Transitional Care In Patients With Hirschsprung Disease: Those Left Behind.

BACKGROUND: The long term effects of Hirschsprung disease are clinically variable. Improved understanding of challenges patients may face as adults can help inform transitional care management. OBJECTIVE: To explore the outcomes and transitional care experiences in adult patients with Hirschsprung. DESIGN: Cohort study. SETTING: Single center. PATIENTS: All patients treated for Hirschsprung 1977-2001 (aged >18 at time of survey July 2018-2019). Eligible patients were sent validated multi-domain surveys as well as qualitative questions regarding their transitional care. MAIN OUTCOME MEASURES: Status of transitional care, bowel function and quality of life assessment. Qualitative analysis of transitional care experience. RESULTS: Of 139 patients, 20 had received transition care (10 had at least 1 visit but had been discharged and 10 were receiving ongoing follow-up). These patients had inferior bowel function and quality of life scores at follow-up. Twenty-three (17%) patients had issues with soiling at time of discharge, 7 received transitional care. Of these, 9/23 (39%) had a normal bowel function score (≥17), 5/23 (22%) had a poor score (<12) and one patient had since had a stoma formation. Eighteen (13%) patients had active moderate-severe issues related to bowel function, only 5 had been transitioned, and just 2 remained under ongoing care. Importantly, when these patients were discharged from our pediatric center, at a median age of 14 (IQR 12-16) years, 10/17 had no perceptible bowel issues, suggesting a worsening of function after discharge. LIMITATIONS: The retrospective design and reliance on clinical notes to gather information of discharge status as well as patient recall of events. CONCLUSION: There remains a small but significant proportion of Hirschsprung patients for whom bowel function either remains or becomes a major burden. These results support a need to better stratify patients requiring transitional care, and ensure a clear route to care if their status changes after discharge. See Video Abstract.

Long-term surgical and patient-reported outcomes of Hirschsprung Disease.

BACKGROUND: Information is needed regarding the complex relationships between long-term functional outcomes and health-related quality of life (HRQoL) in Hirschsprung's Disease (HSCR). We describe long-term outcomes across multiple domains, completing a core outcome set through to adulthood. METHODS: HSCR patients operated at a single center over a 35-year period (1978-2013) were studied. Patients completed detailed questionnaires on bowel and urologic function, and HRQOL. Patients with learning disability (LD) were excluded. Outcomes were compared to normative data. Data are reported as median [IQR] or mean (SD). RESULTS: 186 patients (median age 28 [18-32] years; 135 males) completed surveys. Bowel function was reduced (BFS 17 [14-19] vs. 19 [19-20], p < 0•0001;η2 = 0•22). Prevalence and severity of fecal soiling and fecal awareness improved with age (p < 0•05 for both). Urinary incontinence was more frequent than controls, most of all in 13-26y females (65% vs. 31%,p = 0•003). In adults, this correlated independently with constipation symptoms (OR 3.18 [1.4-7.5],p = 0.008). HRQoL outcomes strongly correlated with functional outcome: 42% of children demonstrated clinically significant reductions in overall PedsQL score, and poor bowel outcome was strongly associated with impaired QOL (B = 22•7 [12•7-32•7],p < 0•001). In adults, GIQLI scores were more often impacted in patients with extended segment disease. SF-36 scores were reduced relative to population level data in most domains, with large effect sizes noted for females in General Health (g = 1.19) and Social Wellbeing (g = 0.8). CONCLUSION: Functional impairment is common after pull-through, but bowel function improves with age. Clustering of poor functional outcomes across multiple domains identifies a need for early recognition and long-term support for these patients.

Relaxation training for management of paediatric headache: A rapid review.

The objective of this review was to assess the evidence on relaxation training for management of paediatric headaches. Our methodology was a rapid review of English-language peer reviewed published literature focused on studies evaluating relaxation training as a primary or adjunct management option for headache in a paediatric population (0 to 18 years of age). Seven studies involving 571 children were included in the review. The quality of evidence was very low using GRADE criteria. Headache frequency, duration, and intensity were the primary outcomes in the included studies. Results for the effects of relaxation training for paediatric headache are inconsistent. Four of the seven studies reported decreased headache frequency, two of the five studies reported decreased headache duration, and two of the six studies reported decreased headache intensity following relaxation training. No adverse events were reported. The current state of the evidence for relaxation training for management of paediatric headache is both inconsistent and of very low quality. High-quality research evaluating the effects of relaxation training for paediatric headaches is required to advance the field.

