fluid. A 50-mL syringe was attached to the distal lumen central venous catheter hub and suction applied for 5 s, and the distance of guidewire retraction was recorded. Simulation 2: a central venous catheter guidewire was intentionally retained within the catheter at either 5 cm above or below skin level in a pigskin model. Simple catheter withdrawal, catheter clamping withdrawal and the 'suck out' method were compared for efficacy using Fisher's exact test. RESULTS: Simulation 1: retained guidewires were retracted by 13 cm on average. Simulation 2: when guidewires were retained 5 cm above skin level, all retrieval methods were 100% effective; however, when retained 5 cm below skin level, simple catheter withdrawal was ineffective, clamping and withdrawal was only 10% effective and the 'suck out' technique was 90% effective (p < 0.001). CONCLUSION: The 'suck out' technique can effectively retract guidewires retained within central venous catheter lumens and demonstrates superiority over traditional methods of retained guidewire extraction in simulated models.

Unintentional endotracheal tube cuff deflation during routine checks: a simulation study.

BACKGROUND: Endotracheal tube cuff pressures should be maintained between 20 and 30 cm H2 O to prevent the aspiration of subglottic secretions past the cuff. Guidance recommends regular monitoring of the cuff pressure, performed using a handheld manometer/inflator. Poor technique can lead to transient deflation of the cuff, leading to the bolus aspiration of upper respiratory tract secretions, tracheal colonization and, ultimately, ventilator-associated pneumonia. AIMS AND OBJECTIVES: To determine whether intensive care staff transiently deflate the endotracheal tube cuff to below 20 cm H2 O during routine cuff pressure checks when using a handheld manometer/inflator device. DESIGN: This was an exploratory simulation study. METHODS: A sample of medical (n = 10) and nursing staff (n = 10), capable of caring for a tracheally intubated patient, participated in the study on a single day. A mannequin was intubated with a standard oral endotracheal tube with the cuff pressure set at 50 cm H2 O. Participants were required to check and correct the cuff pressure to the appropriate level with a manometer. The lowest attained and the final target pressures were recorded. RESULTS: Three doctors were unfamiliar with the manometer and did not attempt measurement. During cuff pressure readjustment, 59% (10/17) of participants transiently deflated the cuff below 20 cm H2 O and then re-inflated to attain the final pressure. Of these participants, four deflated the cuff pressure to 0 cm H2 O before re-adjusting it back into range. Most participants, 88% (15/17), corrected the final cuff pressure to between 20 and 30 cm H2 O. CONCLUSIONS: Poor technique when using the manometer led to unintentional cuff deflation during routine checks. In clinical practice, this could increase the risk of pulmonary aspiration and ventilator-associated pneumonia. Further research into alternatives for handheld manometers, such as automated continuous cuff pressure monitors, is warranted. RELEVANCE TO CLINICAL PRACTICE: Cuff deflations can easily occur during routine cuff pressure checks. Staff should be aware of the implications of cuff deflations and seek to improve training with manometers.

Accidental dual humidification in intensive care units: Repeated alerts and system changes are not enough.

PURPOSE: The inadvertent, simultaneous use of heat and moisture exchangers (HMEs) and heated humidifiers (HHs) can result in waterlogging of the filter and sudden ventilation tube occlusion, with potentially fatal consequences. Following an NHS England Safety Alert, a near miss and educational reminders in our institution, we introduced new guidelines to solely use HHs in the intensive care unit and HMEs only for patient transfers. No further incidents have occurred, however this solution is potentially fallible. Two years later, we sought to assess staff knowledge and likelihood of recognising this error should it occur. MATERIALS AND METHODS: In a simulation study, a tracheally intubated and ventilated mannequin had a breathing circuit containing both a HME and a HH. Participants were asked to assess the circuit, identify errors and undertake corrective measures. RESULTS: Only 30% (6/20) recognised and undertook corrective measures. CONCLUSIONS: Despite educational efforts and system changes, recognition of this error remained poor. System changes may reduce the likelihood of the error occurring, but when it does, recognition may not occur. Substantial reductions or elimination of this error may be achieved through a safety-engineered fail-safe within the equipment, which alerts staff to improve recognition and prevent the mistake.

A Modified Tie Technique for Securing Endotracheal Tubes.

BACKGROUND: Unintentional extubation is a well-documented and potentially life-threatening phenomenon. There is little research into the factors that lead to unintentional extubation, and therefore how to prevent it. Endotracheal tubes (ETTs) are commonly secured with 1 cm twill tape, but there is little evidence on how to best tie them in place. We have devised a new knot for securing these tubes in place, and we have assessed its degree of slippage when exposed to both perpendicular and sliding forces in comparison with other commonly used knots. METHODS: We constructed a weighted apparatus to test the effects of these forces and measure whether conventional ETTs slipped. We tested the knots both wet and dry to better simulate the clinical environment. We also conducted a manual manipulation test in which a single operator attempted to slide the knot along the ETT. Each knot was tested 10 times for the weight test under both wet and dry conditions, and 8 times for the slip test. RESULTS: The normal knot slipped when weighted both wet and dry, while the clove hitch failed the weight test only when wet. Both the modified cow hitch and double hitch withstood all weights. Only the double hitch did not slip under any circumstances on either test. CONCLUSIONS: The new double hitch was superior to all conventional knots tested. It did not slip under any conditions and therefore may be of use to prevent unintentional extubation, particularly in the ICU setting.

