Examining the implementation of facility-based integrated management of childhood illness and insecticide treated nets in Bangladesh: lessons learned through implementation research.

BACKGROUND: Bangladesh significantly reduced under-5 mortality (U5M) between 2000 and 2015, despite its low economic development and projected high mortality rates in children aged under 5 years. A portion of this success was due to implementation of health systems-delivered evidence-based interventions (EBIs) known to reduce U5M. This study aims to understand how Bangladesh was able to achieve this success between 2000 and 2015. Implementation science studies such as this one provide insights on the implementation process that are not sufficiently documented in existing literature. METHODS: Between 2017 and 2020, we conducted mixed methods implementation research case studies to examine how six countries including Bangladesh outperformed their regional and economic peers in reducing U5M. Using existing data and reports supplemented by key informant interviews, we studied key implementation strategies and associated implementation outcomes for selected EBIs and contextual factors which facilitated or hindered this work. We used facility-based integrated management of childhood illnesses and insecticide treated nets as examples of two EBIs that were implemented successfully and with wide reach across the country to understand the strategies put in place as well as the facilitating and challenging contextual factors. RESULTS: Strategies which contributed to the successful implementation and wide coverage of the selected EBIs included community engagement, data use, and small-scale testing, important to achieving implementation outcomes such as effectiveness, reach and fidelity, although gaps persisted including in quality of care. Key contextual factors including a strong community-based health system, accountable leadership, and female empowerment facilitated implementation of these EBIs. Challenges included human resources for health, dependence on donor funding and poor service quality in the private sector. CONCLUSION: As countries work to reduce U5M, they should build strong community health systems, follow global guidance, adapt their implementation using local evidence as well as build sustainability into their programs. Strategies need to leverage facilitating contextual factors while addressing challenging ones.

Integrated Management of Childhood Illness implementation in Nepal: understanding strategies, context, and outcomes.

BACKGROUND: Health system-delivered evidence-based interventions (EBIs) are important to reducing amenable under-5 mortality (U5M). Implementation research (IR) can reduce knowledge gaps and decrease lags between new knowledge and its implementation in real world settings. IR can also help understand contextual factors and strategies useful to adapting EBIs and their implementation to local settings. Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). We use IR to identify strategies used in Nepal's adaptation and implementation of IMCI. METHODS: We conducted a mixed methods case study using an implementation research framework developed to understand how Nepal outperformed its peers between 2000-2015 in implementing health system-delivered EBIs known to reduce amenable U5M. We combined review of existing literature and data supplemented by 21 key informant interviews with policymakers and implementers, to understand implementation strategies and contextual factors that affected implementation outcomes. We extracted relevant results from the case study and used explanatory mixed methods to understand how and why Nepal had successes and challenges in adapting and implementing one EBI, IMCI. RESULTS: Strategies chosen and adapted to meet Nepal's specific context included leveraging local research to inform national decision-makers, pilot testing, partner engagement, and building on and integrating with the existing community health system. These cross-cutting strategies benefited from facilitating factors included community health system and structure, culture of data use, and local research capacity. Geography was a critical barrier and while substantial drops in U5M were seen in both the highest and lowest wealth quintiles, with the wealth equity gap decreasing from 73 to 39 per 1,000 live births from 2001 to 2016, substantial geographic inequities remained. CONCLUSIONS: Nepal's story shows that implementation strategies that are available across contexts were key to adopting and adapting IMCI and achieving outcomes including acceptability, effectiveness, and reach. The value of choosing strategies that leverage facilitating factors such as investments in community-based and facility-based approaches as well as addressing barriers such as geography are useful lessons for countries working to accelerate adaptation and implementation of strategies to implement EBIs to continue achieving child health targets.

Alcohol and cannabis use among women with infertility: associations with psychiatric symptoms, attempts to conceive, and engagement in fertility treatment.

