Interventions for ADHD in children & adolescents with epilepsy: A review and decision tree to guide clinicians.

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common pediatric epilepsy comorbidities. Treating ADHD in the context of epilepsy can be overwhelming for parents and clinicians. Current frontline treatment for ADHD is stimulant medication. However, some parents of pediatric patients with epilepsy have concerns about adding additional medication to their child's epilepsy regimen and/or about adverse effects of stimulant medication. Non-medication ADHD treatments including psychosocial interventions and ketogenic diet have also shown success in improving ADHD symptoms. Our focused review provides an easy-to-use guide for clinicians on ADHD interventions and combinations of interventions for pediatric patients with epilepsy and ADHD. Our guide includes information from 8 electronic databases for peer-reviewed, English language studies of psychosocial treatments for youth with epilepsy and ADHD. One hundred eight studies were selected based on inclusion criteria (21 systematic reviews, 12 meta-analyses, 8 literature reviews, 6 population surveys, 31 clinical trials, 20 cross-sectional studies, and 10 retrospective reviews). Results indicated that stimulant medication is a frontline treatment for ADHD symptoms in youth with epilepsy, with important caveats and alternatives.

Perioperative Outcomes After Preoperative Epidural Analgesia in Patients with Hip Fracture Undergoing Surgical Repair: A Systematic Review.

OBJECTIVE: To examine the effectiveness and safety of epidural analgesia in the presurgical period in patients with hip fracture undergoing surgical repair. DESIGN: Systematic review. METHODS: The study protocol was registered with the PROSPERO systematic reviews registry with the (identifier CRD42019140396). Electronic databases were searched for randomized controlled trials comparing preoperative epidural analgesia with other forms of pain management in patients with a hip fracture. The primary outcomes included perioperative cardiac events and death. Pain, noncardiac complications, and adverse effects were also examined as secondary outcomes. The heterogeneity of the included studies was assessed with the I2 statistic, and a random-effects meta-analysis was conducted once sufficient homogeneity was demonstrated. RESULTS: Four studies, which included a total of 221 patients, met the inclusion criteria. Preoperative epidural analgesia resulted in fewer cardiac events, which was a reported outcome in two included studies (relative risk 0.30; 95% confidence interval 0.14-0.63; I2=0%). Preoperative epidural analgesia was also associated with a decreased perioperative mortality rate in a meta-analysis of two studies (relative risk 0.13; 95% confidence interval 0.02-0.98; I2 = 0%). Pain was not pooled because of variability in assessment methods, but preoperative epidural analgesia was associated with reduced pain in all four studies. CONCLUSIONS: Preoperative epidural analgesia for hip fracture may reduce perioperative cardiac events and deaths, but the number of included studies in this systematic review was low. More research should be done to determine the benefit of early epidural analgesia for patients with hip fracture.

Provider attitudes and satisfaction with rapid preoperative point-of-care COVID-19 testing using ID NOW™.

PURPOSE: Healthcare workers have experienced high levels of anxiety during the COVID-19 pandemic, particularly when caring for patients with unknown infection status. We trialled rapid preoperative point-of-care COVID-19 testing using the Abbott ID NOW™ COVID-19 for clinical validation in an urgent surgical population at a single centre in British Columbia, Canada. Here, we sought to determine the opinions and beliefs of operating room (OR) staff on the usefulness and effectiveness of point-of-care tests on workflow and wellbeing in the OR. METHODS: This descriptive study used a mixed-methods cross-sectional survey of all OR staff (nurses, anesthesiologists, surgeons, and ancillary staff) at a single centre after using the ID NOW for three months. Outcomes of interest included healthcare worker satisfaction with the ID NOW, effects on OR workflow, and worries about COVID-19 transmission. RESULTS: The overall response rate was 56% (n = 133), and was highest among anesthesiologists (100%, n = 38). Respondents were satisfied with the performance of the ID NOW for rapid COVID-19 testing in preoperative patients, giving it a mean (standard deviation [SD]) rate of 4.4 [1.4] on a five-point scale. Most (115/128, 90%) recommended continued use of the ID NOW on asymptomatic patients while there are active cases of COVID-19 in the community. Respondents felt that preoperative COVID-19 testing with the ID NOW made the OR safer for staff (mean [SD] rate, 4.2 [0.8]) and patients (mean [SD] rate, 4.0 [0.9]). CONCLUSION: During the COVID-19 pandemic, it is important to maintain the physical and mental wellbeing of hospital staff. Rapid point-of-care testing increased the sense of workplace safety, improved morale, and reduced worry associated with COVID-19 without excessive disruption of OR workflow.