Preventing Retained Central Venous Catheter Guidewires: A Randomized Controlled Simulation Study Using a Human Factors Approach.

BACKGROUND: Retained central venous catheter guidewires are never events. Currently, preventative techniques rely on clinicians remembering to remove the guidewire. However, solutions solely relying upon humans to prevent error inevitably fail. A novel locked procedure pack was designed to contain the equipment required for completing the procedure after the guidewire should have been removed: suture, suture holder, and antimicrobial dressings. The guidewire is used as a key to unlock the pack and to access the contents; thereby, the clinician must remove the guidewire from the patient to complete the procedure. METHODS: A randomized controlled forced-error simulation study replicated catheter insertion. We created a retained guidewire event and then determined whether clinicians would discover it, comparing standard practice against the locked pack. RESULTS: Guidewires were retrieved from 2/10 (20%) standard versus 10/10 (100%) locked pack, n = 20, P < 0.001. In the locked pack group, participants attempted to complete the procedure; however, when unable to access the contents, this prompted a search for the key (guidewire). Participants discovered the guidewire within the catheter lumen, recovered it, utilized it to unlock the pack, and finish the procedure. A structured questionnaire reported that the locked pack also improved subjective safety of central venous catheter insertion and allowed easy disposal of the sharps and guidewire (10/10). CONCLUSIONS: The locked pack is an engineered solution designed to prevent retained guidewires. Utilizing forced-error simulation testing, we have determined that the locked pack is an effective preventative device and is acceptable to clinicians for improving patient safety.

Nutritional benefits of Crematogaster mimosae ants and Acacia drepanolobium gum for patas monkeys and vervets in Laikipia, Kenya.

Patas monkeys (Erythrocebus patas) are midsized primates that feed extensively on the gum of Acacia drepanolobium and the ants are housed in swollen thorns of this Acacia. Their diet resembles that expected more of smaller bodied primates. Patas monkeys are also more like smaller bodied primates in reproducing at high rates. We sought to better understand the convergence of patas monkeys with smaller bodied primates by comparing their feeding behavior on ants and gum with that of closely related, sympatric vervets (Chlorocebus pygerythrus), and analyzing the nutrient content of the gum of A. drepanolobium and of Crematogaster mimosae, the most common ant species eaten by patas monkeys in Laikipia, Kenya. All occurrences of feeding and moving during focal animal sampling revealed that 1) patas monkeys seek A. drepanolobium gum but vervets avoid it; 2) both species open swollen thorns most often in the morning when antsare less active; 3) patas monkeys continually feed onswollen thorns and gum while moving quickly throughout the day, whereas vervets reduce their consumption of these items and their travel rate at mid-day, and; 4) vervets eat young swollen thorns at a higher rate than patas monkeys. Patas monkeys are able to spend little time acquiring substantial amounts of energy, protein, and minerals from A. drepanolobium gum and C. mimosae ants each day. These findings, when coupled with evidence of causes of infant and adult female mortality, suggest that reproductive success of female patas monkeys is more immediately affected by illness, disease, interactions between adults and infants, and access to water than by food.

The LoTrach system: its role in the prevention of ventilator-associated pneumonia.

OBJECTIVES: To discuss the development of the LoTrach system in light of current evidence around the prevention of ventilator-associated pneumonia (VAP) and its practical application in the intensive care setting. BACKGROUND: VAP causes substantial morbidity and mortality in ventilated patients in the Intensive Care Unit (ICU), increases length of stay in ICU and is extremely costly. Strategies are needed to reduce the risk of VAP. METHOD: We examine the need for an endotracheal tube (ETT) specifically designed for the critically-ill patient, the development of the LoTrach system from conception to production, and the role of the various components of the system in preventing VAP. Early issues in implementing this revolutionary equipment into ICU are explored and three case studies highlight advantages of this system. CONCLUSION: The LoTrach system has been designed to facilitate the provision of a number of evidence-based interventions that have been shown to reduce VAP. Pulmonary aspiration is ubiquitous with conventional cuffs but prevented by the cuff of the LoTrach system when held at a constant and safe pressure against the tracheal wall with a cuff pressure controller. Other aspects incorporated in the ETT are aimed at clearing the secretions from the subglottic space, preventing tube occlusion and accidental extubation, and avoiding damage to the airway. In this way the LoTrach system employs a multifactorial approach to the prevention of VAP and the cost savings from LoTrach rather than a standard ETT will be considerable because of an average 3 day reduction in ICU length of stay related to this. It thus has the potential to be a very useful tool in the ICU setting in the prevention of VAP.