Comparison of the ClearSight™ finger cuff monitor versus invasive arterial blood pressure measurement in elective cardiac surgery patients: a prospective observational study.

PURPOSE: To determine the acceptability of the ClearSight™ system (Edwards Lifesciences Corp., Irvine, CA, USA) for continuous blood pressure monitoring during elective cardiac surgery compared with arterial catheterization. METHODS: We enrolled 30 patients undergoing elective cardiac surgery in a prospective observational study. Blood pressure measurements were recorded every 10 sec intraoperatively. We determined agreement based on the Association for the Advancement of Medical Instrumentation (AAMI) recommendations. Statistical analysis included fixed bias (difference of measurements between methods), percentage error (accuracy between ClearSight measurement and expected measurement from arterial line), and interchangeability (ability to substitute ClearSight monitor without effecting overall outcome of analysis). We used a paired samples t test to compare the time required for placing each monitor. RESULTS: We found fixed bias in the differences between the ClearSight monitor and invasive arterial blood pressure measurement in systolic blood pressure (SBP; mean difference, 8.7; P < 0.001) and diastolic blood pressure (DBP; mean difference, -2.2; P < 0.001), but not in mean arterial pressure (MAP; mean difference, -0.5; P < 0.001). Bland-Altman plots showed that the means of the limits of agreement were greater than 5 mm Hg for SBP, DBP, and MAP. The percentage errors for SBP, DBP, and MAP were lower than the cutoff we calculated from the invasive arterial blood pressure measurements. Average interchangeability rates were 38% for SBP, 50% for DBP, and 50% for MAP. Placement of the ClearSight finger cuff was significantly faster compared with arterial catheterization (mean [standard deviation], 1.7 [0.6] min vs 5.6 [4.1] min; P < 0.001). CONCLUSIONS: In this prospective observational study, we did not find the ClearSight system to be an acceptable substitute for invasive arterial blood pressure measurement in elective cardiac surgery patients according to AAMI guidelines. Nevertheless, based on statistical standards, there is evidence to suggest otherwise. STUDY REGISTRATION: ClinicalTrials.gov ( NCT05825937 ); first submitted 11 April 2023.

RéSUMé: OBJECTIF: Notre objectif était de déterminer l'acceptabilité du système ClearSight™ (Edwards Lifesciences Corp., Irvine, CA, USA) pour la surveillance continue de la tension artérielle pendant une chirurgie cardiaque non urgente par rapport au cathétérisme artériel. MéTHODE: Nous avons recruté 30 patient·es bénéficiant d'une chirurgie cardiaque non urgente pour une étude observationnelle prospective. Les mesures de la tension artérielle ont été enregistrées toutes les 10 sec en période peropératoire. Nous avons déterminé l'accord sur la base des recommandations de l'Association for the Advancement of Medical Instrumentation (AAMI). L'analyse statistique comprenait le biais fixe (différence de mesures entre les méthodes), le pourcentage d'erreur (précision entre la mesure ClearSight et la mesure attendue à partir de la ligne artérielle), et l'interchangeabilité (capacité de remplacer la mesure invasive par le moniteur ClearSight sans affecter le résultat global de l'analyse). Nous avons utilisé des échantillons t appariés pour comparer le temps nécessaire à la mise en place de chaque moniteur. RéSULTATS: Nous avons constaté un biais fixe dans les différences entre le moniteur ClearSight et la mesure invasive de la tension artérielle dans la tension artérielle systolique (TAS; différence moyenne, 8,7; P < 0,001) et la tension artérielle diastolique (TAD; différence moyenne, −2,2; P < 0,001), mais pas dans la tension artérielle moyenne (TAM; différence moyenne, −0,5; P < 0,001). Les graphiques de Bland-Altman ont montré que les moyennes des limites d'accord étaient supérieures à 5 mm Hg pour la TAS, la TAD et la TAM. Les pourcentages d'erreurs pour la TAS, la TAD et la TAM étaient inférieurs au seuil que nous avons calculé à partir des mesures invasives de la tension artérielle. Les taux d'interchangeabilité moyens étaient de 38 % pour la TAS, de 50 % pour la TAD et de 50 % pour la TAM. La mise en place du moniteur digital ClearSight a été significativement plus rapide que celle du cathétérisme artériel (moyenne [écart type], 1,7 [0,6] min vs 5,6 [4,1] min; P < 0,001). CONCLUSION: Dans cette étude observationnelle prospective, nous n'avons pas trouvé que le système ClearSight était un substitut acceptable à la mesure invasive de la tension artérielle chez les patient·es de chirurgie cardiaque non urgente, selon les directives de l'AAMI. Néanmoins, sur la base des normes statistiques, il existe des données probantes suggérant le contraire. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov ( NCT05825937 ); première soumission le 11 avril 2023.

