Use of clinical decision support to improve the quality of care provided to older hospitalized patients.

BACKGROUND: Frail older inpatients are at risk of unintended adverse events while in hospital, particularly falls, functional decline, delirium and incontinence. OBJECTIVE: The aim of this pragmatic trial was to pilot and evaluate a multi-component knowledge translation intervention that incorporated a nurse-initiated computerized clinical decision support tool to reduce harms in the care of older medical inpatients. METHODS: A stepped wedge trial design was conducted on six medical units at two hospitals in Calgary, Alberta, Canada. The primary quantitative outcome was the rate of order set use. Secondary outcomes included the number of falls, the average number of days in hospital, and the total number of consults ordered for each of orthopedics, geriatrics, psychiatry and physiotherapy. Qualitative analysis included interviews with nurses to explore barriers and facilitators around the implementation of the electronic decision support tool. RESULTS: The estimated mean rate of order set use over a 2 week period was 3.1 (95% CI 1.9-5.3) sets higher after the intervention than before. The estimated odds of a fall happening on a unit over a 2-week period was 9.3 (p = 0.065) times higher before than after the intervention. There was no significant effect of the intervention on length of hospital stay (p = 0.67) or consults to related clinical services (all p <0.2). Interviews with front-line nurses and nurse managers/educators revealed that the order set is not being regularly ordered because its content is perceived as part of good nursing care and due to the high workload on these busy medical units. CONCLUSIONS: Although not statistically significant, a reduction in the number of falls as a result of the intervention was noted. Frontline users' engagement is crucial for the successful implementation of any decision support tool. New strategies of implementation will be evaluated before broad dissemination of this knowledge translation intervention.

Comparison of strength development with resistance training and combined exercise training in type 2 diabetes.

Resistance training has been shown to increase strength in type 2 diabetes; however, it is unclear if combining resistance and aerobic training (A + R) impedes strength development compared with resistance training only (R). The purpose of this study was to compare changes in strength with A + R vs R in individuals with type 2 diabetes. We evaluated monthly workload increments in participants from the Diabetes Aerobic and Resistance Exercise clinical trial. Muscular strength was assessed through training volumes and as the eight repetition maximum (8-RM) at 0, 3, and 6 months. Both groups increased their upper and lower body volumes monthly for 6 months. The relative increase in upper body workload in R was significantly greater than A + R at 4 months (161 ± 11% vs 127 ± 11%, P = 0.009) and at 6 months of training (177 ± 11% vs 132 ± 11%, P = 0.008). Both groups had improvements in 8-RM workloads at 3 and 6 months. The resistance training group had a significantly greater improvement in 8-RM on the leg press at 6 months compared with A + R (80 ± 11% vs 58 ± 8%, P = 0.045). Both R and A + R improved strength with a 6-month training program; however, increases in strength may be greater with resistance training alone compared with performing both aerobic and resistance training.

Associations between physical fitness and HbA1(c) in type 2 diabetes mellitus.

AIM/HYPOTHESIS: In people with type 2 diabetes, exercise improves glucose control (as reflected in HbA1(c)) and physical fitness, but it is not clear to what extent these exercise-induced improvements are correlated with one another. We hypothesised that reductions in HbA1(c) would be related: (1) to increases in aerobic fitness and strength respectively in patients performing aerobic training or resistance training; and (2) to changes in strength and aerobic fitness in patients performing aerobic and resistance training. METHODS: We randomly allocated 251 type 2 diabetes patients to aerobic, resistance, or aerobic plus resistance training, or to a sedentary control group. Peak oxygen consumption VO2(peak), workload, treadmill time and ventilatory threshold measurements from maximal treadmill exercise testing were measured at baseline and 6 months. Muscular strength was measured as the maximum weight that could be lifted eight times on the leg press, bench press and seated row exercises. RESULTS: With aerobic training, significant associations were found between changes in both VO2(peak) (p = 0.040) and workload (p = 0.022), and changes in HbA1(c.) With combined training, improvements in VO2(peak) (p = 0.008), workload (p = 0.034) and ventilatory threshold (p = 0.003) were significantly associated with changes in HbA1(c.) Increases in strength on the seated row (p = 0.006) and in mid-thigh muscle cross-sectional area (p = 0.030) were significantly associated with changes in HbA1(c) after resistance exercise, whereas the association between increases in muscle cross-sectional area and HbA1(c) in participants doing aerobic plus resistance exercise (p = 0.059) was of borderline significance. CONCLUSIONS/INTERPRETATION: There appears to be a link between changes in fitness and HbA1(c). The improvements in cardiorespiratory fitness with aerobic training may be a better predictor of changes in HbA1(c) than improvements in strength.

Predictors of outcome after temporal lobectomy for the treatment of intractable epilepsy.

To assess short- and long-term seizure freedom, the authors reviewed 371 patients who underwent anterior temporal lobectomy to treat pharmacoresistant epilepsy. The mean follow-up duration was 5.5 years (range 1 to 14.1 years). Fifty-three percent of patients were seizure free at 10 years. The authors identified multiple predictors of recurrence. Results of EEG performed 6 months postoperatively correlated with occurrence and severity of seizure recurrence, in addition to breakthrough seizures with discontinuation of antiepileptic drugs.

The effect of diverticular disease on the colonic J pouch.

OBJECTIVE: The aim of this study was to assess the impact of the diverticular disease (DD) on function and on postoperative complications of the colonic J-pouch (CJP) with pouch-anal anastomosis. METHODS: Patients who underwent a CJP between December 1990 and August 2001, were retrospectively reviewed. The presence of DD in the CJP was assessed on pouchogram prior to ileostomy closure. A questionnaire designed to evaluate the degree of continence (total incontinence score (IS): 0 = worst, 20 = best) and pouch evacuation (total evacuation score (ES): 0 = worst, 28 = best) was used for comparison between patients with DD and those without DD (NDD). RESULTS: Sixty-six patients (47 males; 19 females) with a median age of 68 years (range 28-87 years) were included. The median follow-up period was 22 months (range 2-106 months). Twenty-four patients comprised the DD group and 42 were in the NDD group. The two groups were comparable for age, gender and time from ileostomy closure; all patients with postoperative chemoradiation therapy were in the NDD group. The total ES and IS total did not significantly differ between the two groups with a P-value of 0.11 and 0.09 respectively. Furthermore, there was no significant difference in the total incidence of pouch complications between the two groups (3 strictures, 1 leak, 1 fistula in the NDD group vs. 1 pelvic sepsis in the DD group; P = 0.4). CONCLUSIONS: The presence of DD in a CJP does not seem to impact pouch function or the postoperative complication rate.