RéSUMé: OBJECTIF: Les travailleurs de la santé ont connu des niveaux élevés d'anxiété au cours de la pandémie de COVID-19, en particulier lorsqu'ils prenaient soin de patients dont le statut infectieux était inconnu. Nous avons testé le dépistage préopératoire rapide de la COVID-19 au point de service avec le dispositif ID NOW™ COVID-19 d'Abbott pour validation clinique auprès d'une population devant bénéficier de chirurgie urgente dans un seul centre en Colombie-Britannique, au Canada. Notre objectif était ici de déterminer les opinions et les croyances du personnel de la salle d'opération (SOP) quant à l'utilité et à l'efficacité des tests au point de service en matière de flux de travail et de bien-être en salle d'opération. MéTHODE: Cette étude descriptive a utilisé un sondage transversal à méthodes mixtes auprès de tout le personnel de la SOP (infirmières, anesthésiologistes, chirurgiens et personnel auxiliaire) dans un seul centre après avoir utilisé le système ID NOW pendant trois mois. Les issues de l'étude comprenaient la satisfaction des travailleurs de la santé à l'égard de ID NOW, les effets sur le flux de travail de la SOP et les inquiétudes concernant la transmission de la COVID-19. RéSULTATS: Le taux de réponse global a été de 56 % (n = 133), et était le plus élevé chez les anesthésiologistes (100 %, n = 38). Les répondants étaient satisfaits de la performance de ID NOW pour le dépistage rapide de la COVID-19 chez les patients préopératoires, lui accordant une note moyenne (écart type [ÉT]) de 4,4 [1,4] sur une échelle à cinq points. La plupart (115/128, 90 %) ont recommandé de continuer à utiliser ID NOW avec les patients asymptomatiques tant qu'il y a des cas actifs de COVID-19 dans la communauté. Les répondants étaient d'avis que le dépistage préopératoire de la COVID-19 avec ID NOW rendait la SOP plus sécuritaire pour le personnel (note moyenne [ÉT], 4,2 [0,8]) et les patients (note moyenne [ÉT], 4,0 [0,9]). CONCLUSION: Pendant la pandémie de COVID-19, il est important de maintenir le bien-être physique et mental du personnel hospitalier. Le dépistage rapide au point de service a accru le sentiment de sécurité au travail, amélioré le moral et réduit l'inquiétude associée à la COVID-19, sans perturbation excessive du flux de travail de la SOP.

Effect of peripheral IV based blood collection on catheter dwell time, blood collection, and patient response.

AIM: To evaluate the effect of daily PIV-based phlebotomy using the PIVO device on PIVC dwell times and replacement rates, as well as the reliability of blood sample collection, and patient response to this method of blood collection. BACKGROUND: Blood draws which are also known as phlebotomy for laboratory analyses are one of the most common experiences for hospitalized patients. When performed by venipuncture, they are often associated with pain and anxiety for patients. Most hospitals avoid phlebotomy from peripheral IV catheters due to sample hemolysis, sample dilution by fluids in PIVC line or infused medications, PIVC dislodgement or infiltration, and increased rates of phlebitis. METHODS: A prospective, randomized- controlled study of 160 GI surgery patients was enrolled. Patients were randomized to either control evaluation of PIVC dwell or to receive daily PIVO blood collections in addition to evaluation of PIVC dwell. RESULTS: Daily PIVO blood collections did not negatively affect PIVC dwell or replacement rates. Overall 81% of blood collection attempts were successful and the likelihood of success was strongly associated with PIVC condition. Patients reported 0.7/10 pain for PIVO blood collection on a 0-10 pain scale and a 9.1/10 preference for PIVO on a 0 (strongly prefer needle) to 10 (strongly prefer PIVO) preference scale. Results suggest that use of a PIV based blood collection was a reliable and valid approach and was superior to routine phlebotomy in self-reported responses from patients.

