How can social workers facilitate suicide prevention in primary care? Findings from a national survey of primary care physicians.

There are currently no national data regarding U.S. Primary Care Physicians' (PCPs') suicide screening practices. This study surveyed 302 U.S. PCPs about their current suicide screening practices to identify service gaps and intervention points for social workers. Although one-third of PCPs reported providing screening and safety planning, few were using evidence-based tools. Factors that increased the likelihood of routine screening were belief in the importance of screening (p < .01), time (p < .01), and access to co-located behavioral health (p < .01). Findings support the role of social workers in primary care and suggest areas for training and collaboration.

Perceptions of resuscitation care among in-hospital cardiac arrest responders: a qualitative analysis.

BACKGROUND: In-hospital cardiac arrests (IHCA) occur commonly and are associated with poor survival and variable outcomes. This study aimed to directly survey IHCA responders to understand their perceptions of resuscitation care. METHODS: As part of a quality improvement initiative, we surveyed participating providers of IHCAs at our institution from Jan 2014 to May 2016. The survey included unstructured free text feedback, which was the focus of this study. We systematically coded the free text and organized identifiable latent themes using thematic analysis. We used the natural timeline of an IHCA - pre-arrest, arrest, and post-arrest - for organization of the identifiable latent themes, and created a separate category for holistic remarks that arched across the timeline. RESULTS: We identified 172 IHCAs with a mean of 1.7 responses per arrest (range: 1-8 responses). The mean age of this patient population was 59 years at the time of arrest, and 107 (62%) were men. We identified several themes - [1] issues around code activation and code status characterized the pre-arrest period [2] ,team interactions and issues around supplies/equipment dominated the intra-arrest period, and [3] code cessation and transitions of care typified the post-arrest period. Holistic remarks focused on attentiveness paid by the arrest team to patient comfort and family. Some comments reflected positive experiences but most focused on areas of improvement consistent with the initiative's purpose. In certain cases, we identified a tension between the need to balance established resuscitation protocols with flexibility required by real-life circumstances. CONCLUSIONS: Directly surveying those who participated in IHCAs led to novel insights about their experiences. Our findings suggest that parsing through such qualitative feedback can help hospitals identify areas of improvement, modulate expectations, temper emotions, and refine protocols.

STRONG-D: Strength training regimen for normal weight diabetics: Rationale and design.

BACKGROUND: Currently, there is a lack of data on effective lifestyle recommendations for normal-weight diabetics (NWD), who can represent up to 1 in 5 individuals with Type II Diabetes Mellitus (T2DM). NWD is especially prevalent in Asian populations and the elderly. Specific exercise treatment recommendations are needed for patients with normal-weight diabetes (NWD), as those in this category face higher mortality rates than overweight and obese diabetics. Standard T2DM treatment recommends aerobic training; however, performing aerobic training alone may not be appropriate for NWD and strength training may be a more effective treatment recommendation. OBJECTIVE: While it is known that strength and aerobic training are beneficial in obese diabetics, there is currently insufficient evidence to recommend this regimen in NWD. The Strength Training Regimen for Normal Weight Diabetics (STRONG-D) study aims to determine the best exercise regimen for NWD and address the current lack of appropriate physical activity recommendations for this population. The primary goal of this study is to determine whether strength training aids glycemic control better than aerobic training in NWD. STUDY DESIGN: STRONG-D is a three-arm randomized controlled trial designed to compare the clinical effectiveness of structured strength training only, aerobic training only, and combination (strength + aerobic) training sessions, modeled after the intervention in the Health Benefits of Aerobic and Resistance Training in T2DM patients (HART-D) study. Potential participants meeting eligibility criteria of HbA1c values of 6.5% to 13.0% and BMI of 18.5 kg/m2 to 25 kg/m2 will be enrolled. After randomization, participants will begin a 9-month exercise intervention. The primary outcomes will be HbA1c levels. The secondary endpoints will include physical fitness, body composition measured by Dual X-Ray Absorptiometry (DXA) scans, and leg strength and endurance measured by Biodex testing. Initial follow-up visits will occur at 3 months, 6 months, and 9 months. To determine the long-term effects of the exercise intervention, passive follow-up will continue via electronic health records (EHR) until a 24-month follow-up visit. A total of 282 participants will be randomized into the three study arms determine the clinically significant differences between strength-only, aerobic-only and combination regimens.

Evaluating the clinical implementation of structured exercise: A randomized controlled trial among non-insulin dependent type II diabetics.