Determining residual gastric volume in healthy children using ultrasound.

PURPOSE: Fasting guidelines for children recommend restricting clear fluids for one or two hours before a procedure to reduce pulmonary aspiration. Gastric volumes < 1.5 mL·kg-1 do not seem to present an increased risk of pulmonary aspiration. Our aim was to quantify the time to achieve a gastric volume < 1.5 mL·kg-1 after clear fluid ingestion in children. METHODS: We conducted a prospective observational study in healthy volunteers aged 1-14 yr. Participants followed American Society of Anesthesiologists fasting guidelines prior to data collection. Gastric ultrasound (US) was performed in the right lateral decubitus (RLD) position to determine the antral cross-sectional area (CSA). Following baseline measurements, participants consumed 250 mL of a clear fluid. We then performed gastric US at four time intervals: 30, 60, 90, and 120 min. Data were collected following a predictive model for gastric volume estimation using the formula: volume (mL) = -7.8 + (3.5 × RLD CSA) + (0.127) × age (months). RESULTS: We recruited 33 healthy children aged 2-14 yr. The mean gastric volume per weight (mL·kg-1) at baseline was 0.51 mL·kg-1 (95% confidence interval [CI], 0.46 to 0.57). The mean gastric volume was 1.55 mL·kg-1 (95% CI, 1.36 to 1.75) at 30 min, 1.17 mL·kg-1 (95% CI, 1.01 to 1.33) at 60 min, 0.76 mL·kg-1 (95% CI, 0.67 to 0.85) at 90 min, and 0.58 mL·kg-1 (95% CI, 0.52 to 0.65) at 120 min. CONCLUSION: Our results show that total gastric fluid volume was < 1.5 mL·kg-1 after 60 min, suggesting that current fasting guidelines for children could be liberalized.

RéSUMé: OBJECTIF: Les directives de jeûne pour les enfants recommandent de restreindre les liquides clairs pendant une ou deux heures avant une intervention pour réduire l'aspiration pulmonaire. Des volumes gastriques < 1,5 mL·kg−1 ne semblent pas présenter un risque accru d'aspiration pulmonaire. Notre objectif était de quantifier le temps nécessaire pour atteindre un volume gastrique < 1,5 mL·kg−1 après ingestion de liquides clairs chez les enfants. MéTHODE: Nous avons mené une étude observationnelle prospective chez des volontaires en bonne santé âgé·es de 1 à 14 ans. Les participant·es ont suivi les directives de jeûne de l'American Society of Anesthesiologists avant la collecte de données. L'échographie gastrique a été réalisée en décubitus latéral droit (DLD) pour déterminer la section transversale antrale. Après les mesures initiales, les participant·es ont consommé 250 mL d'un liquide clair. Nous avons ensuite réalisé une échographie gastrique à quatre intervalles de temps : 30, 60, 90 et 120 minutes. Les données ont été recueillies selon un modèle prédictif pour l'estimation du volume gastrique à l'aide de la formule : volume (mL) = −7,8 + (3,5 × section transversale antrale en DLD) + (0,127) × âge (mois). RéSULTATS: Nous avons recruté 33 enfants en bonne santé âgé·es de 2 à 14 ans. Le volume gastrique moyen par poids (mL·kg−1) au début de l'intervention était de 0,51 mL·kg−1 (intervalle de confiance [IC] à 95 %, 0,46 à 0,57). Le volume gastrique moyen était de 1,55 mL·kg−1 (IC 95 %, 1,36 à 1,75) à 30 min, 1,17 mL·kg−1 (IC 95 %, 1,01 à 1,33) à 60 min, 0,76 mL·kg−1 (IC 95 %, 0,67 à 0,85) à 90 min, et 0,58 mL·kg−1 (IC 95 %, 0,52 à 0,65) à 120 min. CONCLUSION: Nos résultats montrent que le volume total de liquide gastrique était < 1,5 mL·kg−1 après 60 min, suggérant que les directives actuelles de jeûne pour les enfants pourraient être libéralisées.