Views from the field: Medical student experiences and perceptions of interprofessional learning and collaboration in rural settings.

Exploring the perceived environment where students are educated, as well as where they practice, is particularly important for educators and practitioners working in situations of interprofessional rural and remote health. In this study, we explored the perceptions of undergraduate medical students regarding interprofessionalism across their four-year undergraduate program which focuses on rural health. A thematic content analysis of the text-data was conducted on a convenience sample of 47 student responses to essay questions across four cohorts of a four-year undergraduate medical program. The medical program has an explicit social accountability mandate for responsiveness to the needs of a rural population and thus students have multiple opportunities to experience interprofessional education and collaboration in rural contexts. Participants reported (a) blurring and flexibility of roles in a primarily positive manner, (b) participating in unstructured interprofessional learning and collaboration, (c) experiencing the importance of social connections to interprofessional collaboration and learning, and (d) realisations that interprofessional collaboration is a means of overcoming barriers in rural areas. We discuss our findings using the socio-material perspective of complexity theory. These findings may be used to inform undergraduate programs in re-defining, re-creating, developing, and fostering interprofessional learning opportunities for medical students in rural communities as well as to support clinical faculty through ongoing professional development.

An unusual presentation of ischaemic mitral regurgitation as P2 prolapse.

A 54-year-old gentleman presented with pulmonary oedema secondary to anterolateral papillary muscle (PPM) rupture and acute mitral regurgitation subsequent to myocardial ischaemia (MI). Angiography revealed complete occlusion of the first obtuse marginal (OM1) branch of the circumflex coronary artery and a 70% occlusion of the left anterior descending (LAD) coronary artery. Operatively, unusual anatomy was noted; an accessory head was attached superiorly to the anterior lateral PPM. This gave rise to chordae that were subsequently attached to the posterior second (P2) scallop. Additionally, the P2 scallop was deficient in chordae from the posteromedial PPM, thus, loss of this accessory head led to severe mitral regurgitation. We review the PPM anatomy and pathological context of PPM rupture and ischaemic mitral regurgitation.

Changes in Running Economy, Respiratory Exchange Ratio and VO2max in Runners following a 10-day Altitude Training Camp.

Running economy (RE) and VO2max are important predictors of endurance performance for elite and semi-elite endurance athletes, with RE being an appropriate predictor in a homogenous running population. Altitude training has been observed to change RE (mL.kg-1.min-1), and VO2max due to alterations resulting from acclimatization. This study tracked changes in RE and VO2max before and after a 10-day altitude training camp at 1828 meters. VO2max, RE expressed calorically, and respiratory exchange ratio (RER), were measured below anaerobic threshold (AT) to observe differences between pre-and post-altitude training. Eight varsity cross-country runners between the ages of 18 and 22 years performed an incremental treadmill test, pre- and post-10-day altitude training. Paired samples t-tests were used to statistically analyze the data. Average RE (VO2 mL.kg-1.min-1) improved following altitude intervention (M= 56.44 ± 4.28) compared to pre-altitude training (61.30 ± 7.56). These differences were statistically significant t(7)= 2.71, p =.014. RE expressed as kcals.kg-1.km-1 improved following altitude training (16.73 ± 2.96) compared to (18.44 ± 4.04) pre-altitude training and was statistically significant t(7) =3.08, p = .008. RER taken during the last minute of steady-state was higher (0.97, ± .019) post-altitude training, compared to (0.90 ± .043) pre-altitude. These differences were statistically significant t(7) -3.62, p =.008. VO2max (mL.kg-1.min-1) was lower in 6 out of 8 participants (63.91, ± 8.65) post-altitude compared to (69.90, ± 10.80) pre-altitude and was statistically significant t(7) = 2.33, p =.026. The observed improvements in RE may be beneficial for endurance athletes competing and/or training at moderate altitudes near 1828 meters.