Little is known about substance use among women with infertility, yet substance use has implications for fertility and pregnancy. The purpose was to estimate the prevalence of substance use among women with infertility and examine whether substance use was associated with psychiatric symptoms, active attempts to conceive, and engagement in fertility treatments. Eligible patients were from a single healthcare system who received a female infertility diagnosis within the past 2 years. Participants (n = 188) completed an online questionnaire regarding substance use, psychiatric symptoms, attempts to conceive, and fertility treatments. The prevalence of hazardous alcohol use, any cannabis use, and hazardous cannabis use were 30.3%, 30.9%, and 8.5%, respectively. Hazardous alcohol use was not associated with psychiatric symptoms (p > .05). Those with any cannabis use were more likely to have higher depression scores than those without (p = .02). Those with hazardous cannabis use were more likely to have higher depression scores (p = .001) and higher anxiety scores (p = .03). Substance use was not associated with actively trying to conceive. Those pursuing fertility treatments had a lower percentage engaging in hazardous alcohol use compared to those not pursuing fertility treatments (19.0% vs. 36.3%, p = .02). Substance use among women with infertility is common. Hazardous cannabis use was associated with greater psychiatric symptoms, suggesting that cannabis may be used to cope with distress. Pursuing fertility treatments may serve as a protective factor for hazardous alcohol use. Clinicians treating patients with infertility may want to screen for substance use.

Trends in the Utilization of Herbal and Dietary Supplements in Patients with Chronic Liver Disease During the SARS-CoV2 Pandemic.

Background: We studied the pattern of herbal and dietary supplement (HDS) use in patients with chronic liver disease (CLD) during the first year of the COVID-19 pandemic. Methods: A questionnaire/survey was sent to hepatology patients with CLD under the care of hepatologists at Johns Hopkins University School of Medicine. Results: The 5 most taken dietary supplements during the pandemic included vitamin B12 (27.7%), vitamin C (32.4%), vitamin D (54.6%), zinc (25.4%) and green tea extract (20.8%). Most participants (82.3%) did not discuss their HDS use with their hepatology providers. Conclusions: Healthcare providers should be mindful of potential HDS use in patients with CLD.

Pulmonary injury after radioactive iodine therapy in pediatric papillary thyroid cancer: a case report.

INTRODUCTION: Radiation-induced lung injury is a rare complication of radioactive iodine therapy (RAIT) in pediatric thyroid cancer treatment. In this case report, we describe a pediatric patient with an ERC1::RET-positive classic papillary thyroid carcinoma who developed progressive respiratory symptoms and chest imaging abnormalities following RAIT for lymph node and pulmonary disease. CASE PRESENTATION: A pediatric patient with ERC1::RET-positive classic papillary thyroid carcinoma was hospitalized for pulmonary decompensation three months following one empiric dose of RAIT. Testing revealed no evidence of infection or progression of pulmonary metastases, and there was no improvement with empiric antibiotic therapy for pneumonia. Despite empiric anti-inflammatory therapies, the patient remains symptomatic from a respiratory standpoint with requirement for supplemental oxygen and evidence of fibrotic changes on chest imaging. CONCLUSIONS: This patient's pulmonary condition is consistent with radiation-induced pulmonary injury including development of pulmonary fibrosis. With the availability of RET fusion targeted inhibitors, this case highlights a rare pulmonary side effect of radioactive iodine for clinicians to recognize. Upfront targeted therapy protocols may help avoid radioactive iodine-associated adverse reactions.

The efficacy and safety of cannabidiol as adjunct treatment for drug-resistant idiopathic epilepsy in 51 dogs: A double-blinded crossover study.

BACKGROUND: Approximately 30% of dogs with idiopathic epilepsy (IE) are drug-resistant. Recent studies have suggested cannabidiol (CBD) may be an effective anticonvulsant in dogs with IE. OBJECTIVE: To evaluate the addition of CBD to antiseizure drugs (ASDs) on seizure frequency and to report adverse events in dogs with drug-resistant IE. ANIMALS: Fifty-one dogs. Dogs having at least 2 seizures per month while receiving at least 1 ASD were included in the trial. METHODS: Double-blinded placebo-controlled crossover study. The 5 mg/kg/day dosage met futility requirements after 12 dogs, and a dosage of 9 mg/kg/day was used in the next 39 dogs. Dogs were randomly assigned to receive CBD or placebo for 3 months, with a 1-month washout period between oils. Total numbers of seizures and seizure days were recorded. Diagnostic testing was performed periodically throughout the trial. RESULTS: At the 9 mg/kg/day dose, the decrease in total seizure frequency was significant compared with placebo. A 24.1% decrease in seizure days occurred in dogs receiving CBD and a 5.8% increase occurred in dogs receiving placebo (P ≤ .05). No significant difference was found in the number of responders (≥50% decrease in total seizures or seizure days). Liver enzyme activities increased at both dosages. Decreased appetite and vomiting were more common in the CBD phase (P ≤ .05). CONCLUSIONS AND CLINICAL IMPORTANCE: Cannabidiol decreased total seizures and seizure days compared to placebo when administered to dogs PO at 9 mg/kg/day. Liver enzymes should be monitored with administration of CBD in dogs.

Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People.

Importance: Postpartum transfusion is the most common indicator of severe maternal morbidity in the US. Higher rates of anemia are associated with a higher blood transfusion rate. Objective: To determine if providing, rather than recommending, supplements with iron at prenatal visits in a medically underserved community is associated with improved hematologic indices and reduced blood transfusion. Design, Setting, and Participants: In this quality improvement study, patients who delivered between May 13 and December 13, 2020, and thus were provided a prenatal supplement with iron throughout pregnancy were compared with those who delivered between January 1 and August 1, 2019, before supplements were dispensed. The study was conducted at Parkland Health, a safety net hospital in Dallas, Texas, with a 95% Medicaid-funded or self-pay population and included all patients who delivered at our institution during the study period with available hematologic data. Exposures: In the earlier cohort, all patients were recommended to obtain and take iron supplements. In the later cohort, prenatal supplements with iron were dispensed via clinic pharmacy to all patients during prenatal visits. Main Outcomes and Measures: Maternal hematocrit levels (28-32 weeks, delivery admission, and discharge), rates of anemia (hematocrit <30%), and postpartum transfusion for acute blood loss anemia were compared using χ2 and analysis of variance methods with P < .05 considered significant. The analysis took place in July of 2022. Results: Overall, 13 910 patients (98%) met inclusion criteria (mean age [SD], 27.9 [6.5] and 27.6 [6.5] years, mean [SD] body mass index at first visit, 29.2 [6.6] and 29.3 [6.6]). Mosty of the patients in both cohorts were of Hispanic ethnicity (76%). Providing iron-containing prenatal supplements was associated with higher average hematocrit levels at all time points including a mean difference of 1.27% (95% CI, 1.13%-1.42%) on admission for delivery, when compared with those who were not directly dispensed iron. Among patients prior to providing supplements, 18% had anemia on admission compared with 11% with iron-containing supplements dispensed (risk ratio [RR], 0.61; 95% CI, 0.56-0.66). Postpartum transfusion for acute blood loss anemia was reduced by one-third in patients after program implementation from 10 per 1000 to 6.6 per 1000 (RR, 0.62; 95% CI, 0.43-0.91). Conclusions and Relevance: In this quality improvement study, providing supplements with iron to patients at prenatal visits was associated with improved hematocrit levels, rates of anemia, and reduced transfusions unrelated to obstetric catastrophes among a predominantly Medicaid population.

Integrating Spirituality and Religious Beliefs in a Mindfulness Based Cognitive Behavioral Therapy for PTSD with Latinx Unaccompanied Immigrant Children.

Purpose: Unaccompanied immigrant children (UIC) experience significant mental health concerns, particularly posttraumatic stress. This is a vulnerable population, yet little systematic research has examined the effectiveness of evidence-based models such as cognitive behavioral therapy (CBT) to meet their needs. Integrating religious beliefs and spirituality into therapy could elucidate better understandings of traumatic stress, and posttraumatic cognitions when working with UIC with strong faith traditions/beliefs. Methods: We report on modifications made to a pre-existing treatment, consisting of integrating religious and spiritual themes, to engage and work with UIC participants in a pilot study of Mindfulness-Based CBT. Thematic analysis of therapy notes evaluated the implementation process for integrating religious and spiritual themes. Three composite vignettes illustrate how religiosity and spirituality were salient for UIC participants in this pilot study, and how these were integrated into therapy to address posttraumatic cognitions and symptoms. We assessed changes in PTSD symptom severity and posttraumatic cognitions for UIC and in comparison, to non-UIC participants using the Child PTSD Symptom Scale and the Posttraumatic Cognitions Inventory. Results: Religiosity and spirituality were important for coping and conceptualizations of trauma, served as facilitators for engaging UIC in therapy, and related to improving posttraumatic cognitions and symptoms. Conclusion: Religious identity and spirituality can be important for meaning making, trauma cognitions and symptoms, and can be important to explore in therapy with unaccompanied immigrant children and adolescents. Clinical Trial Registration: Not applicable.

