Retraining programme for older patients undergoing peritoneal dialysis: A randomised controlled trial.

BACKGROUND: Peritonitis is a common cause of hospitalisation and death among patients undergoing peritoneal dialysis. Periodic retraining is recommended to prevent peritonitis, especially in older adults. OBJECTIVES: We evaluated the effectiveness of a retraining programme for reducing peritonitis and exit site infection rates in older adults on peritoneal dialysis. The cost-benefit ratio was also calculated. DESIGN: A two-arm prospective randomised controlled trial. PARTICIPANTS: One hundred and thirty patients aged 55 years or older were recruited. Participants were randomly assigned to the intervention or control group. While both groups received usual care, the intervention group received a retraining programme (a knowledge and practical assessment and a one-on-one retraining session) 90 days after starting home-based continuous ambulatory peritoneal dialysis therapy. MEASUREMENTS: The outcomes included peritonitis rate, exit site infection rate and direct medical costs at 180, 270, and 360 days after starting home-based continuous ambulatory peritoneal dialysis therapy. RESULTS: No significant differences were found in the baseline characteristics between groups. The peritonitis rates were 0.11 episodes per patient-year in the intervention group versus 0.13 in the control group. The incidence of exit site infection was 20.0% in the intervention group and 12.3% in the control group. The cost-benefit ratio of retraining was 1:9.6. None of the results were statistically significant. CONCLUSIONS: The absence of statistical significance may be partly explained by the premature termination of the study. Large-scale multi-centre trials are warranted to examine the effectiveness of retraining. The timing and long-term effects of retraining also need to be examined.

Assessment of retinal neurodegeneration with spectral-domain optical coherence tomography: a systematic review and meta-analysis.

OBJECTIVES: To comprehensively assess diabetic retinopathy neurodegeneration (DRN) as quantified by retinal neuronal and axonal layers measured with spectral-domain optical coherence tomography (SD-OCT) in subjects with diabetes mellitus (DM). METHODS: Articles on the topic of examining macular ganglion cell-inner plexiform layer (m-GCIPL), macular retinal nerve fibre layer (m-RNFL), macular ganglion cell complex (m-GCC), and peripapillary RNFL (p-RNFL) measured with SD-OCT in DM subjects without DR (NDR) or with non-proliferative DR (NPDR) were searched in PubMed and Embase up to November 31, 2019. Standardized mean difference (SMD) as effect size were pooled using random-effects model. RESULTS: Thirty-six studies searched from online databases and the CUHK DM cohort were included in the meta-analysis. In the comparison between NDR and control, macular measures including mean m-GCIPL (SMD = -0.26, p = 0.003), m-RNFL (SMD = -0.26, p = 0.046), and m-GCC (SMD = -0.28; p = 0.009) were significantly thinner in the NDR group. In the comparison between NPDR and NDR, only mean p-RNFL was significantly thinner in the NPDR group (SMD = -0.27; p = 0.03), but not other macular measures. CONCLUSIONS: Thinning of retinal neuronal and axonal layers at macula as measured by SD-OCT are presented in eyes with NDR, supporting DRN may be the early pathogenesis in the DM patients without the presence of clinical signs of DR. In the future, these SD-OCT measures may be used as surrogates of DRN to stratify DM patients with a high risk of DR, and may be used as a therapeutic target if neuroprotection treatment for DR is available.

Validating Fall Prevention Icons to Support Patient-Centered Education.

INTRODUCTION: Falls with injury are the most prevalent hospital adverse event. The objective of this project was to refine fall risk and prevention icons for a patient-centric bedside toolkit to promote patient and nurse engagement in accurately assessing fall risks and developing a tailored fall prevention plan. METHODS: Eighty-eight patients and 60 nurses from 2 academic medical centers participated in 4 iterations of testing to refine 6 fall risk and 10 fall prevention icons. During individual interviews, participants rated their satisfaction with the degree to which that icon represented the concept on a 4-point Likert scale, enabling computation of a Content Validity Index (CVI), and provided comments and suggestions for improvement. After reviewing CVI scores and feedback, the research team consulted with the illustrator to revise the icons. RESULTS: Content Validity Index scores improved after icon modifications. Icons that depicted multiple concepts required further iterations to be acceptable. DISCUSSION: Using icons to depict an accurate and easy-to-interpret fall risk assessment and intervention plan for all care team members including patients and family to follow should lead to improved adherence with that plan and decreased falls. CONCLUSIONS: All 16 icons were refined and used to form the basis for a bedside fall prevention toolkit.

Patient Activation Related to Fall Prevention: A Multisite Study.