Developing Abilities to Navigate Through the Grey Zones in Complex Environments: Nurses' Reasons for Applying to a Clinical Ethics Residency for Nurses.

BACKGROUND AND PURPOSE: Nurses face complex ethical issues in practice and have to determine appropriate actions. An inability to conceptualize or follow a preferred course of action can give rise to moral uncertainty or moral distress. Both moral uncertainty and moral distress are problematic for nurses and their patients. A program designed to increase nurse confidence in moral decision making, the clinical ethics residency for nurses (CERN), was offered selectively to nurses affiliated with two academic medical centers. This is a report of the analysis of their application essays. DESIGN: Over a 3-year period, 67 application essays were analyzed using conventional content analysis. Applicants comprised one third advanced practice nurses (APNs) and two thirds staff nurses. They were asked to describe their reasons for interest in the CERN and how they would apply the knowledge gained. METHODS: For conventional content analyses, no theoretical presumptions are used; rather, codes are identified from the data in an iterative manner and eventually collapsed into themes. Initially, broad themes were identified by the CERN team. Subsequently, in-depth and recursive readings were completed by a subset of three members, resulting in refinement of themes and subthemes. FINDINGS: The overarching theme identified was "developing abilities to navigate through the 'grey zones' in complex environments." Three subthemes were: (a) nurses encountering patients who are chronically critically ill, culturally diverse, and presenting with complex circumstances; (b) nurses desiring enhanced ethics knowledge and skills to improve quality of care, understand different perspectives, and act as a resource for others; and (c) nurses supporting and facilitating patient-centered ethical decision making. CONCLUSIONS: Findings are consistent with those appearing in the international literature but provide a more cohesive and comprehensive account than previously, and hold promise for the development of educational and policy strategies to address moral distress and uncertainty. CLINICAL RELEVANCE: This study is relevant to clinical practice in its verification of the need nurses have for ethics knowledge, skill refinement, and application through communication. These findings affirmed the challenge that nurses feel in communicating their ethical concerns in an effective and engaging way and their commitment to advocacy and improvement in the quality of care for patients.

Association between Withholding Angiotensin Receptor Blockers in the Early Postoperative Period and 30-day Mortality: A Cohort Study of the Veterans Affairs Healthcare System.

BACKGROUND: Despite widespread use, there is limited information to guide perioperative management of angiotensin receptor blockers (ARBs). METHODS: In this retrospective cohort study, the authors evaluated the patterns of postoperative ARB use in veterans regularly prescribed ARBs admitted for noncardiac surgery at the Veterans Affairs Healthcare system between 1999 and 2011. Multivariable and propensity score-matched Cox proportional hazards models were used to determine the independent effect of failure to resume ARB by postoperative day 2 on the primary outcome of all-cause 30-day mortality. RESULTS: Out of 1,167,482 surgical admissions, 30,173 inpatient surgical admissions met inclusion criteria. Approximately 10,205 patients (33.8%) in the cohort did not resume ARB by day 2. Those that resumed ARB had a 30-day mortality rate of 1.3% (260 of 19,968), whereas 3.2% (323 of 10,205) died in the group that withheld ARB. The unadjusted hazard ratio (HR) for 30-day mortality was 2.45 (95% CI, 2.08 to 2.89; P < 0.001) for those that withheld ARB compared with those that resumed, whereas the multivariable adjusted HR was 1.74 (95% CI, 1.47 to 2.06; P < 0.001). When restricted to a propensity score-matched subset of 19,490, the HR was similar (1.47; 95% CI, 1.22 to 1.78; P < 0.001). Withholding ARB in younger patients increased mortality risk (HR = 2.52; 95% CI, 1.69 to 3.76; P < 0.001 for age <60 yr) compared with older patients (HR = 1.42; 95% CI, 1.09 to 1.85; P = 0.01 for age >75 yr). CONCLUSIONS: Postoperative delay in resuming ARB is common, particularly in patients who are frail after surgery. Withholding ARB is strongly associated with increased 30-day mortality, especially in younger patients, although residual confounding may be present.

Long-term quit rates after a perioperative smoking cessation randomized controlled trial.