National Trends in Third-Line Treatment for Overactive Bladder Among Commercially Insured Women, 2010-2019.

OBJECTIVE: To investigate whether the 2010 introduction of percutaneous tibial nerve stimulation and the 2013 introduction of intradetrusor onabotulinumtoxinA were associated with an increase in overall utilization of third-line treatments. METHODS: Using medical claims data from IBM Marketscan database 2010-2019, diagnosis codes were used to identify adult women with overactive bladder. Procedure codes were used to identify third-line treatments. The annual proportion of patients receiving third-line treatments was calculated, as well as the proportion of each treatment received. These were modeled as a function of treatment year using linear regression; a regression coefficient significantly different from 0 was considered evidence of a significant change in utilization over time. RESULTS: We identified 3,067,515 unique individuals with a diagnosis of overactive bladder, including 14,652 who initiated third-line treatments. The annual percentage of women with overactive bladder who initiated third-line treatment was 0.18% and did not change significantly over 10 years (P = .82). However, the proportion receiving sacral neuromodulation decreased significantly (P <.001), with a compensatory increase in intradetrusor onabotulinumtoxinA. Within 6 years of its introduction, onabotulinumtoxinA accounted for almost half of third-line treatments initiated. CONCLUSION: Overall, third-line therapies for non-neurogenic overactive bladder are utilized infrequently among privately insured women. Over the past decade, the introduction of new treatment options has led to a shift in the type of treatment initiated, rather than to an increase in the overall utilization of third-line therapies.

Religion and Spirituality: Why and How to Address It in Clinical Practice.

Religion and spirituality (R/S) have been influential in societies' history, daily life, and identity in the past and in today's society. From a sociological perspective, R/S contributes to family development and organization, influences culture, and often contributes to forming opinions, beliefs, and concepts about oneself, family, society, and the world. In addition, R/S help shape individuals, families, and communities' ethical and moral understanding, thus influencing their behavior. This review article aims to provide the clinician with tools to understand, assess, and provide interventions that consider the patients' and their families' R/S. A recent review of the topic focused on general aspects of the R/S but we are unaware of reviews that integrate attachment, moral foundation theory, and forgiveness. This review will integrate these additional features into our understanding of the role of R/S in the delivery of mental health.

Mucosal-Associated Invariant T Cells Accumulate in the Lungs during Murine Pneumocystis Infection but Are Not Required for Clearance.

Pneumocystis is a fungal pathogen that can cause pneumonia in immunosuppressed hosts and subclinical infection in immunocompetent hosts. Mucosal-associated invariant T (MAIT) cells are unconventional lymphocytes with a semi-invariant T-cell receptor that are activated by riboflavin metabolites that are presented by the MHC-1b molecule MR1. Although Pneumocystis can presumably synthesize riboflavin metabolites based on whole-genome studies, the role of MAIT cells in controlling Pneumocystis infection is unknown. We used a co-housing mouse model of Pneumocystis infection, combined with flow cytometry and qPCR, to characterize the response of MAIT cells to infection in C57BL/6 mice, and, using MR1-/- mice, which lack MAIT cells, to examine their role in clearing the infection. MAIT cells accumulated in the lungs of C57BL/6 mice during Pneumocystis infection and remained at increased levels for many weeks after clearance of infection. In MR1-/- mice, Pneumocystis infection was cleared with kinetics similar to C57BL/6 mice. Thus, MAIT cells are not necessary for control of Pneumocystis infection, but the prolonged retention of these cells in the lungs following clearance of infection may allow a more rapid future response to other pathogens.

Sodium Content and Labelling of Packaged Foods and Beverages in Nigeria: A Cross-Sectional Study.