The influence of welfare spending on national immunization outcomes: A scoping review.

Background: National policies influence the environments in which people live, but the ways in which these national policies influence people's health are not well understood. Welfare spending is one national policy that may influence population health. While some research indicates higher levels of welfare investment may positively influence health, mixed findings contradict this conclusion. These mixed results examining the link between welfare policies and health may be better understood by investigating the relationship between welfare spending and preventative health interventions, such as immunization. Objective: This article's purpose is to summarize the literature studying the relationship between national welfare spending and immunization outcomes. Design: This scoping review used the Joanna Briggs scoping review method. Data sources: The scoping review utilized scholarly databases and a focused gray literature search to find research articles that explored relationships between welfare spending and immunization outcomes. Review methods: Data was extracted from articles, including themes, aims, populations, years of study, methods, and findings. The articles' themes were further analyzed with a word cloud and principal component analysis to determine which themes were more likely to coincide in the literature. Results: Seven articles were included in the review. Most of these articles did not address the relationship between welfare spending or policy and immunizations directly or with rigorous methods. Conclusions: Ultimately, the results of the scoping review suggest a lack of literature regarding the relationship between welfare spending and immunization outcomes. Further research is needed to understand the impacts of national welfare spending on immunization outcomes.

Intervention to reduce transmission of resistant bacteria in intensive care.

BACKGROUND: Intensive care units (ICUs) are high-risk settings for the transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). METHODS: In a cluster-randomized trial, we evaluated the effect of surveillance for MRSA and VRE colonization and of the expanded use of barrier precautions (intervention) as compared with existing practice (control) on the incidence of MRSA or VRE colonization or infection in adult ICUs. Surveillance cultures were obtained from patients in all participating ICUs; the results were reported only to ICUs assigned to the intervention. In intervention ICUs, patients who were colonized or infected with MRSA or VRE were assigned to care with contact precautions; all the other patients were assigned to care with universal gloving until their discharge or until surveillance cultures obtained at admission were reported to be negative. RESULTS: During a 6-month intervention period, there were 5434 admissions to 10 intervention ICUs, and 3705 admissions to 8 control ICUs. Patients who were colonized or infected with MRSA or VRE were assigned to barrier precautions more frequently in intervention ICUs than in control ICUs (a median of 92% of ICU days with either contact precautions or universal gloving [51% with contact precautions and 43% with universal gloving] in intervention ICUs vs. a median of 38% of ICU days with contact precautions in control ICUs, P<0.001). In intervention ICUs, health care providers used clean gloves, gowns, and hand hygiene less frequently than required for contacts with patients assigned to barrier precautions; when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts, and when universal gloving was specified, gloves were used for a median of 72% of contacts and hand hygiene after 62% of contacts. The mean (±SE) ICU-level incidence of events of colonization or infection with MRSA or VRE per 1000 patient-days at risk, adjusted for baseline incidence, did not differ significantly between the intervention and control ICUs (40.4±3.3 and 35.6±3.7 in the two groups, respectively; P=0.35). CONCLUSIONS: The intervention was not effective in reducing the transmission of MRSA or VRE, although the use of barrier precautions by providers was less than what was required. (Funded by the National Institute of Allergy and Infectious Diseases and others; STAR*ICU ClinicalTrials.gov number, NCT00100386.).

The Quality of Assessment for Learning score for evaluating written feedback in anesthesiology postgraduate medical education: a generalizability and decision study.