BACKGROUND: While surgery and perioperative smoking cessation interventions may motivate patients to quit smoking in the short term, it is unknown how often this translates into permanent cessation. In this study, we sought to determine the rates of long-term smoking cessation after a perioperative smoking cessation intervention and predictors of successful cessation at 1 year. METHODS: We previously reported short-term results from a perioperative randomized controlled trial comparing usual care with an intervention involving (1) brief counseling by the preadmission nurse, (2) smoking cessation brochures, (3) referral to a telephone quitline, and (4) a free 6-week supply of transdermal nicotine replacement. We now report our 1-year follow-up outcomes. RESULTS: Between October 2010 and April 2012, 168 patients were randomized. At 1 year, 127 patients (76%) were available for follow-up telephone interview. Smoking cessation occurred in 8% of control patients compared with 25% of patients in the intervention group (relative risk, 3.0; 95% confidence interval [CI], 1.2-7.8; P = 0.018). The number needed-to-treat to achieve smoking cessation for 1 patient at 1 year postoperatively was 5.9 (95% CI, 3.4-25.9). Multivariable logistic regression modeling found that the intervention (P = 0.020) and lower nicotine dependency at baseline (P < 0.001) were predictive of success at smoking cessation at 1 year. Poisson regression showed that adjusted for nicotine dependency, those randomized to the intervention group were 2.7 times (95% CI, 1.1-6.7; P = 0.028) more likely to achieve long-term cessation than those in the control group. Adjusted for randomization group, a low level of nicotine dependency resulted in a relative risk of quitting of 5.1 (95% CI, 2.0-12.8; P = 0.001). CONCLUSIONS: This study demonstrates that an intervention designed for a busy preadmission clinic results in decreased smoking rates not only around the time of surgery but also continued benefit in smoking cessation at 1 year. Perioperative care providers have a unique opportunity to assist patients in smoking cessation and achieve long-lasting results.

Clinical ethics residency for nurses: an education model to decrease moral distress and strengthen nurse retention in acute care.

The experience of unaddressed moral distress can lead to nurse attrition and/or distancing from patients, compromising patient care. Nurses who are confident in their ethical decision making abilities and moral agency have the antidote to moral distress for themselves and their colleagues and can act as local or institutional ethics resources. We describe a grant-funded model education program designed to increase ethics competence throughout the institution.

Enhancing moral agency: clinical ethics residency for nurses.

One antidote to moral distress is stronger moral agency-that is, an enhanced ability to act to bring about change. The Clinical Ethics Residency for Nurses, an educational program developed and run in two large northeastern academic medical centers with funding from the Health Resources and Services Administration, intended to strengthen nurses' moral agency. Drawing on Improving Competencies in Clinical Ethics Consultation: An Education Guide, by the American Society for Bioethics and Humanities, and on the goals of the nursing profession, CERN sought to change attitudes, increase knowledge, and develop skills to act on one's knowledge. One of the key insights the faculty members brought to the design of this program is that knowledge of clinical ethics is not enough to develop moral agency. In addition to lecture-style classes, CERN employed a variety of methods based in adult learning theory, such as active application of ethics knowledge to patient scenarios in classroom discussion, simulation, and the clinical practicum. Overwhelmingly, the feedback from the participants (sixty-seven over three years of the program) indicated that CERN achieved transformative learning.

The effectiveness of a perioperative smoking cessation program: a randomized clinical trial.