Increased consumption of unhealthy processed foods, particularly those high in sodium, is a major risk factor for cardiovascular diseases. The nutrition information on packaged foods can help guide consumers toward products with less sodium and support government actions to improve the healthiness of the food supply. The aims of this study were to estimate the proportion of packaged foods displaying nutrition information for sodium and other nutrients specified by Nigerian nutrition labelling regulations and to determine the amount of sodium in packaged foods sold in Nigeria using data from the nutritional information panel. Data were collected from November 2020 to March 2021 from in-store surveys conducted in supermarkets in three states. A total of 7039 products were collected. Overall, 91.5% (n = 6439) provided only partial nutrition information, 7.0% (n = 495) provided no nutritional information, and only 1.5% (n = 105) displayed a nutrient declaration that included all nutrients specified by 2019 Nigerian regulations. Some form of sodium content information was displayed for 86% of all products (n = 6032), of which around 45% (n = 2689) expressed this as 'salt' and 59% (n = 3559) expressed this as 'sodium', while a small number of food products had both 'salt' and 'sodium' content (3.6%). Provision of sodium or salt information on the label varied between food categories, ranging from 50% (vitamins and supplements, n = 2/4) to 96% (convenience foods, n = 44/46). Food categories with the highest median sodium content were 'meat and meat alternatives' (904 mg/100 g), 'sauces, dressings, spreads, and dips' (560 mg/100 g), and 'snack foods' (536 mg/100 g), although wide variation was often observed within categories. These findings highlight considerable potential to improve the availability and consistency of nutrition information on packaged products in Nigeria and to introduce further policies to reduce the amount of sodium in the Nigerian food supply.

Testing the Feasibility and Acceptability of an Acceptance and Commitment Therapy Intervention to Increase Physical Activity among Individuals with Depression: A Protocol Paper.

Background: Engaging in regular physical activity (PA) is particularly important among individuals with depression, who are at heightened risk for a host of negative health outcomes. However, people with depression are 50% less likely to meet national guidelines for PA and face unique barriers to PA adherence, including lower distress tolerance and motivation for exercise. Acceptance and Commitment Therapy (ACT) may offer promise for increasing PA among adults with depressive symptoms due to its effects on distress tolerance and motivation. Therefore, we developed ACTivity, an ACT-based intervention designed to promote PA among low-active adults with elevated depressive symptoms. Prior to testing the efficacy of ACTivity in an RCT, an important first step is to conduct a preliminary trial to establish feasibility of study procedures for the ACTivity and comparison intervention programs, as well as to establish the credibility/acceptability of the intervention. The purpose of this paper is to describe the ACTivity intervention and the design of this feasibility trial. Method/Design: We will conduct a feasibility RCT with two parallel groups and a 1:1 allocation ratio comparing ACTivity to a comparison intervention (relaxation training + PA promotion) among 60 low-active adults with elevated depressive symptoms. All study procedures will be conducted remotely. Discussion: Results of this feasibility study will inform a subsequent RCT designed to test the efficacy of ACTivity. If shown to be efficacious, ACTivity will provide a treatment that can be widely disseminated to increase PA among adults with depressive symptoms and thereby decrease their risk for chronic disease.

Burnout, Self-Efficacy, and Resilience in Haitian Nurses: A Cross-Sectional Study.

Purpose of Study: Though nursing burnout is a global problem, research on nurse burnout in Haiti is scarce. In a context of multiple personal, social, and environmental challenges, this study assessed burnout and associated factors among Haitian nurses. Design of Study: A multi-site cross-sectional study. Methods: A survey in French and Haitian Creole was conducted in five Haitian hospitals using forward and back translated scales measuring burnout (emotional exhaustion [EE], depersonalization [DP], personal accomplishment [PA]), self-efficacy, nursing work environment, resilience, and demographics. Findings: Haitian nurses (N = 179) self-reported moderate EE (M = 21, SD = 11.18), low DP (Mdn = 2.0, range = 29), and high personal accomplishment (Mdn = 41.0, range = 33). General self-efficacy (M = 32.31, SD = 4.27) and resilience (M = 26.68, SD = 5.86) were high. Dissatisfaction with salary, autonomy, and staffing were evident. Conclusions: It is noteworthy that burnout was lower than expected given the scarce resource, difficult socio-politico-economic environment. High levels of self-efficacy and resilience likely mitigated a higher level of burnout. Adaptation enables these nurses to manage their critical conditions and practice holistic nursing, which may inspire hope among nurses in similar contexts.

Opportunities to Integrate Mobile App-Based Interventions Into Mental Health and Substance Use Disorder Treatment Services in the Wake of COVID-19.

