Exploring the Application of Interpretive Description in Chronic Illness: A Scoping Review.

BACKGROUND AND PURPOSE: Chronic illness is a complex condition that affects over one billion people. To develop a deeper insight of the needs of this patient population, interpretive description uses disciplinary knowledge as the source of understanding. This methodology is a pragmatic approach to research without focusing on a strict methodological directive. The aims of this scoping review are twofold, (a) to describe the findings of studies that have used Thorne's interpretive description to research chronic illness and (b) to discuss the application of interpretive description in clinical research. Thereby, showing interpretive description as a valuable tool to advance nursing knowledge and patient care. METHODS: The methodological framework for this review was based on the Johanna Briggs Institute guidelines for scoping reviews. RESULTS: To develop an understanding of interpretive description, it is essential to examine the results of studies which have applied the methodology. Our scoping review showed that researchers utilizing interpretive description identified four common challenges experienced by individuals living with chronic illness: symptom management, education and knowledge, supportive care, and cultural disadvantages. By demonstrating how interpretive description is applied, it shows how it can be used to understand and interpret clinical phenomena to improve practice. IMPLICATION FOR PRACTICE: This scoping review demonstrates how interpretive description was used to develop knowledge about chronic illness. The premise of interpretive description is that disciplinary knowledge offers a sufficient foundation to develop meaningful research to support health practices. By approaching research from a disciplinary perspective, new knowledge can be discovered to complex health problems.

Efficacy of ferumoxytol versus sodium ferric gluconate in anemia management in outpatient hemodialysis patients: A prospective cohort study.

BACKGROUND: Intravenous iron is one of the main therapies for anemia management in hemodialysis-dependent patients. Data comparing the efficacy of ferumoxytol versus other parenteral iron supplements are scarce. The objective of the study was to compare the efficacy of ferumoxytol with that of sodium ferric gluconate in outpatient hemodialysis patients. MATERIALS AND METHODS: A prospective, observational study was conducted in outpatients receiving ferumoxytol 510 mg once or twice quarterly compared to sodium ferric gluconate 125 mg weekly in a single center hemodialysis center in Ontario, Canada. Patient demographics, hemoglobin levels, iron indices, iron doses, and erythropoiesis-stimulating agent (ESA) doses were collected. RESULTS: The study sample consisted of 291 observations from 173 patients. Generalized estimating equations of multiple linear regression modeling were conducted to compare the outcomes while adjusting for baseline scores. Approximately 25% of the study participants received ferumoxytol while 75% received sodium ferric gluconate. Patients treated were mainly males (58.4%), and the mean age was 68.73 (SD ± 13.03) years. Both groups did not show significant differences in their hemoglobin levels (Wald z = 0.54; p = 0.46), ESA utilization at 3 months (Wald z = 0.20; p = 0.65), and TSAT levels (Wald z = 3.45; p = 0.06). However, the iron levels (Wald z = 4.24; p = 0.04) and ferritin levels (Wald z = 5.14; p = 0.02) were higher in the ferric gluconate group (Wald z = 58.78; p ≤ 0.001), and patients who received ferumoxytol received more blood transfusions as compared to those who received sodium ferric gluconate (χ2 = 16.71; p ≤ 0.001). CONCLUSION: Both iron products maintained hemoglobin levels, but patients receiving ferumoxytol had lower iron indices and received more blood transfusions compared to patients who received sodium ferric gluconate.

Multivariate Outliers: A Conceptual and Practical Overview for the Nurse and Health Researcher.

The presence of statistical outliers is a shared concern in research. If ignored or improperly handled, outliers have the potential to distort parameter estimates and possibly compromise the validity of research findings. The purpose of this paper is to provide a conceptual and practical overview of multivariate outliers with a focus on common techniques used to identify and manage multivariate outliers. Specifically, this paper discusses the use of Mahalanobis distance and residual statistics as common multivariate outlier identification techniques. It also discusses the use of leverage and Cook's distance as two common techniques to determine the influence that multivariate outliers may have on statistical models. Finally, this paper discusses techniques that are commonly used to handle influential multivariate outlier cases.

The Population Health OutcomEs aNd Information EXchange (PHOENIX) Program - A Transformative Approach to Reduce the Burden of Chronic Disease.

This concept article introduces a transformative vision to reduce the population burden of chronic disease by focusing on data integration, analytics, implementation and community engagement. Known as PHOENIX (The Population Health OutcomEs aNd Information EXchange), the approach leverages a state level health information exchange and multiple other resources to facilitate the integration of clinical and social determinants of health data with a goal of achieving true population health monitoring and management. After reviewing historical context, we describe how multilevel and multimodal data can be used to facilitate core public health services, before discussing the controversies and challenges that lie ahead.

Guidance for the Reporting of an Intervention's Theory.

