Perceptions of weather-based pain forecasts and their effect on daily activities.

As studies begin to have more success uncovering the relationships between atmospheric conditions and pain, weather-based pain forecasting becomes more of a reality. In this study, a survey was used to determine if people living with migraines and/or other pain-related conditions are receptive to weather-based pain forecasts. Moreover, we wished to identify whether these forecasts actually impact the decision-making of those who use them. Survey respondents were generally eager to use these novel forecasts. Furthermore, when provided with different scenarios involving weather-based pain forecasts, the respondents' actions were altered. When a hypothetical forecast indicated that the weather was conducive to migraines or other types of pain, many indicated that they would likely take preventative measures (e.g., medication). Additionally, respondents were less likely to continue with a planned activity, regardless of length, as forecast severity increased. The results from this survey highlight the importance of developing and improving weather-based pain forecasting.

Geographical variability in the relationship between synoptic weather type and emergency department visits for pain across North Carolina.

Bodily pain plagues populations across the globe. Past studies have discovered some links between synoptic weather types and different kinds of pain. These relationships are essential as they can aide in treatment and potentially prevention of pain. In this study, the role of geographical characteristics on the relationships between synoptic weather type and pain were looked at. North Carolina was separated into three geographic sections: Appalachian Mountains, Piedmont Plateau, and Coastal Plain. Over a 7-year period, synoptic weather types and emergency department (ED) visits for various kinds of pain (migraine, fibromyalgia, rheumatoid arthritis, osteoarthritis, and general back pain) were collected. Bootstrapped confidence intervals of the mean number of population-adjusted ED visit rates (per 100,000 persons), for the different synoptic weather types, were compared across the different geographic regions. In the plateau region, Moist Tropical and Moist Moderate weather types were often linked to the highest rates of ED visits, while Polar weather types were frequently associated with the fewest visits. The mountainous portion of the state displayed similar patterns between synoptic weather types and the different forms of pain, with migraine and fibromyalgia being the exceptions. Few statistically significant relationships were noted for the coastal region.

Theoretical Matters: On the Need for Hazard and Disaster Theory Developed Through Interdisciplinary Research and Collaboration.

Hazard and disaster research requires a willingness to step outside of traditional disciplinary ontological and epistemological assumptions to both accommodate and integrate different perspectives. Moreover, the complex qualities of hazards and disasters necessitate interdisciplinary approaches to inform theory development that encompasses environmental, human, and infrastructure systems at multiple scales and units of analysis. Unfortunately, truly integrative hazard and disaster theory at a scale broad enough to account for the many systems and processes involved is currently limited. In this article, we argue that robust hazard and disaster theory can only arise from interdisciplinary research and collaboration. We examine challenges to the development of interdisciplinary hazard and disaster theory, and discuss the characteristics of theory necessary for the goal-oriented nature of research aimed at reducing disaster impact.

Interdisciplinary Research as an Iterative Process to Build Disaster Systems Knowledge.

Disasters occur at the intersections of social, natural, and built environments, and robust understanding of these interactions can only occur through insight generated from different disciplines. Yet, there are cultural, epistemological, and methodological differences across the many disciplines concerned with hazards and disasters that can make conducting interdisciplinary research difficult. Approaches are needed to overcome these challenges. This article argues that interdisciplinary disaster research can be successful when it entails an iterative process in which researchers from different disciplines work collaboratively and exert reciprocal influence to generate disaster systems knowledge. Disaster systems knowledge is interdisciplinary and is defined as a comprehensive understanding of the intersections of built, natural, and human environmental factors and their interplay in hazards and disasters. The iterative process can reduce disciplinary biases and privileges by encouraging collaboration among researchers to help ensure disciplinary knowledge complements other disciplinary knowledge, to ultimately generate interdisciplinary disaster systems knowledge. The article concludes by illustrating the process by analyzing a research case study of an interdisciplinary approach to volcanic risk reduction.

Hepatitis C donor viremic cardiac transplantation: A practical approach.