The Effects of a 10-day Altitude Training Camp at 1828 Meters on Varsity Cross-Country Runners.

Altitude training has been shown to alter blood lactate (BL) levels due to alterations resulting from acclimatization. This study aims to estimate the impact of altitude training on BL changes immediately following an incremental treadmill test and during recovery before and after 10-day altitude training at approximately 1828 meters. Eight varsity cross-country runners performed an incremental treadmill test (ITT), pre and post-altitude training. Resting and post-warm-up BL values were recorded. During ITT, heart rate (HR), oxygen saturation (SpO2), and time to exhaustion were monitored. BL was also measured post-ITT at 0, 2, 4, 6, and 8 minutes. The average of all BL values was higher following altitude intervention (8.8 ± 4.6 mmol/L) compared to pre-intervention (7.4 ± 3.3 mmol/L). These differences were statistically significant (t(6) = -2.40, p = .026). BL immediately (0 minutes) after the ITT was higher following the altitude intervention (13.6 ± 3.6 mmol/L) compared to pre-intervention (9.7 ± 3.8 mmol/L) and was statistically significant (t(7) = -3.30, p = .006). Average HR during the ITT was lower following the altitude intervention (176.9 ± 11.1 bpm) compared to pre (187 ± 9.5 bpm), these differences were statistically significant (t(28)= 18.07, p= <.001. Time to exhaustion was longer after the intervention, however was not statistically significant p = 0.13. These findings indicate that a 10 - day altitude intervention at 1828 meters may benefit varsity cross-country runners. The higher post-exercise BL may be attributed to more anaerobic contributions. Lower HR may suggest a larger stroke volume and/or more efficient O2 carrying capacity.

Scoping review of complexity theory in health services research.

BACKGROUND: There are calls for better application of theory in health services research. Research exploring knowledge translation and interprofessional collaboration are two examples, and in both areas, complexity theory has been identified as potentially useful. However, how best to conceptualize and operationalize complexity theory in health services research is uncertain. The purpose of this scoping review was to explore how complexity theory has been incorporated in health services research focused on allied health, medicine, and nursing in order to offer guidance for future application. Given the extensiveness of how complexity theory could be conceptualized and ultimately operationalized within health services research, a scoping review of complexity theory in health services research is warranted. METHODS: A scoping review of published research in English was conducted using CINAHL, EMBASE, Medline, Cochrane, and Web of Science databases. We searched terms synonymous with complexity theory. RESULTS: We included 44 studies in this review: 27 were qualitative, 14 were quantitative, and 3 were mixed methods. Case study was the most common method. Long-term care was the most studied setting. The majority of research was exploratory and focused on relationships between health care workers. Authors most commonly used complexity theory as a conceptual framework for their study. Authors described complexity theory in their research in a variety of ways. The most common attributes of complexity theory used in health services research included relationships, self-organization, and diversity. A common theme across descriptions of complexity theory is that authors incorporate aspects of the theory related to how diverse relationships and communication between individuals in a system can influence change. CONCLUSION: Complexity theory is incorporated in many ways across a variety of research designs to explore a multitude of phenomena.. Although complexity theory shows promise in health services research, particularly related to relationships and interactions, conceptual confusion and inconsistent application hinders the operationalization of this potentially important perspective. Generalizability from studies that incorporate complexity theory is, therefore, difficult. Heterogeneous conceptualization and operationalization of complexity theory in health services research suggests there is no universally agreed upon approach of how to use this theory in health services research. Future research should include clear definitions and descriptions of complexity and how it was used in studies. Clear reporting will aid in determining how best to use complexity theory in health services research.

Surgical aspects of celiac disease.