The COVID-19 pandemic has heightened concerns about the impact of depression, anxiety, alcohol, and drug use on public health. Mobile apps to address these problems were increasingly popular even before the pandemic, and may help reach people who otherwise have limited treatment access. In this review, we describe pandemic-related substance use and mental health problems, the growing evidence for mobile app efficacy, how health systems can integrate apps into patient care, and future research directions. If equity in access and effective implementation can be addressed, mobile apps are likely to play an important role in mental health and substance use disorder treatment.

Factors influencing breastfeeding practices in China: A meta-aggregation of qualitative studies.

The World Health Organization recommends that women exclusively breastfeed until their babies are 6 months old and continue to breastfeed while introducing complementary foods. A meta-aggregation methodology was used to systematically review and synthesise the qualitative studies on factors influencing breastfeeding practices of healthy Chinese women in Greater China. English and Chinese databases were searched to identify peer-reviewed qualitative studies (published 2008-2019). Relevant data were extracted, and key themes related to factors influencing breastfeeding practices were identified. Of 7587 articles identified, 22 qualitative studies met inclusion criteria for the review, 10 of which were published in Chinese. A total of 87 themes were extracted from all included studies and classified into 9 subcategories: government enactment of policies, implementation of policies in workplaces, social expectations, social support, medical and health services, services with Chinese characteristics, breastfeeding and pumping facilities, maternal perceptions of breastfeeding and self-efficacy to breastfeed. The nine subcategories were then grouped into four categories. Potential effect associations among these influence factors of breastfeeding practices emerged from categories and subcategories. Family members' influence on breastfeeding motivation and self-efficacy suggest a potential benefit of breastfeeding promotion interventions targeting the whole family. The role of primary care should be fully exploited in breastfeeding promotion, including both prenatal education and post-partum visits. Standardising the training and qualifications of maternity matrons (yuesao) and folk breastfeeding specialists (cuirushi) can promote evidence-based approaches to facilitating breastfeeding during the confinement period. Increased availability of breastfeeding and pumping facilities in the workplace would facilitate continuing breastfeeding after returning to work.

Oils Rich in α-Linolenic Acid or Docosahexaenoic Acid Have Distinct Effects on Plasma Oxylipin and Adiponectin Concentrations and on Monocyte Bioenergetics in Women with Obesity.

BACKGROUND: Omega-3 fatty acids, including DHA and α-linolenic acid (ALA), are proposed to improve metabolic health by reducing obesity-associated inflammation. Their effects are mediated in part by conversion to oxylipins. ALA is relatively understudied, and direct comparisons to other omega-3 fatty acids are limited. OBJECTIVES: We compared the effects of equal doses of ALA and DHA on plasma oxylipins and markers of metabolic health in women with obesity. METHODS: We carried out a randomized, double-blind, crossover clinical trial where women aged 20-51 with a BMI of 30-51 kg/m2 were supplemented with 4 g/day of ALA or DHA for 4 weeks in the form of ALA-rich flaxseed oil or DHA-rich fish oil. The primary outcome, the plasma oxylipin profile, was assessed at Days 0 and 28 of each phase by HPLC-MS/MS. Plasma fatty acids, inflammatory markers, and the monocyte glucose metabolism were key secondary outcomes. Data were analyzed using a mixed model. RESULTS: Compared to the baseline visit, there were higher plasma levels of nearly all oxylipins derived from DHA (3.8-fold overall; P < 0.001) and EPA (2.7-fold overall; P < 0.05) after 28 days of fish-oil supplementation, while there were no changes to oxylipins after flaxseed-oil supplementation. Neither supplement altered plasma cytokines; however, adiponectin was increased (1.1-fold; P < 0.05) at the end of the fish-oil phase. Compared to the baseline visit, 28 days of flaxseed-oil supplementation reduced ATP-linked oxygen consumption (0.75-fold; P < 0.05) and increased spare respiratory capacity (1.4-fold; P < 0.05) in monocytes, and countered the shift in oxygen consumption induced by LPS. CONCLUSIONS: Flaxseed oil and fish oil each had unique effects on metabolic parameters in women with obesity. The supplementation regimens were insufficient to reduce inflammatory markers but adequate to elicit increases in omega-3 oxylipins and adiponectin in response to fish oil and to alter monocyte bioenergetics in response to flaxseed oil. This trial was registered at clinicaltrials.gov as NCT03583281.

How can we ensure the success of specialised palliative home-care? A qualitative study (ELSAH) identifying key issues from the perspective of patients, relatives and health professionals.