INTRODUCTION: Patients with end-stage heart failure eligible for orthotopic heart transplantation (OHT) exceed the number of available donor organs. With highly effective hepatitis C virus (HCV) antiviral therapy now available, HCV+ organs are increasingly utilized. We seek to describe our experience with patients receiving HCV viremic organs as compared to non-HCV transplant recipients. METHODS: Our center began utilizing HCV hearts in February 2018. We retrospectively reviewed baseline demographics, laboratory data and outcomes for those undergoing OHT with majority being from a viremic HCV donor. RESULTS: Twenty-three of 25 HCV recipients received hearts from NAT+ donors with 22 of 23 seroconverting within 7 days. Fifteen recipients have completed HCV treatment, with the longest duration of follow-up being 13 months. No differences in rates of rejection, hospitalizations or death were seen between non-HCV and HCV transplant patients. DISCUSSION: With the advent of available direct-acting antivirals (DAAs), viremic HCV hearts provide an opportunity to increase organ availability. Moreover, treatment for HCV in the setting of immunosuppression is well-tolerated and results in sustained viremic response. CONCLUSION: Viremic, discordant HCV OHT can be performed in a safe and effective manner utilizing a systematic, multidisciplinary approach without an effect on short-term outcomes.

Relationship between synoptic weather type and emergency department visits for different types of pain across the Triangle region of North Carolina.

Many people around the world are impacted by some form of bodily pain. Outside factors, such as weather, are thought to help trigger pain, especially in those who have pain-related conditions. When it comes to human health and comfort, understanding the potential external factors that aide in triggering pain is essential. Identifying such factors makes prevention and treatment of pain more feasible. This study focused on how those who suffer from various pain-related conditions (fibromyalgia, rheumatoid arthritis, osteoarthritis, and general back pain) are impacted by different synoptic weather types (i.e., air masses). Synoptic weather types and emergency department (ED) visits for pain in select central North Carolina counties were collected over a seven-year period to determine a potential relationship. Bootstrapped confidence intervals revealed that moist tropical weather types resulted in the highest number of ED visits for each of the conditions examined, while moist polar weather types often resulted in the fewest. The barometric pressure changes associated with transitional weather types, which are often associated with fronts, did not have any significant relationships with pain.

National Patient Safety Consortium: Learning from Large-Scale Collaboration.

From 2014 to 2018, the Canadian Patient Safety Institute brought together key partners and established the National Patient Safety Consortium to drive a shared action plan for safer healthcare. With ongoing consensus development on key priorities, an unprecedented level of collaboration and shared leadership with diverse stakeholders and patients and families as full partners, the Consortium and its Integrated Patient Safety Action Plan built a culture of engagement and improvement across Canada.

Prevalence, etiology, and clinical implications of reduced longitudinal systolic strain in renal transplant candidates.

AIMS: Reduced global longitudinal systolic strain (GLS) is a common finding in end-stage renal disease (ESRD) patients with normal ejection fraction (EF), and GLS is a stronger predictor of mortality than EF. We sought to determine what factors may be responsible for the decreased strain in this population. METHODS AND RESULTS: The study group was comprised of 139 renal transplant candidates with a normal EF who had echocardiography with assessment of GLS and basal longitudinal systolic strain (BLS). A GLS of less than -18 and a BLS less than -17 were defined as abnormal. Logistic regression was used to determine variables associated with abnormal GLS and BLS. Of the 139 patients, 49% had abnormal GLS and 70% had abnormal BLS. The univariate predictors of abnormal GLS (P<.05) were low-normal EF, increased interventricular septal thickness (IVS), diabetes, and dihydropyridine calcium channel blocker use. The univariate predictors of abnormal BLS (P<.05) were elevated systolic blood pressure, elevated diastolic blood pressure, elevated heart rate, decreased EF, increased IVS, increased left ventricular posterior wall thickness (LVPW), increased left ventricular mass index, regular dialysis, and clonidine use. On multivariate analysis, low-normal EF (P<.001), increased IVS (P=.024), and diabetes (P=.042) were independent predictors of abnormal GLS, while increased DBP (P=.018), increased LVPW (P=.001), and regular dialysis (P=.006) were independent predictors of abnormal BLS. CONCLUSIONS: Clinical variables and co-findings beyond EF are associated with abnormal strain measurements and may partially explain the large incidence of abnormal strain in renal transplant candidates.

Longitudinal disparities in social determinants of health and COVID-19 incidence and mortality in the United States from the three largest waves of the pandemic.