Celiac disease, characterized by intestinal inflammation and malabsorption, occurs in 1 per cent of the population and is often undiagnosed. These patients are at increased risk for surgical procedures resulting from symptoms, associated intestinal disorders, and malignancy. Our aim was to determine the incidence and outcome of abdominal operations in patients with celiac disease. Records of 512 adult patients with celiac disease evaluated over a 22-year period were reviewed. Operations were classified as related or unrelated to celiac disease. One hundred eighty-eight (36%) of 512 patients underwent abdominal operations. One hundred twenty-seven (68%) of the 188 patients had unrelated procedures. Sixty-one (32%) had operations considered related to celiac disease. Twenty-six (43%) of 61 with related procedures were diagnosed preoperatively. Procedures were performed for pain, obstruction, motility disorders, and malignancy. Six patients had recurrent pancreatitis. Seven patients underwent liver transplantation. Thirty-five (57%) related procedures led to the diagnosis of celiac disease including "unmasking" (n = 25) and diagnostic findings (n = 10). One-third of patients with celiac disease undergo abdominal operations of which one-third are related to celiac disease. Operations are related to complications of celiac disease and often lead to the initial diagnosis.

Hospital-wide infection control practice and Meticillin-resistant Staphylococcus aureus (MRSA) in the intensive care unit (ICU): an observational study.

OBJECTIVES: To estimate trends in infection/colonisation with meticillin-resistant Staphylococcus aureus (MRSA) in an intensive care unit (ICU). DESIGN: Observational study of results of ICU admission and weekly screens for MRSA. SETTING AND PARTICIPANTS: All ICU admissions in 2001-2012. INTERVENTIONS: ICU admissions were screened for MRSA throughout. In late 2006, screening was extended to the whole hospital and extra measures taken in ICU. MAIN OUTCOME MEASURES: Prevalence of MRSA in ICU admissions and number acquiring MRSA therein. RESULTS: In all, 366 of 6565 admissions to ICU were MRSA positive, including 270 of 4466 coming from within the hospital in which prevalence increased with time prior to transfer to ICU. Prevalence in this group was 9.4% (8.2-10.6) in 2001-2006, decreasing to 3.4% (2.3-4.5) in 2007-2009 and 1.3% (0.6-2.0) in 2010-2012, p < 0.001, due to decreased prevalence in those spending >5 days on wards before ICU admission: 18.9% (15.6-22.2) in 2001-2006, 7.1% (4.0-10.2) in 2007-2009 and 1.6% (0.1-3.1) in 2010-2012, p < 0.001. In addition, 201 patients acquired MRSA within ICU, the relative risk being greater when known positives present: 4.34 (3.98-4.70), p < 0.001. Acquisition rate/1000 bed days decreased from 13.3 (11.2-15.4) in 2001-2006 to 3.6 (2.6-4.6) in 2007-2012, p < 0.0001. Of 41 ICU-acquired MRSA bacteraemias, 38 were in 2001-2006. The risk of bacteraemia in those acquiring MRSA decreased from 25% (18.1-31.9) in 2001-2006 to 6.1% (0-12.8) thereafter, p = 0.022. CONCLUSIONS: Following better hospital-wide infection control, fewer MRSA-positive patients were admitted to ICU with a parallel decrease in acquisition therein. Better practice there reduced the risk of bacteraemia.

Efficient, physiologically realistic lung airflow simulations.

One of the key challenges for computational fluid dynamics (CFD) simulations of human lung airflow is the sheer size and complexity of the complete, multiscale geometry of the bronchopulmonary tree. Since 3-D CFD simulations of the full airway tree are currently intractable, researchers have proposed reduced geometry models in which multiple airway paths are truncated downstream of the first few generations. This paper investigates a recently proposed method for closing the CFD model by application of physiologically correct boundary conditions at truncated outlets. A realistic, reduced geometry model of the lung airway based on CT data has been constructed up to generation 18, including extrathoracic, bronchi, and bronchiole regions. Results indicate that the new method yields reasonable results for pressure drop through the airway, at a small fraction of the cost of fully resolved simulations.

The BARRIERS scale -- the barriers to research utilization scale: A systematic review.