BACKGROUND: Cigarette smoking by surgical patients is associated with increased complications, particularly perioperative respiratory problems and poor wound healing. In this study, we sought to determine whether a pragmatic perioperative smoking cessation intervention designed for a busy preadmission clinic would be successful in reducing smoking rates and intraoperative and immediate postoperative complications. METHODS: This randomized controlled trial was conducted at a university-affiliated hospital in London, Ontario, Canada. Patients seen in the preadmission clinic at least 3 weeks preoperatively were randomized to either the control group (84 patients) or the intervention group (84 patients). The control group received no specific smoking cessation intervention. The intervention group received (1) brief counseling by the preadmission nurse, (2) brochures on smoking cessation, (3) referral to the Canadian Cancer Society's Smokers' Helpline, and (4) a free 6-week supply of transdermal nicotine replacement therapy. All outcome assessors and caregivers on the operative day were blinded to group assignment. The primary outcome was the rate of smoking cessation as confirmed by exhaled carbon monoxide breath test. Secondary outcomes included perioperative complications and smoking status at 30 days postoperatively. RESULTS: Between October 2010 and April 2012, 168 patients were recruited into the study. Smoking cessation occurred in 12 patients (14.3%) in the intervention group as compared with 3 patients (3.6%) in the control group (relative risk 4.0; 95% confidence interval [CI], 1.2-13.7; P = 0.03). The overall rate of combined intraoperative and immediate postoperative complications was not significantly different between intervention and control groups (13.1% and 16.7%, respectively; relative risk 0.79; 95% CI, 0.38-1.63; P = 0.67). At follow-up 30 days postoperatively, smoking cessation was reported in 22 patients (28.6%) in the intervention group compared with 8 patients (11%) in controls (relative risk 2.6; 95% CI, 1.2-5.5; P = 0.008). CONCLUSIONS: One of the objections to widespread use of smoking cessation interventions in the preadmission clinic is that it is too labor-intensive. The results of this study show that a smoking cessation intervention, designed to minimize additional use of physician or nursing time, results in decreased smoking rates on the day of surgery and promotes abstinence 30 days postoperatively.

The national AgeWISE pilot.

AgeWISE is a 6-month nurse residency program designed to prepare hospital nurses to meet the needs of older adults, a population that comprises nearly 50% of all US hospital admissions. The goal of AgeWISE, now being piloted in 12 hospitals in the United States, is to produce a tested and refined national model for building geropalliative care capacity among hospital nurses.

Evaluation of Dipeptidyl Peptidase-4 Inhibitors versus Thiazolidinediones or Insulin in Patients with Type 2 Diabetes Uncontrolled with Metformin and a Sulfonylurea in a Real-World Setting.

BACKGROUND: Guidelines do not make clear recommendations for third add-on agents to metformin plus a sulfonylurea. This study compared the effectiveness and safety of dipeptidyl peptidase-4 inhibitors (DPP4is) to thiazolidinedione (TZD) or insulin as a third add-on agent to metformin plus a sulfonylurea in an integrated health care setting. METHODS: This retrospective database cohort study included adults with type 2 diabetes not at goal hemoglobin A1C (HbA1C) who initiated DPP4i, TZD, or insulin as a third add-on agent to metformin plus a sulfonylurea from January 2006 to June 2016. Primary outcomes were the proportion of patients who achieved goal HbA1C after starting the third add-on agent and change in HbA1C. Subgroup analysis was performed for patients with baseline HbA1C greater than 9%. RESULTS: In this study, 2080 patients started on a DPP4i were matched to 8320 patients started on TZD and to 8320 patients taking insulin. A significantly higher percentage of patients taking TZD reached goal HbA1C (31.0% versus 23.6%; p < 0.05) and had a significantly larger HbA1C reduction (-0.94% ± 1.34% versus -0.79% ± 1.23%; p < 0.01) compared to patients taking a DPP4i. No difference in the percentage of patients meeting goal HbA1C nor in change in HbA1C was demonstrated between insulin versus DPP4i regimens. For patients with baseline HbA1C greater than 9%, insulin or TZD resulted in a significantly higher proportion of patients achieving goal HbA1C compared to DPP4i (17.3% and 19.0% versus 12.4%, respectively; p < 0.01). CONCLUSION: TZD was more effective than DPP4i but DPP4i was as effective as insulin as a third add-on agent in the overall study population. Insulin was more effective than DPP4i only in the subgroup analysis of patients with baseline HbA1C greater than 9%.

Hepatitis C Virus in the Elderly in the Direct-Acting Antiviral Era: from Diagnosis to Cure.