Background: Competency based residency programs depend on high quality feedback from the assessment of entrustable professional activities (EPA). The Quality of Assessment for Learning (QuAL) score is a tool developed to rate the quality of narrative comments in workplace-based assessments; it has validity evidence for scoring the quality of narrative feedback provided to emergency medicine residents, but it is unknown whether the QuAL score is reliable in the assessment of narrative feedback in other postgraduate programs. Methods: Fifty sets of EPA narratives from a single academic year at our competency based medical education post-graduate anesthesia program were selected by stratified sampling within defined parameters [e.g. resident gender and stage of training, assessor gender, Competency By Design training level, and word count (≥17 or <17 words)]. Two competency committee members and two medical students rated the quality of narrative feedback using a utility score and QuAL score. We used Kendall's tau-b co-efficient to compare the perceived utility of the written feedback to the quality assessed with the QuAL score. The authors used generalizability and decision studies to estimate the reliability and generalizability coefficients. Results: Both the faculty's utility scores and QuAL scores (r = 0.646, p < 0.001) and the trainees' utility scores and QuAL scores (r = 0.667, p < 0.001) were moderately correlated. Results from the generalizability studies showed that utility scores were reliable with two raters for both faculty (Epsilon=0.87, Phi=0.86) and trainees (Epsilon=0.88, Phi=0.88). Conclusions: The QuAL score is correlated with faculty- and trainee-rated utility of anesthesia EPA feedback. Both faculty and trainees can reliability apply the QuAL score to anesthesia EPA narrative feedback. This tool has the potential to be used for faculty development and program evaluation in Competency Based Medical Education. Other programs could consider replicating our study in their specialty.

Contexte: La qualité de la rétroaction à la suite de l'évaluation d'activités professionnelles confiables (APC) est d'une importance capitale dans les programmes de résidence fondés sur les compétences. Le score QuAL (Quality of Assessment for Learning) est un outil développé pour évaluer la qualité de la rétroaction narrative dans les évaluations en milieu de travail. Sa validité a été démontrée dans le cas des commentaires narratifs fournis aux résidents en médecine d'urgence, mais sa fiabilité n'a pas été évaluée dans d'autres programmes de formation postdoctorale. Méthodes: Cinquante ensembles de commentaires portant sur des APC d'une seule année universitaire dans notre programme postdoctoral en anesthésiologie ­ un programme fondé sur les compétences ­ ont été sélectionnés par échantillonnage stratifié selon des paramètres préétablis [par exemple, le sexe du résident et son niveau de formation, le sexe de l'évaluateur, le niveau de formation en Compétence par conception, et le nombre de mots (≥17 ou <17 mots)]. Deux membres du comité de compétence et deux étudiants en médecine ont évalué la qualité de la rétroaction narrative à l'aide d'un score d'utilité et d'un score QuAL. Nous avons utilisé le coefficient tau-b de Kendall pour comparer l'utilité perçue de la rétroaction écrite et sa qualité évaluée à l'aide du score QuAL. Les auteurs ont utilisé des études de généralisabilité et de décision pour estimer les coefficients de fiabilité et de généralisabilité. Résultats: Les scores d'utilité et les scores QuAL des enseignants (r = 0,646, p < 0,001) et ceux des étudiants (r = 0,667, p < 0,001) étaient modérément corrélés. Les résultats des études de généralisabilité ont montré qu'avec deux évaluateurs les scores d'utilité étaient fiables tant pour les enseignants (Epsilon=0,87, Phi=0,86) que pour les étudiants (Epsilon=0,88, Phi=0,88). Conclusions: Le score QuAL est en corrélation avec l'utilité de la rétroaction sur les APC en anesthésiologie évaluée par les enseignants et les étudiants. Les uns et les autres peuvent appliquer de manière fiable le score QuAL aux commentaires narratifs sur les APC en anesthésiologie. Cet outil pourrait être utilisé pour le perfectionnement professoral et l'évaluation des programmes dans le cadre d'une formation médicale fondée sur les compétences. D'autres programmes pourraient envisager de reproduire notre étude dans leur spécialité.