The United States experienced at least five COVID-19 waves linked with different mutated SARS-CoV-2 variants including Alpha, Delta and Omicron. In addition to the variants, the intensity, geographical distribution, and risk factors related to those waves also vary within socio-demographic characteristics and timeframes. In this project, we have examined the spatial and temporal pattern of COVID-19 in the USA and its associations with Social Determinants of Health (SDoH) by utilizing the County Health Rankings & Roadmaps (CHRR) dataset. Our epidemiologic investigation at the county level showed that the burden of COVID-19 cases and deaths is higher in counties with high percentages of smoking, number of preventable hospital stays, primary care physician rate, the average daily density of PM2.5 and percentages of high proportions of Hispanic residents. In addition, the analysis also demonstrated that COVID-19 incidence and mortality had distinct characteristics in their association with SDoH variables. For example, the percentages of the population 65 and older had negative associations with incidence while a significant positive association with mortality. In addition to the elderly population, median household income, unemployment, and number of drug overdose deaths showed a mixed association with COVID-19 incidence and mortality. Our findings validate several influential factors found in the existing social epidemiology literature and highlight temporal associations between SDoH variables and COVID-19 incidence and mortality not yet frequently studied.

Rehospitalizations, early revisions, infections, and hospital resource use in the first year after hip and knee arthroplasties.

We examined 3 negative outcomes for 58 351 hip and knee arthroplasty patients: rehospitalization, revision and infection, and their impact on resource use in the year after surgery. In the year before surgery, 12.9% of elective hip and 10.2% of knee patients were hospitalized. In the year after, 14.8% of elective hip and 15.5% of knee patients were hospitalized, representing a 15% and 52% increase, respectively. Twenty-eight percent of emergent hip patients were hospitalized at least once preoperatively; this did not change after surgery. Revision occurred in 2.0% of emergent hip, 1.7% of elective hip, and 0.9% of knee patients. Joint infection was diagnosed in 1.3% of patients. The increased hospitalization after the elective hip and knee procedures represents an incremental cost of 10% over the index hospital stay.

Public Reporting of Performance Indicators in Long-Term Care in Canada: Does it Make a Difference?

Evidence of the impact of public reporting of health care performance on quality improvement is not yet sufficient for definitive conclusions to be drawn, despite the important policy implications. This study explored the association of public reporting of performance indicators of long-term care facilities in Canada with performance trends. We considered 16 performance indicators in long-term care in Canada, 8 of which are publicly reported at a facility level, whereas the other 8 are not publicly reported, between the fiscal years 2011-2012 and 2018-2019. Data from 1,087 long-term care facilities were included. Improving trends were observed among publicly reported indicators more often than among indicators that were not publicly reported. Our analysis also suggests that the association between publication of data and improvement is stronger among indicators for which there was no improvement prior to publication and among the worst performing facilities.

Use of Performance Data by Mid-Level Hospital Managers in Ontario: Results of a Province-Wide Survey and a Comparison with Hospital Managers in Europe.

This paper provides insights into the use of performance data by middle managerial staff in Ontario hospitals in 2019 and compares the results to a study conducted in Europe in the same year. A total of 236 managers working in 61 hospitals across Ontario provided responses to the survey. Compared to their European colleagues, Ontario respondents self-assessed using significantly more performance data for managerial decision making. The use of performance data in Ontario was mostly motivated by external accountability requirements, followed by internal quality improvement efforts. Ontario managers also reported accessibility, appropriateness and timeliness of data and human resources and engagement as the biggest barriers to further performance data utilization. Comparative studies, such as the one this paper is based on, provide the foundation for drawing lessons across jurisdictions. This paper also affirms the importance of hospital middle management in moving from quality assurance to quality improvement efforts and developing sustainable learning healthcare organizations and systems.

Safety and effects of SGLT-2 inhibitor use among LVAD patients with type 2 diabetes mellitus.

SGLT-2 inhibitors have been shown to confer reduced risk of adverse cardiovascular events in patients with heart failure, and have also been studied preliminarily among heart transplant patients, with overall positive findings. Use of SGLT-2 inhibitors among patients with durable mechanical circulatory support has not been studied. Here we present our results from a combined retrospective cohort of LVAD patients on SGLT-2 inhibitors at two major academic centers, which showed a good safety profile but prompted questions for further investigation. We advocate for further research into the safety and impact of SGLT-2 inhibitors among LVAD patients.