BACKGROUND: A commonly recommended strategy for increasing research use in clinical practice is to identify barriers to change and then tailor interventions to overcome the identified barriers. In nursing, the BARRIERS scale has been used extensively to identify barriers to research utilization. AIM AND OBJECTIVES: The aim of this systematic review was to examine the state of knowledge resulting from use of the BARRIERS scale and to make recommendations about future use of the scale. The following objectives were addressed: To examine how the scale has been modified, to examine its psychometric properties, to determine the main barriers (and whether they varied over time and geographic locations), and to identify associations between nurses' reported barriers and reported research use. METHODS: Medline (1991 to September 2009) and CINHAL (1991 to September 2009) were searched for published research, and ProQuest(R) digital dissertations were searched for unpublished dissertations using the BARRIERS scale. Inclusion criteria were: studies using the BARRIERS scale in its entirety and where the sample was nurses. Two authors independently assessed the study quality and extracted the data. Descriptive and inferential statistics were used. RESULTS: Sixty-three studies were included, with most using a cross-sectional design. Not one study used the scale for tailoring interventions to overcome identified barriers. The main barriers reported were related to the setting, and the presentation of research findings. Overall, identified barriers were consistent over time and across geographic locations, despite varying sample size, response rate, study setting, and assessment of study quality. Few studies reported associations between reported research use and perceptions of barriers to research utilization. CONCLUSIONS: The BARRIERS scale is a nonspecific tool for identifying general barriers to research utilization. The scale is reliable as reflected in assessments of internal consistency. The validity of the scale, however, is doubtful. There is no evidence that it is a useful tool for planning implementation interventions. We recommend that no further descriptive studies using the BARRIERS scale be undertaken. Barriers need to be measured specific to the particular context of implementation and the intended evidence to be implemented.

The relationship between busyness and research utilization: it is about time.

AIMS AND OBJECTIVES: To explore the concept of busyness in nursing and to understand the relationship between busyness and nurses' research utilization better. BACKGROUND: Lack of time and busyness are consistently reported as barriers to research utilization. Current literature fails to identify the dimensions of busyness and offers little insight into the relationship between busyness and nurses' research utilization. DESIGN/METHODS: We performed a secondary analysis of qualitative data and created a conceptual map of busyness in nursing. RESULTS: Our results suggested that busyness consists of physical and psychological dimensions. Interpersonal and environmental factors influenced both dimensions. Cultural and intrapersonal factors contributed to psychological elements. The effects of busyness reported included missed opportunities, compromised safety, emotional and physical strain, sacrifice of personal time, incomplete nursing care and the inability to find or use resources. CONCLUSIONS: Our beginning description of busyness contributes to a greater understanding of the relationship between busyness and research utilization. Our findings suggest that lack of time as a barrier to research utilization is more complex than depicted in the literature. Instead, the mental time and energy required to navigate complex environments and a culture of busyness more accurately reflect what may be meant by 'lack of time' as a barrier to research utilization. RELEVANCE TO CLINICAL PRACTICE: Future interventions aimed at increasing research utilization may be more effective if they focus on factors that contribute to a culture of busyness in nursing and address the mental time and energy required for nurses to use research in practice.

The mouse frizzy mutation (fr) maps between D7Csu5 and D7Mit165.

We have previously shown that the rat fuzzy and Charles River 'hairless' mutations are defects in the same gene on rat Chr 1, and are likely orthologues of the frizzy mutation (fr) on mouse Chr 7. To test the hypothesis that these variants could result from defects in Fgfr2, we crossed fr/fr mice (from the inbred FS/EiJ strain) with mice that carry a recessive lethal mutation in Fgfr2. Mice inheriting both mutations were phenotypically normal, indicating that fr is not an allele of Fgfr2. To genetically map fr, we crossed these hybrid mice, or F(1) mice made by crossing FS/EiJ with the wild-type C57BL/6J or BALB/cBy strains, back to the FS/EiJ strain. The resulting 546 backcross progeny were typed for linked markers to position fr centromeric of Fgfr2, between D7Csu5 and D7Mit165; an interval that contains only 2.7 Mb and fewer than 70 genes. Further characterization of regional recombinants for sequence-level polymorphisms should allow sufficient refinement of fr's location to facilitate an eventual molecular assignment for this classical mutation.

Interventions aimed at increasing research use in nursing: a systematic review.