PURPOSE OF REVIEW: Hepatitis C (HCV) is the most common cause of viral hepatitis in elderly individuals. This patient population previously experienced suboptimal outcomes with interferon-based regimens. Unfortunately, patients aged 65 years and older were underrepresented in phase 2 and 3 clinical trials with newer direct acting antiviral (DAA) therapies. Since the advent of second-generation DAA in 2013, numerous robust real-world experiences highlighting the efficacy and safety of DAA in the elderly have been published. This review article summarizes the cascade of care for hepatitis C from diagnosis to cure from an evidence-based perspective of the aging population. RECENT FINDING: In a large study from the Veterans Affairs Healthcare System, the overall sustained virologic response (SVR) of 15,884 patients treated with DAA regimens was 91.2%. These newer therapies remained highly effective in the subset of patients aged 65 years and older with SVR rates above 90%. A Spanish National Registry reported outcomes in patients ≥ 65 years old treated for HCV with oral DAA regimens over a 2-year period. The overall SVR was 94% in the study of 1252 subjects. SUMMARY: Current real-world data imply DAA treatment regimens remain highly effective and safe in elderly patients when compared to the general population.

An evidence-based nurse residency program in geropalliative care.

As U.S. baby boomers age and the older population doubles by 2030, unprecedented numbers of older adults will need and benefit from nursing care that is evidence-based and tailored to their needs and preferences. To address this need, Massachusetts General Hospital developed the RN Residency: Transitioning to Geriatrics and Palliative Care program. Guided by two national curricula, the RN Residency program was designed to expand the disease model of geriatrics to a functional, emotional, and social perspective of aging, in which palliative care is an integral component. This article describes the RN Residency program, which was designed to improve the effectiveness of nursing assessment, interventions, and outcomes for older adults and their families.

Evaluation of Outcomes After Initiating Triple Antidiabetic Therapy with a GLP-1 RA in an Integrated Health Care System.

BACKGROUND: Type 2 diabetes (T2D) is characterized by chronic hyper-glycemia and can lead to life-threatening complications if not treated. A stepwise and patient-centered approach is recommended when managing patients with T2D. Metformin is the preferred first-line agent, while sulfonylureas (SU) are often chosen as second-line agents. If a patient's hemoglobin A1c (A1c) goal is not achieved despite 3 months of treatment with dual therapy, then triple therapy is recommended. However, due to the lack of head-to-head trials for different triple antidiabetic regimens, the recommendations are unclear for selection of an optimal third-line agent. OBJECTIVE: To evaluate the comparative effectiveness of a glucagon-like peptide-1 receptor agonist (GLP-1 RA) compared with a thiazolidinedione (TZD) or insulin as a third-line add-on therapy in patients who have not achieved A1c goals while receiving metformin and SU dual therapy in the real-world setting within an integrated health care system. METHODS: This is a retrospective cohort study of adult patients with T2D who were not at goal A1c while on dual therapy with metformin and an SU and initiated triple antidiabetic therapy. The primary outcome was the proportion of patients who achieved goal A1c within 3-7 months after starting triple therapy with a GLP-1 RA compared with a TZD or insulin. Goal A1c was defined as an A1c of < 7% for patients aged less than 65 years and A1c of < 8% for patients aged 65 years or older. Secondary outcomes included mean change in A1c, mean change in weight, and the proportion of patients with an emergent health care encounter due to a hypoglycemic event. Propensity score matching was used to select comparison groups from the insulin and TZD groups with similar baseline characteristics to the GLP-1 RA group in a 4:1 ratio. RESULTS: 274 patients initiated a GLP-1 RA in addition to dual therapy with metformin and an SU. A propensity matched group of 1,096 patients who initiated insulin and 1,096 patients who initiated a TZD were selected as the control groups. Addition of a GLP-1 RA resulted in a significantly lower proportion of patients achieving goal A1c (23.0%) compared with the addition of a TZD (30.8%, P = 0.011). There was no significant difference with the addition of a GLP-1 RA when compared with insulin (24.1%, P = 0.704). CONCLUSIONS: This study reflects data from real-world practice in a large integrated health care system. Significantly less patients achieved goal A1c with the addition of a GLP-1 RA as a third-line add-on option to dual therapy with metformin and an SU compared with the addition of a TZD. Providers and patients should carefully weigh the risks and benefits of different antidiabetic agents when choosing triple therapy regimens. DISCLOSURES: No outside funding supported this study. The authors have nothing to disclose. Part of this study was presented as a nonreviewed resident poster at the Academy of Managed Care & Specialty Pharmacy Annual Meeting 2017 in Denver, CO, on March 27-29, 2017.