Connectivity-guided intermittent theta burst versus repetitive transcranial magnetic stimulation for treatment-resistant depression: a randomized controlled trial.

Disruption in reciprocal connectivity between the right anterior insula and the left dorsolateral prefrontal cortex is associated with depression and may be a target for neuromodulation. In a five-center, parallel, double-blind, randomized controlled trial we personalized resting-state functional magnetic resonance imaging neuronavigated connectivity-guided intermittent theta burst stimulation (cgiTBS) at a site based on effective connectivity from the right anterior insula to the left dorsolateral prefrontal cortex. We tested its efficacy in reducing the primary outcome depression symptoms measured by the GRID Hamilton Depression Rating Scale 17-item over 8, 16 and 26 weeks, compared with structural magnetic resonance imaging (MRI) neuronavigated repetitive transcranial magnetic stimulation (rTMS) delivered at the standard stimulation site (F3) in patients with 'treatment-resistant depression'. Participants were randomly assigned to 20 sessions over 4-6 weeks of either cgiTBS (n = 128) or rTMS (n = 127) with resting-state functional MRI at baseline and 16 weeks. Persistent decreases in depressive symptoms were seen over 26 weeks, with no differences between arms on the primary outcome GRID Hamilton Depression Rating Scale 17-item score (intention-to-treat adjusted mean, -0.31, 95% confidence interval (CI) -1.87, 1.24, P = 0.689). Two serious adverse events were possibly related to TMS (mania and psychosis). MRI-neuronavigated cgiTBS and rTMS were equally effective in patients with treatment-resistant depression over 26 weeks (trial registration no. ISRCTN19674644).

'Function First': how to promote physical activity and physical function in people with long-term conditions managed in primary care? A study combining realist and co-design methods.

OBJECTIVES: To develop a taxonomy of interventions and a programme theory explaining how interventions improve physical activity and function in people with long-term conditions managed in primary care. To co-design a prototype intervention informed by the programme theory. DESIGN: Realist synthesis combining evidence from a wide range of rich and relevant literature with stakeholder views. Resulting context, mechanism and outcome statements informed co-design and knowledge mobilisation workshops with stakeholders to develop a primary care service innovation. RESULTS: A taxonomy was produced, including 13 categories of physical activity interventions for people with long-term conditions. ABRIDGED REALIST PROGRAMME THEORY: Routinely addressing physical activity within consultations is dependent on a reinforcing practice culture, and targeted resources, with better coordination, will generate more opportunities to address low physical activity. The adaptation of physical activity promotion to individual needs and preferences of people with long-term conditions helps affect positive patient behaviour change. Training can improve knowledge, confidence and capability of practice staff to better promote physical activity. Engagement in any physical activity promotion programme will depend on the degree to which it makes sense to patients and professions, and is seen as trustworthy. CO-DESIGN: The programme theory informed the co-design of a prototype intervention to: improve physical literacy among practice staff; describe/develop the role of a physical activity advisor who can encourage the use of local opportunities to be more active; and provide materials to support behaviour change. CONCLUSIONS: Previous physical activity interventions in primary care have had limited effect. This may be because they have only partially addressed factors emerging in our programme theory. The co-designed prototype intervention aims to address all elements of this emergent theory, but needs further development and consideration alongside current schemes and contexts (including implications relevant to COVID-19), and testing in a future study. The integration of realist and co-design methods strengthened this study.

'Function First-Be Active, Stay Independent'-promoting physical activity and physical function in people with long-term conditions by primary care: a protocol for a realist synthesis with embedded co-production and co-design.