BACKGROUND: There has been considerable interest recently in developing and evaluating interventions to increase research use by clinicians. However, most work has focused on medical practices; and nursing is not well represented in existing systematic reviews. The purpose of this article is to report findings from a systematic review of interventions aimed at increasing research use in nursing. OBJECTIVE: To assess the evidence on interventions aimed at increasing research use in nursing. METHODS: A systematic review of research use in nursing was conducted using databases (Medline, CINAHL, Healthstar, ERIC, Cochrane Central Register of Controlled Trials, and Psychinfo), grey literature, ancestry searching (Cochrane Database of Systematic Reviews), key informants, and manual searching of journals. Randomized controlled trials and controlled before- and after-studies were included if they included nurses, if the intervention was explicitly aimed at increasing research use or evidence-based practice, and if there was an explicit outcome to research use. Methodological quality was assessed using pre-existing tools. Data on interventions and outcomes were extracted and categorized using a pre-established taxonomy. RESULTS: Over 8,000 titles were screened. Three randomized controlled trials and one controlled before- and after-study met the inclusion criteria. The methodological quality of included studies was generally low. Three investigators evaluated single interventions. The most common intervention was education. Investigators measured research use using a combination of surveys (three studies) and compliance with guidelines (one study). Researcher-led educational meetings were ineffective in two studies. Educational meetings led by a local opinion leader (one study) and the formation of multidisciplinary committees (one study) were both effective at increasing research use. CONCLUSION: Little is known about how to increase research use in nursing, and the evidence to support or refute specific interventions is inconclusive. To advance the field, we recommend that investigators: (1) use theoretically informed interventions to increase research use, (2) measure research use longitudinally using theoretically informed and psychometrically sound measures of research use, as well as, measuring patient outcomes relevant to the intervention, and (3) use more robust and methodologically sound study designs to evaluate interventions. If investigators aim to establish a link between using research and improved patient outcomes they must first identify those interventions that are effective at increasing research use.

A guide to knowledge translation theory.

Despite calls over several decades for theory development, there remains no overarching knowledge-translation theory. However, a range of models and theoretical perspectives focused on narrower and related areas have been available for some time. We provide an overview of selected perspectives that we believe are particularly useful for developing testable and useful knowledge-translation interventions. In addition, we discuss adjuvant theories necessary to complement these perspectives. We draw from organizational innovation, health, and social sciences literature to illustrate the similarities and differences of various theoretical perspectives related to the knowledge-translation field.A variety of theoretical perspectives useful to knowledge translation exist. They are often spread across disciplinary boundaries, making them difficult to locate and use. Poor definitional clarity, discipline-specific terminology, and implicit assumptions often hinder the use of complementary perspectives. Health care environments are complex, and assessing the setting prior to selecting a theory should be the first step in knowledge-translation initiatives. Finding a fit between setting (context) and theory is important for knowledge-translation initiatives to succeed. Because one theory will not fit all contexts, it is helpful to understand and use several different theories. Although there are often barriers associated with combining theories from different disciplines, such obstacles can be overcome, and to do so will increase the likelihood that knowledge-translation initiatives will succeed.

Sepsis alert and diagnostic system: integrating clinical systems to enhance study coordinator efficiency.

Screening patients for clinical studies is time-consuming for researchers. Inefficiencies from human-based eligibility screening cause delay in scientific breakthroughs and are costly. We sought to determine the reliability of an automated computer-based real-time eligibility screening tool. A time-motion diary study was conducted in two university-based intensive care units using a cohort-controlled design. Time saved by automated eligibility screening and the positive and negative predictive values of the integrated eligibility screening system were compared with the gold standard of manual chart review. Sepsis Alert and Diagnostic System sensitivity and specificity were 82% and 95%, respectively. Positive and negative predictive values were 87.5% and 93%, respectively. During evaluation, Sepsis Alert and Diagnostic System saved a minimum of 137 minutes for the study coordinator. Sepsis Alert and Diagnostic System serves as a reliable tool for real-time eligibility screening in an intensive care unit setting. Time efficiencies through use of Sepsis Alert and Diagnostic System may translate into cost savings for funding agencies. The concept and methodology deployed in this study are applicable to any facility with electronic medical record capacity, as long as the data within that system are granular enough to support the specific query.