BACKGROUND: Falls are a major problem in hospitals. The fall prevention program Fall TIPS (Tailoring Interventions for Patient Safety) has been shown to be effective in preventing inpatient falls and related injuries. The purpose of this study was to examine the impact of the Fall TIPS program on patient activation related to fall prevention. METHODS: Patient activation was measured by surveying a random sample of adult patients before and after implementation of Fall TIPS at three health care systems. Researchers used the short form Patient Activation Measure (PAM-13) adapted for fall prevention. This 13-item survey assesses a patient's knowledge, skill, and confidence in managing his or her fall prevention. Patients (N = 343) were surveyed on medical units at Brigham and Women's Hospital (BWH), Montefiore Medical Center (MMC), and New York-Presbyterian (NYP) Hospital. Statistical analysis using the robust t-test was done to compare patient activation in the preintervention and postintervention groups. RESULTS: Patient activation improved from preintervention to postintervention at all sites (BWH, p < 0.0001; NYP, p = 0.0373; MMC, p < 0.0001). Overall, the mean PAM score improved from 63.82 (standard deviation [SD] ± 17.35) to 80.88 (SD ± 17.48), p < 0.0001. CONCLUSION: Patients with access to the Fall TIPS program are more activated and engaged in their fall prevention plan. Members of the care team should engage patients in their fall prevention plan to increase their knowledge, skill, and confidence.

Impact of Pseudomonas aeruginosa Isolation on Mortality and Outcomes in an Outpatient Chronic Obstructive Pulmonary Disease Cohort.

BACKGROUND: Tracheobronchial colonization by Pseudomonas aeruginosa (PA) has been shown to negatively impact outcomes in cystic fibrosis and bronchiectasis. There is uncertainty whether the same association is prevalent in chronic obstructive pulmonary disease (COPD), especially in the outpatient setting. Our objective was to determine (1) whether PA isolation is associated with mortality and (2) changes in exacerbation and hospitalization rates within a longitudinal cohort of COPD outpatients. METHODS: Pseudomonas aeruginosa colonization was ascertained in monthly sputum cultures in a prospective cohort of COPD patients from 1994 to 2014. All-cause mortality was compared between patients who were colonized during their follow-up period (PA + ) and those who remained free of colonization (PA - ); Cox proportional hazards models were used. Exacerbation and hospitalization rates were evaluated by 2-rate χ 2 and segmented regression analysis for 12 months before and 24 months after PA isolation. RESULTS: Pseudomonas aeruginosa was isolated from sputum in 73 of 181 (40%) patients. Increased mortality was seen with PA isolation: 56 of 73 (77%) PA +  patients died compared with 73 of 108 (68%) PA - patients (P = .004). In adjusted models, PA +  patients had a 47% higher risk of mortality (adjusted hazard ratio = 1.47; 95% confidence interval, 1.03-2.11; P = .04). Exacerbation rates were higher for the PA +  group during preisolation (15.4 vs 9.0 per 100 person-months, P < .001) and postisolation periods (15.7 vs 7.5, P < .001). Hospitalization rates were higher during the postisolation period among PA +  patients (6.25 vs 2.44, P < .001). CONCLUSIONS: Tracheobronchial colonization by PA in COPD outpatients was associated with higher morbidity and mortality. This suggests that PA likely contributes to adverse clinical outcomes rather than just a marker of worsening disease.

Acute care patient portals: a qualitative study of stakeholder perspectives on current practices.

OBJECTIVE: To describe current practices and stakeholder perspectives of patient portals in the acute care setting. We aimed to: (1) identify key features, (2) recognize challenges, (3) understand current practices for design, configuration, and use, and (4) propose new directions for investigation and innovation. MATERIALS AND METHODS: Mixed methods including surveys, interviews, focus groups, and site visits with stakeholders at leading academic medical centers. Thematic analyses to inform development of an explanatory model and recommendations. RESULTS: Site surveys were administered to 5 institutions. Thirty interviews/focus groups were conducted at 4 site visits that included a total of 84 participants. Ten themes regarding content and functionality, engagement and culture, and access and security were identified, from which an explanatory model of current practices was developed. Key features included clinical data, messaging, glossary, patient education, patient personalization and family engagement tools, and tiered displays. Four actionable recommendations were identified by group consensus. DISCUSSION: Design, development, and implementation of acute care patient portals should consider: (1) providing a single integrated experience across care settings, (2) humanizing the patient-clinician relationship via personalization tools, (3) providing equitable access, and (4) creating a clear organizational mission and strategy to achieve outcomes of interest. CONCLUSION: Portals should provide a single integrated experience across the inpatient and ambulatory settings. Core functionality includes tools that facilitate communication, personalize the patient, and deliver education to advance safe, coordinated, and dignified patient-centered care. Our findings can be used to inform a "road map" for future work related to acute care patient portals.

Iterative user centered design for development of a patient-centered fall prevention toolkit.