BACKGROUND: Specialised palliative home-care supports patients with life-limiting diseases in their familiar surroundings. The number of palliative care teams and patients being cared for is increasing worldwide. To assess and improve quality, it is needed to understand, how specialised palliative home-care can be provided successfully. For this purpose we examined the views of all involved stakeholders. AIM: To identify the issues that patients, their relatives and involved health professionals view as important in ensuring the success of specialised palliative home-care. DESIGN: We used a qualitative design based on participant observations, interviews and focus groups following the principles of a Grounded Theory approach. SETTING/PARTICIPANTS: All specialised palliative home-care teams (n = 22) caring for adults in Hesse, Germany, participated. We conducted participant observations (n = 5), and interviewed patients (n = 14), relatives (n = 14) and health professionals working in or collaborating with specialised palliative home-care (n = 30). We also conducted focus groups (n = 4) with health professionals including a member check. RESULTS: Successful specialised palliative home-care needs to treat complex symptoms, and provide comprehensive care including organisation of care, involving relatives and addressing issues of death and dying. Sense of security for patients and relatives is key to enable care at home. Care delivery preferences include a focus on the quality of relationships, respect for individuality and the facilitation of self-determination. CONCLUSIONS: Consideration of the identified key issues can help to ensure successful specialised palliative home-care. Knowledge of these should also be considered when researching and assessing quality of care. TRIAL REGISTRATION: German Clinical Trials Register DRKS-ID: DRKS00012421; http://www.germanctr.de.

Holistic Approaches to Support Sleep in the Intensive Care Unit Patient.

Sleep disruption in intensive care unit patients has internal, interpersonal, behavioral, and environmental factors to consider when developing sleep promotion protocols. Holistic approaches are integrative practices that go beyond modifying environmental factors. This article presents 3 holistic approaches that are cost-effective, easy to use, and independent nursing actions that are integrative in nature. Aromatherapy, guided imagery, and mindfulness show promising effects in the literature to improve comfort, anxiety and stress, which are thought to improve sleep.

Prevalence of Vitamin D Insufficiency and Deficiency in Young, Female Patients With Lower Extremity Musculoskeletal Complaints.

BACKGROUND: Low levels of vitamin D have well-known impacts on bone health, but vitamin D also has a more global role throughout many tissues, including skeletal muscle. The high prevalence of hypovitaminosis D and the vast physiological features of vitamin D have led researchers to examine the influence of vitamin D on physical performance and injury. Because of the critical role of vitamin D in maintaining musculoskeletal health and function, a high rate of hypovitaminosis D among female patients with a variety of musculoskeletal issues could be of high clinical relevance. HYPOTHESIS: There is a high prevalence of low vitamin D in female patients with both acute and overuse sports-related issues of both soft tissue and bone. STUDY DESIGN: Prospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Female patients, aged 16 to 40 years, presenting with lower extremity injury diagnosed within the past 4 weeks, no use of multivitamin or vitamin D supplement, and no history of malabsorption syndrome met the inclusion criteria. Vitamin D levels were assessed and categorized as normal (≥32 ng/mL) and low, which includes insufficient (20.01-31.9 ng/mL) and deficient (≤20 ng/mL). RESULTS: Of the 105 patients enrolled, 65.7% had low vitamin D. Within the low vitamin D cohort, 40.6% were deficient and 59.4% were insufficient. Injuries were grouped into overuse or acute with 74 overuse injuries and 31 acute injuries, exhibiting low vitamin D prevalence of 60.8% and 77.4%, respectively. Patients with ligamentous/cartilaginous injuries exhibited the highest percentage of low vitamin D (76.5%), followed by those with patellofemoral-related complaints (71.0%), muscle/tendon injuries (54.6%), and bone stress injuries (45.5%). In univariable analysis, older age, non-White race, less physical activity, less high-intensity interval training days, less endurance training days, and more rest days showed an association with low vitamin D, but none showed an independent association in multivariable analysis. CONCLUSION: The prevalence of low vitamin D in female patients with various musculoskeletal complaints was high. Clinicians should evaluate for low vitamin D in both acute and overuse injuries. CLINICAL RELEVANCE: In addition to screening, this study suggests that clinicians should evaluate for low vitamin D levels beyond bone stress injuries in the setting of acute and overuse injuries.