BACKGROUND: Interventions in clinical trials should be clearly and completely described to inform their evaluation in replication studies and implementation in clinical practice. Guidelines were developed to standardize the reporting of interventions, but failed to provide guidance on reporting of the theory of interventions. Further, space constraints imposed by many research journals often limit the comprehensive description of both the theoretical and operational aspects of interventions. PURPOSE: To address these gaps, we propose that the theory of interventions be published in separate conceptual papers that would provide an in-depth description of the health problem targeted by an intervention, the components comprising an intervention, the causal mechanism responsible for an intervention's impact on the outcomes, and the conditions necessary for the proper implementation and the effectiveness of an intervention. IMPLICATIONS: Such papers would assist in the critical appraisal of the adequacy, implementation, and evaluation of interventions. A description of the theory of interventions clarifies to health professionals what the interventions are about, who is likely to benefit from the interventions, how the interventions work and under what context.

One Stop: Examining the Reasons Patients Use the Emergency Department for Nonurgent Care and the Barriers They Face.

INTRODUCTION: Despite the plethora of research on the use of emergency department services for nonurgent primary health care, the vast majority of this research is quantitative in nature. To date, there is little research that reports on the problem from the patients' perspective and/or lived experience, which compromises health care providers' understanding of the essence of the problem as described by the patients. Thus, this study will provide a qualitative description of nonurgent ED visits from the patients' perspective. Specifically, this study answers the following research questions: 1) What are the reasons for patients and/or caregivers visiting the emergency department for nonurgent health conditions? and 2) What are the barriers experienced by patients and/or caregivers when seeking access to health care? METHODS: A qualitative descriptive design with face-to-face interviews of 33 consenting participants was conducted at 4 emergency departments. All interviewed participants were triaged as nonurgent patients by the ED personnel. RESULTS: Three themes surfaced from the data regarding reasons for using the emergency department: 1) Practitioner referral; 2) Efficacy of care; and 3) Time saver. When describing barriers that participants experienced when seeking care outside of the emergency department for their nonurgent conditions, 3 themes that emerged are lack of primary care provider, financial difficulties, and lack of comprehensive care outside the emergency department. DISCUSSION: The results of the study can help inform patient-centered care and future policy initiatives that will address the practices and barriers contributing to nonurgent ED visits.

Efficacy of alteplase 1 versus 2 mg dose in restoring haemodialysis catheter function (Alte-dose 2): A randomized double-blind controlled study.

AIM: Data about the optimal alteplase dose required to treat haemodialysis catheter occlusion (HDC) are scarce. The purpose of the clinical trial was to examine the effectiveness of alteplase 2 mg as compared with 1 mg in restoring HDC function. METHODS: A double-blind, randomized, controlled clinical trial was conducted in a single-centre in southwestern Ontario, Canada. Rate of clot resolution, catheter replacements, catheter stripping, and mean catheter survival time were assessed using Kaplan-Meier, Cox-proportional hazard and clustered logic regression analyses. RESULTS: On a sample of 48 haemodialysis patients who provided 252 catheter occlusion events, the rate of clot resolution at the catheter site in the 2 mg group was 85.7% as opposed to 84.9% in the 1 mg group. There were only six catheter removals and 10 catheter stripping events. Cox regression analysis revealed no difference between the two groups in the hazard of occlusion on the primary 48 observations after the initial alteplase management (P = 0.267; hazard ratio = 0.72; 95% confidence interval 0.40-1.3). Correlated logistic regression on all 252 observations indicated no difference in the rate of post alteplase clot resolution (P = 0.336; odds ratio = 2.4, 95% confidence interval 0.399-14.6) between the two groups. CONCLUSION: Alteplase 1 mg is as effective as 2 mg in restoring HDC malfunction and may result in cost reduction in haemodialysis units.

Factors predicting vancomycin therapy outcomes in hemodialysis outpatients and the role of the nephrology stewardship pharmacist.

BACKGROUND: Vancomycin is the default antibiotic to treat methicillin-resistant Staphylococcus aureus (MRSA) in hemodialysis (HD) units. Current guidelines recommend a vancomycin trough range of 15 to 20 mg/L for serious infections. Data regarding the clinical success of these recommendations are scarce in HD patients. PURPOSE: The purpose of this studies is to evaluate the treatment outcomes of vancomycin in HD patients. METHODS: A retrospective chart review of HD outpatients who received parenteral vancomycin for suspected or documented MRSA infections in a community hospital in southwestern Ontario, Canada. Stepwise binary logistic regression analysis was conducted to identify the independent predictors of the treatment outcomes. RESULTS: Of 77 HD patients, 113 vancomycin treatment courses were identified. The unadjusted bivariate comparisons suggested that there was no difference between treatment success and failure groups in terms of: mean loading dose (1663.6 ± 451.9 mg vs. 1614.3 ± 471 mg, P = 0.621), mean pre-HD concentration after loading dose (12.78 ± 4.4 mg/L vs. 13.34 ± 4.5 mg/L, P = 0.601), and mean maintenance dose (1012.1 ± 108 mg vs. 1069.7 ± 227 mg, P = 0.093). The groups were, however, different on their mean pre-HD drug concentration after maintenance dose (15.99 ± 4.6 mg/L vs. 19.9 ± 5.8 mg/L, P = 0.002). The adjusted logistic regression results, however, suggested that the type of infection was the only independent predictor of vancomycin success (OR = 11.07; 95% confidence interval [CI] = 3.2-38.48). Specifically, patients treated for bacteremia were 11 times more likely to experience cure as compared with diabetic foot infection and/or osteomyelitis. Similarly, those with skin and soft tissue infections were 10.7 times more likely to experience cure than those with diabetic foot infection and/or osteomyelitis (OR = 10.7; 95% CI = 3.63-31.58). CONCLUSION: The suggested vancomycin pre-HD concentration in the guidelines did not predict the treatment outcomes. Patients with bacteremia and/or skin or soft tissue infections were more likely to achieve clinical cure than patients with diabetic foot/osteomyelitis infections.