INTRODUCTION: People with long-term conditions typically have reduced physical functioning, are less physically active and therefore become less able to live independently and do the things they enjoy. However, assessment and promotion of physical function and physical activity is not part of routine management in primary care. This project aims to develop evidence-based recommendations about how primary care can best help people to become more physically active in order to maintain and improve their physical function, thus promoting independence. METHODS AND ANALYSIS: This study takes a realist synthesis approach, following RAMESES guidance, with embedded co-production and co-design. Stage 1 will develop initial programme theories about physical activity and physical function for people with long-term conditions, based on a review of the scientific and grey literature, and two multisector stakeholder workshops using LEGO® SERIOUS PLAY®. Stage 2 will involve focused literature searching, data extraction and synthesis to provide evidence to support or refute the initial programme theories. Searches for evidence will focus on physical activity interventions involving the assessment of physical function which are relevant to primary care. We will describe 'what works', 'for whom' and 'in what circumstances' and develop conjectured programme theories using context, mechanism and outcome configurations. Stage 3 will test and refine these theories through individual stakeholder interviews. The resulting theory-driven recommendations will feed into Stage 4 which will involve three sequential co-design stakeholder workshops in which practical ideas for service innovation in primary care will be developed. ETHICS AND DISSEMINATION: Healthcare and Medical Sciences Academic Ethics Committee (Reference 2018-16308) and NHS Wales Research Ethics Committee 5 approval (References 256 729 and 262726) have been obtained. A knowledge mobilisation event will address issues relevant to wider implementation of the intervention and study findings. Findings will be disseminated through peer-reviewed journal publications, conference presentations and formal and informal reports. PROSPERO REGISTRATION NUMBER: CRD42018103027.

Point-of-use filters for prevention of health care-acquired Legionnaires' disease: Field evaluation of a new filter product and literature review.

BACKGROUND: The Centers for Medicare & Medicaid Services requires that health care facilities assess their building water systems and minimize the risk of growth and spread of Legionella and other waterborne pathogens. Increasingly, point-of-use (POU) filters are being used to prevent exposure to these pathogens. This study provides efficacy and performance specifications (membrane size, pore size, and use restrictions), which will aid in selecting POU filters. METHODS: New faucet and shower filters rated for 62 days of use were evaluated at an acute care facility in Southwestern Ontario, Canada. Five faucets and 5 showers served as controls or were equipped with filters. Hot water samples were collected weekly for 12 weeks and cultured for Legionella, heterotrophic plate count, and Pseudomonas. Literature searches for articles on POU filters used in health care settings were performed using PubMed and Google Scholar. Filter specifications from 5 manufacturers were also compared. RESULTS: The 62-day POU filters installed on both faucets and showers eliminated Legionella and reduced heterotrophic plate count concentrations for 12 weeks. No Pseudomonas was recovered during this study. Twenty peer-reviewed studies are summarized, and 21 features of 53 POU filters have been compiled. CONCLUSIONS: The information provides infection preventionists and facility engineers with information to verify claims from manufacturers and compare differences among POU products, including validated efficacy, filter design, and operational specifications.

Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence.

BACKGROUND: Strategies to improve the effectiveness and quality of health and care have predominantly emphasised the implementation of new research and evidence into service organisation and delivery. A parallel, but less understood issue is how clinicians and service leaders stop existing practices and interventions that are no longer evidence based, where new evidence supersedes old evidence, or interventions are replaced with those that are more cost effective. The aim of this evidence synthesis is to produce meaningful programme theory and practical guidance for policy makers, managers and clinicians to understand how and why de-implementation processes and procedures can work. METHODS AND ANALYSIS: The synthesis will examine the attributes or characteristics that constitute the concept of de-implementation. The research team will then draw on the principles of realist inquiry to provide an explanatory account of how, in what context and for whom to explain the successful processes and impacts of de-implementation. The review will be conducted in four phases over 18 months. Phase 1: develop a framework to map the preliminary programme theories through an initial scoping of the literature and consultation with key stakeholders. Phase 2: systematic searches of the evidence to develop the theories identified in phase 1. Phase 3: validation and refinement of programme theories through stakeholder interviews. Phase 4: formulating actionable recommendations for managers, commissioners and service leaders about what works through different approaches to de-implementation. DISCUSSION: This evidence synthesis will address gaps in knowledge about de-implementation across health and care services and ensure that guidance about strategies and approaches accounts for contextual factors, which may be operating at different organisational and decision-making levels. Through the development of the programme theory, which explains what works, how and under which circumstances, findings from the evidence synthesis will support managers and service leaders to make measured decisions about de-implementation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017081030.

SIX3 deletions and incomplete penetrance in families affected by holoprosencephaly.