BACKGROUND: The American Diabetes Association (ADA) currently recommends 150 min of moderate-intensity aerobic exercise per week and resistance exercise at least twice per week in individuals with type 2 diabetes (T2DM) to improve overall health [1]. However, approximately 38% of patients with T2DM do not exercise at recommended levels and 31% do not exercise at all [2]. The efficacy of structured exercise interventions has been proven effective in reducing glycosylated hemoglobin A1c (HbA1c) levels in patients, but practical approaches are needed to translate these findings into the clinical setting [3-7]. OBJECTIVE: The Initiate and Maintain Physical Activity in Clinics (IMPACT) Study aims to compare structured group exercise within the clinic to usual care in T2DM patients. The main purpose of the study is to determine the optimal and feasible level and weekly frequency of structured contact in a clinical setting needed to initiate and maintain physical activity recommendations long-term. STUDY DESIGN: IMPACT is a longitudinal, randomized-controlled study designed to track study participants over 30 months. Once study participants have met eligibility and enrollment criteria, they are randomized and enrolled into one of three arms: 1× per week exercise, 3× per week exercise, or the usual care control group. After randomization, participants begin Phase 1: Initiate lasting 6 months. Over the course of Phase 1, participants in the exercise groups will attend instructor led group training at a Stanford approved physical fitness facility. At the end of 6 months, participants enter Phase 2: Maintain lasting 24 months. Over the course of Phase 2, participants in all three arms will attend periodic follow-up visits for clinical measurements and survey administration for their final two years of participation. These findings will enable the clinical implementation of a structured exercise regimen designed to specifically address the aerobic and resistance training recommendations for patients with T2DM.

Sleep-wake cycling and cerebral oxygen metabolism among critically ill neonates.

Among adults, wakefulness and rapid eye movement (REM) sleep, compared to non-REM sleep, require higher overall brain metabolism, but in neonates analogous data are not available. Behavioral states with higher metabolic demand could increase vulnerability to hypoperfusion or hypoxia in the compromised neonatal brain. Using cerebral oximetry (near-infrared spectroscopy), and simultaneous polysomnography, we evaluated whether brain oxygen metabolism varies by sleep-wake state among critically ill newborns. For each of 10 infants, sleep-wake cycling was detectable and cerebral oximetry varied (P < .0001) across behavioral states, but the patterns differed among subjects. We conclude that cerebral oxygen metabolism varies with sleep-wake states in high-risk newborns. The direction and degree of these changes are variable and subject-specific in this initial sample, but could reflect or affect brain injury and vulnerability.

Limited short-term prognostic utility of cerebral NIRS during neonatal therapeutic hypothermia.

OBJECTIVE: We evaluated the utility of amplitude-integrated EEG (aEEG) and regional oxygen saturation (rSO2) measured using near-infrared spectroscopy (NIRS) for short-term outcome prediction in neonates with hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia. METHODS: Neonates with HIE were monitored with dual-channel aEEG, bilateral cerebral NIRS, and systemic NIRS throughout cooling and rewarming. The short-term outcome measure was a composite of neurologic examination and brain MRI scores at 7 to 10 days. Multiple regression models were developed to assess NIRS and aEEG recorded during the 6 hours before rewarming and the 6-hour rewarming period as predictors of short-term outcome. RESULTS: Twenty-one infants, mean gestational age 38.8 ± 1.6 weeks, median 10-minute Apgar score 4 (range 0-8), and mean initial pH 6.92 ± 0.19, were enrolled. Before rewarming, the most parsimonious model included 4 parameters (adjusted R(2) = 0.59; p = 0.006): lower values of systemic rSO2 variability (p = 0.004), aEEG bandwidth variability (p = 0.019), and mean aEEG upper margin (p = 0.006), combined with higher mean aEEG bandwidth (worse discontinuity; p = 0.013), predicted worse short-term outcome. During rewarming, lower systemic rSO2 variability (p = 0.007) and depressed aEEG lower margin (p = 0.034) were associated with worse outcome (model-adjusted R(2) = 0.49; p = 0.005). Cerebral NIRS data did not contribute to either model. CONCLUSIONS: During day 3 of cooling and during rewarming, loss of physiologic variability (by systemic NIRS) and invariant, discontinuous aEEG patterns predict poor short-term outcome in neonates with HIE. These parameters, but not cerebral NIRS, may be useful to identify infants suitable for studies of adjuvant neuroprotective therapies or modification of the duration of cooling and/or rewarming.

Does public health nurse home visitation make a difference in the health outcomes of pregnant clients and their offspring?

Public health nurses (PHNs) at Lincoln-Lancaster County Health Department have used the Care Pathway tool to track client progress. Conceptually similar to critical pathways used in hospital settings, the Care Pathway is used by the PHN to document milestones of progress by trimester of pregnancy. Data for this research was gathered from chart review of 55 prenatal clients. Study results demonstrate that subjects who had from five to nine home visits by a PHN during pregnancy showed a higher average hemoglobin for the mothers and a higher average birthweight for the babies than those visited four or fewer times. None of the low birthweight babies was born to mothers in the "more visits" category. Furthermore, more breastfeeding was recorded for those who had received more PHN visits. This documentation enabled us to describe better the referent population and to begin to estimate the effect of PHN home visitation on the health outcomes of clients. In essence, we addressed the questions: (1) "Does PHN home visitation make a difference in health outcomes of clients and their families?" and (2) "If so, how can effects be measured?"