Exploring the factors associated with non-urgent emergency department utilisation for mental health care.

BACKGROUND: Emergency department visits for mental health care are on the rise across North America. Patients with mental illness are at an increased risk for frequent and non-urgent emergency department visitation. AIMS: The purpose of this study was to examine the independent predictors of non-urgent emergency department use for mental health care. METHODS: A secondary data analysis was conducted with archived data provided by the Erie St. Clair Local Health Integration Network in Ontario. RESULTS: A total of 13,114 mental health-related emergency department visits were analysed using logistic regression with generalised estimating equations modelling. The findings suggest the following characteristics are predictive of non-urgent emergency department use for mental health care: age, season, time of day, access to primary health care, mode of arrival, hospital type, referral source and patient diagnosis. CONCLUSIONS: The findings of this study can be utilised to assist clinicians and policy makers in identifying and managing patients using the emergency department for non-urgent mental health care.

Univariate Outliers: A Conceptual Overview for the Nurse Researcher.

The presence of statistical outliers is a shared concern in research. If ignored or improperly handled, outliers have the potential to distort the estimate of the parameter of interest and thus compromise the generalizability of research findings. A variety of statistical techniques are available to assist researchers with the identification and management of outlier cases. The purpose of this paper is to provide a conceptual overview of univariate outliers with special focus on common techniques used to detect and manage univariate outliers. Specifically, this paper discusses the use of histograms, boxplots, interquartile range, and z-score analysis as common univariate outlier identification techniques. The paper also discusses the outlier management techniques of deletion, substitution, and transformation.

Predicting Maintenance Doses of Vancomycin for Hospitalized Patients Undergoing Hemodialysis.

BACKGROUND: Methicillin-resistant Staphylococcus aureus is a leading cause of death in patients undergoing hemodialysis. However, controversy exists about the optimal dose of vancomycin that will yield the recommended pre-hemodialysis serum concentration of 15-20 mg/L. OBJECTIVE: To develop a data-driven model to optimize the accuracy of maintenance dosing of vancomycin for patients undergoing hemodialysis. METHODS: A prospective observational cohort study was performed with 164 observations obtained from a convenience sample of 63 patients undergoing hemodialysis. All vancomycin doses were given on the floor after completion of a hemodialysis session. Multivariate linear generalized estimating equation analysis was used to examine independent predictors of pre-hemodialysis serum vancomycin concentration. RESULTS: Pre-hemodialysis serum vancomycin concentration was independently associated with maintenance dose (B = 0.658, p < 0.001), baseline pre-hemodialysis serum concentration of the drug (B = 0.492, p < 0.001), and interdialytic interval (B = -2.133, p < 0.001). According to the best of 4 models that were developed, the maintenance dose of vancomycin required to achieve a pre-hemodialysis serum concentration of 15-20 mg/L, if the baseline serum concentration of the drug was also 15-20 mg/L, was 5.9 mg/kg with interdialytic interval of 48 h and 7.1 mg/kg with interdialytic interval of 72 h. However, if the baseline pre-hemodialysis serum concentration was 10-14.99 mg/L, the required dose increased to 9.2 mg/kg with an interdialytic interval of 48 h and 10.0 mg/kg with an interdialytic interval of 72 h. CONCLUSIONS: The maintenance dose of vancomycin varied according to baseline pre-hemodialysis serum concentration of the drug and interdialytic interval. The current practice of targeting a pre-hemodialysis concentration of 15-20 mg/L may be difficult to achieve for the majority of patients undergoing hemodialysis.

Les infections à Staphylococcus aureus résistant à la méthicilline comptent parmi les principales causes de mortalité chez les patients traités par hémodialyse. Or, les avis sont partagés quant à la dose optimale de vancomycine qui permet d'atteindre la concentration sérique recommandée de 15­20 mg/L préalablement à l'hémodialyse.