Discordant pathologic diagnoses of myelodysplastic neoplasms and their implications for registries and therapies.

Myelodysplastic neoplasms (MDS) are a collection of hematopoietic disorders with widely variable prognoses and treatment options. Accurate pathologic diagnoses present challenges because of interobserver variability in interpreting morphology and quantifying dysplasia. We compared local clinical site diagnoses with central, adjudicated review from 918 participants enrolled in the ongoing National Heart, Lung, and Blood Institute National MDS Natural History Study, a prospective observational cohort study of participants with suspected MDS or MDS/myeloproliferative neoplasms (MPNs). Locally, 264 (29%) were diagnosed as having MDS, 15 (2%) MDS/MPN overlap, 62 (7%) idiopathic cytopenia of undetermined significance (ICUS), 0 (0%) acute myeloid leukemia (AML) with <30% blasts, and 577 (63%) as other. Approximately one-third of cases were reclassified after central review, with 266 (29%) diagnosed as MDS, 45 (5%) MDS/MPN overlap, 49 (5%) ICUS, 15 (2%) AML with <30%, and 543 (59%) as other. Site miscoding errors accounted for more than half (53%) of the local misdiagnoses, leaving a true misdiagnosis rate of 15% overall, 21% for MDS. Therapies were reported in 37% of patients, including 43% of patients with MDS, 49% of patients with MDS/MPN, and 86% of patients with AML with <30% blasts. Treatment rates were lower (25%) in cases with true discordance in diagnosis compared with those for whom local and central diagnoses agreed (40%), and receipt of inappropriate therapy occurred in 7% of misdiagnosed cases. Discordant diagnoses were frequent, which has implications for the accuracy of study-related and national registries and can lead to inappropriate therapy. This trial was registered at www.clinicaltrials.gov as #NCT05074550.

Economist intelligence unit democracy index in relation to health services accessibility: a regression analysis.

BACKGROUND: The relationship between political environment and health services accessibility (HSA) has not been the focus of any specific studies. The purpose of this study was to address this gap in the literature by examining the relationship between political environment and HSA. METHODS: This relationship that HSA indicators (physicians, nurses and hospital beds per 10 000 people) has with political environment was analyzed with multiple least-squares regression using the components of democracy (electoral processes and pluralism, functioning of government, political participation, political culture, and civil liberties). The components of democracy were represented by the 2011 Economist Intelligence Unit Democracy Index (EIUDI) sub-scores. The EIUDI sub-scores and the HSA indicators were evaluated for significant relationships with multiple least-squares regression. RESULTS: While controlling for a country's geographic location and level of democracy, we found that two components of a nation's political environment: functioning of government and political participation, and their interaction had significant relationships with the three HSA indicators. CONCLUSIONS: These study findings are of significance to health professionals because they examine the political contexts in which citizens access health services, they come from research that is the first of its kind, and they help explain the effect political environment has on health.

Qualities of exemplary nurse leaders: perspectives of frontline nurses.

AIM:  This paper reports on a study that looked at the characteristics of exemplary nurse leaders in times of change from the perspective of frontline nurses. BACKGROUND:  Large-scale changes in the health care system and their associated challenges have highlighted the need for strong leadership at the front line. METHODS:  In-depth personal interviews with open-ended questions were the primary means of data collection. The study identified and explored six frontline nurses' perceptions of the qualities of nursing leaders through qualitative content analysis. This study was validated by results from the current literature. RESULTS:  The frontline nurses described several common characteristics of exemplary nurse leaders, including: a passion for nursing; a sense of optimism; the ability to form personal connections with their staff; excellent role modelling and mentorship; and the ability to manage crisis while guided by a set of moral principles. All of these characteristics pervade the current literature regarding frontline nurses' perspectives on nurse leaders. CONCLUSION:  This study identified characteristics of nurse leaders that allowed them to effectively assist and support frontline nurses in the clinical setting. IMPLICATIONS FOR NURSING MANAGEMENT:  The findings are of significance to leaders in the health care system and in the nursing profession who are in a position to foster development of leaders to mentor and encourage frontline nurses.