Due to the large number of falls that occur in hospital settings, inpatient fall prevention is a topic of great interest to patients and health care providers. The use of electronic decision support that tailors fall prevention strategy to patient-specific risk factors, known as Fall T.I.P.S (Tailoring Interventions for Patient Safety), has proven to be an effective approach for decreasing hospital falls. A paper version of the Fall T.I.P.S toolkit was developed primarily for hospitals that do not have the resources to implement the electronic solution; however, more work is needed to optimize the effectiveness of the paper version of this tool. We examined the use of human factors techniques in the redesign of the existing paper fall prevention tool with the goal of increasing ease of use and decreasing inpatient falls. The inclusion of patients and clinical staff in the redesign of the existing tool was done to increase adoption of the tool and fall prevention best practices. The redesigned paper Fall T.I.P.S toolkit showcased a built in clinical decision support system and increased ease of use over the existing version.

Nutritional vitamin D supplementation and health-related outcomes in hemodialysis patients: a protocol for a systematic review and meta-analysis.

BACKGROUND: The prevalence of vitamin D deficiency in hemodialysis patients is high. While most hemodialysis patients are treated with activated vitamin D (1,25[OH]2D) to prevent renal osteodystrophy, clinical practices of the screening and treatment of 25(OH)2D deficiency are highly variable. It is unclear if nutritional vitamin D supplementation with D2 or D3 provides an additional clinical benefit beyond that provided by activated vitamin D treatment in this population. METHODS/DESIGN: We will conduct a systematic review of nutritional vitamin D (D2/D3) supplementation and health-related outcomes in hemodialysis patients according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary objective is to assess the impact of nutritional vitamin D supplementation on clinical outcomes relevant in hemodialysis patients, such as mortality, cardiovascular events, infections, and fractures. Secondary outcomes will include anemia, hyperparathyroidism, medication use (erythrocyte-stimulating agents, activated vitamin D), and quality of life. We will search MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov for randomized, controlled trials of nutritional vitamin D supplementation (ergocalciferol/D2 or cholecalciferol/D3) in chronic hemodialysis patients. The Cochrane Risk Assessment Tool will be used to assess the quality of eligible studies. We will perform meta-analyses using standard techniques for the outcomes listed above if pooling is deemed appropriate/sufficient. The results of this systematic review may highlight gaps in our knowledge of the relevance of nutritional vitamin D in end-stage renal disease, allowing for the informed design of clinical trials assessing the impact of nutritional vitamin D therapy in the hemodialysis population in the future. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014013931.

Histological quantification of angiogenesis after focal cerebral infarction: a systematic review.

Ischemic stroke is a leading cause of disability, and current treatments to improve recovery are limited. Part of the natural recovery process after brain injury is angiogenesis. The formation of new blood vessels around the infarct appears to be important for restoration of adequate perfusion to allow for healing of brain tissue. Many potential restorative treatments may affect, and be affected by, angiogenesis, so accurate quantification of this outcome is needed. We performed a systematic review of histological methods to quantify angiogenesis after cerebral infarction. We found reports of the use of a variety of histological and general and immunostaining techniques in conjunction with a variety of analysis methods. We found no direct comparison studies and concluded that more research is needed to optimize the assessment of this important stroke outcome.

Protein kinase D2 mediates lysophosphatidic acid-induced interleukin 8 production in nontransformed human colonic epithelial cells through NF-kappaB.

The signaling pathways mediating lysophosphatidic acid (LPA)-stimulated PKD(2) activation and the potential contribution of PKD(2) in regulating LPA-induced interleukin 8 (IL-8) secretion in nontransformed, human colonic epithelial NCM460 cells were examined. Treatment of serum-deprived NCM460 cells with LPA led to a rapid and striking activation of PKD(2), as measured by in vitro kinase assay and phosphorylation at the activation loop (Ser706/710) and autophosphorylation site (Ser876). PKD(2) activation induced by LPA was abrogated by preincubation with selective PKC inhibitors GF-I and Ro-31-8220 in a dose-dependent manner. These inhibitors did not have any direct inhibitory effect on PKD(2) activity. LPA induced a striking increase in IL-8 production and stimulated NF-kappaB activation, as measured by NF-kappaB-DNA binding, NF-kappaB-driven luciferase reporter activity, and IkappaBalpha phosphorylation. PKD(2) gene silencing utilizing small interfering RNAs targeting distinct PKD(2) sequences dramatically reduced LPA-stimulated NF-kappaB promoter activity and IL-8 production. PKD(2) activation is a novel early event in the biological action of LPA and mediates LPA-stimulated IL-8 secretion in NCM460 cells through a NF-kappaB-dependent pathway. Our results demonstrate, for the first time, the involvement of a member of the PKD family in the production of IL-8, a potent proinflammatory chemokine, by epithelial cells.