Implementing a New Capstone Leadership Clinical Course.

BACKGROUND: Nurse educators are challenged to ensure clinical education meets the changing health care environments and needs. PROBLEM: New nurses remain unprepared for practice, have insufficient foundational leadership capacities, and lack systems-thinking awareness. APPROACH: Responding to educational gaps, increased enrollment, and scarce clinical placements, faculty used an eclectic education model to develop a new capstone leadership clinical course that included 5 types of experiences. The total acute care clinical hours were reduced, while adding leadership-focused experiences and simulated learning. OUTCOMES: Stakeholders' evaluations indicate the pilot provided opportunities to strengthen students' leadership capacity, systems thinking, and professional identity while still providing sufficient practice managing care of multiple patients, engaging in teamwork, and applying evidence. CONCLUSION: The new clinical course addressed students' transition into practice needs and enrollment capacity issues. Thoughtful planning by invested stakeholders, communication among faculty, and clear expectations are necessary to implement eclectic clinical models.

Journeying through the DNP project: A qualitative, descriptive study.

BACKGROUND: As a requirement of doctor in nursing practice (DNP) programs, a final scholarly project is required. Little is known about the student experience initiating, implementing, evaluating, and disseminating the scholarly DNP project. PURPOSE: The purpose of this qualitative, descriptive study was to explore descriptions of what it is like to move through the DNP project process, from the perspective of successful recent DNP graduates. METHOD: Using purposive, convenience, and snowball sampling, 15 recent DNP graduates were recruited to participate in a semi-structured interview. Using a pragmatic, open coding approach with constant comparison, four researchers evaluated the transcripts and reduced the data three times by coding and categorizing, clustering responses so the essential theme emerged. RESULTS: Nine categories were interpreted, and one overarching theme emerged: Journeying Through the DNP Project. A metaphor weaving together the categories is offered. CONCLUSION: Faculty support, through communication and mentorship, is strongly encouraged. Rigor of projects needs to be enhanced. Student experiences may be improved by faculty establishing supportive student relationships and ensuring that faculty understand the differences between and among research, evidence-based practice, quality improvement, and process improvement. The DNP student experience can be enhanced with program support and faculty mentorship and support.

Rate Control Versus Rhythm Control in Patients with Left Ventricular Assist Devices and Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a common comorbidity in patients with left ventricular assist devices (LVAD) with no defined guideline treatment strategy of rate versus rhythm control. The purpose of this study is to determine the effects of rate versus rhythm control for AF on the outcomes of patients with LVAD at our institution. METHODS: Consecutive patients who underwent LVAD implantation at St Vincent Hospital from January 1, 2015 to December 31, 2017 were retrospectively evaluated. Patients with AF were identified and divided into rate control or rhythm control groups. The primary outcome evaluated was a composite of death, heart failure admission, gastrointestinal bleed, ventricular tachycardia, cerebrovascular accident, hemolysis, and pump thrombosis. Secondary outcomes included the individual variables from the primary outcome. RESULTS: Out of 201 patients that underwent LVAD implantation, 81 had AF after implantation and were included with a median follow-up period of 384 days. The rate control group (n = 31; 38%) and the rhythm control group (n = 51; 62%) had no difference in composite outcomes (61% vs 59%, p = 0.83). When taken individually there was no difference in outcomes between the two groups. Thirteen patients underwent electrical cardioversion and successful conversion to normal sinus rhythm occurred in 71% of cases with a 60% recurrence rate. CONCLUSIONS: There was no difference in primary outcome between rate and rhythm control groups. These data suggest that maintenance of sinus rhythm may not be necessary in all patients with LVAD.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study.

BACKGROUND: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25619.

Making Practical Progress on Climate Change in Healthcare: Seizing Opportunities.

Climate change concerns have gained traction with many Canadians and impacted their individual choices. However, as a country, we have repeatedly failed to meet international emission-reduction targets. Setting an ambitious goal of net zero in healthcare may continue the discouraging pattern of missing the mark. This commentary proposes a new approach - identifying practical solutions and measuring their beneficial impact for both health and the environment. A few options are suggested, some likely to benefit from near-term government investments. Making tangible progress where opportunities present themselves will create positive health and environmental benefits and a solid foundation for future achievements.