Holoprosencephaly (HPE) is failure of the forebrain to divide completely during embryogenesis. Incomplete penetrance has not been reported previously in SIX3 whole gene deletions, which are known to cause HPE. Both chromosomal microarray and whole exome sequencing (WES) were used to evaluate families with inherited HPE. Two families showed inherited deletions that contain SIX3 and were incompletely penetrant for HPE. Using WES, we ruled out parental mosaicism, a SIX3 hypomorph, and clinically significant variants in genes that are known to interact with SIX3 as causes of incomplete penetrance. We demonstrate the importance of molecular cascade testing in families with HPE and we answer important questions about incomplete penetrance.

Managers' use of nursing workforce planning and deployment technologies: protocol for a realist synthesis of implementation and impact.

INTRODUCTION: Nursing staffing levels in hospitals appear to be associated with improved patient outcomes. National guidance indicates that the triangulation of information from workforce planning and deployment technologies (WPTs; eg, the Safer Nursing Care Tool) and 'local knowledge' is important for managers to achieve appropriate staffing levels for better patient outcomes. Although WPTs provide managers with predictive information about future staffing requirements, ensuring patient safety and quality care also requires the consideration of information from other sources in real time. Yet little attention has been given to how to support managers to implement WPTs in practice. Given this lack of understanding, this evidence synthesis is designed to address the research question: managers' use of WPTs and their impacts on nurse staffing and patient care: what works, for whom, how and in what circumstances? METHODS AND ANALYSIS: To explain how WPTs may work and in what contexts, we will conduct a realist evidence synthesis through sourcing relevant evidence, and consulting with stakeholders about the impacts of WPTs on health and relevant public service fields. The review will be in 4 phases over 18 months. Phase 1: we will construct an initial theoretical framework that provides plausible explanations of what works about WPTs. Phase 2: evidence retrieval, review and synthesis guided by the theoretical framework; phase 3: testing and refining of programme theories, to determine their relevance; phase 4: formulating actionable recommendations about how WPTs should be implemented in clinical practice. ETHICS AND DISSEMINATION: Ethical approval has been gained from the study's institutional sponsors. Ethical review from the National Health Service (NHS) is not required; however research and development permissions will be obtained. Findings will be disseminated through stakeholder engagement and knowledge mobilisation activities. The synthesis will develop an explanatory programme theory of the implementation and impact of nursing WPTs, and practical guidance for nurse managers. TRIAL REGISTRATION NUMBER: CRD42016038132.

Describing Older Adults' Awareness of Fall Risk Using Situation Awareness Research Techniques: A Pilot Study.

The purpose of the current study was to evaluate efficacy of techniques adapted from situation awareness research for describing how older adults perceive and understand fall risk factors in the context of daily routine. Eleven older adults watched a video of an older woman performing daily activities. Thirteen intrinsic, extrinsic, and behavioral fall risks were embedded throughout the scenario. The video was periodically frozen/blanked from view while participants answered questions about their understanding of the situation and associated story elements. Participants perceived a variety of fall risk factors but did not necessarily interpret them as indicating fall risk. Many fall risks held non-fall meaning for participants (e.g., newspapers on the floor meant the woman liked to read). Although four participants readily identified a fall risk situation, seven did not until they were explicitly asked to consider safety. Study techniques were effective for describing situation awareness of fall risk and several suggestions for improvement are described. [Res Gerontol Nurs. 2016; 9(4):161-166.].

Improving skills and care standards in the support workforce for older people: a realist review.

INTRODUCTION: In the context of a population that is growing older, and a number of high-profile scandals about care standards in hospital and community settings, having a skilled and knowledgeable workforce caring for older people is an ethical and policy imperative. Support workers make up the majority of the workforce in health and social care services for older people (aged 65 years and over), and yet little is known about the best way to facilitate their development. Given this gap, this review will draw on evidence to address the question: how can workforce development interventions improve the skills and the care standards of support workers within older people's health and social care services? METHODS AND ANALYSIS: As we are interested in how and why workforce development interventions might work, in what circumstances and with whom, we will conduct a realist review, sourcing evidence from health, social care, policing and education. The review will be conducted in four steps over 18 months to (1) construct a theoretical framework, that is, the review's programme theories; (2) retrieve, review and synthesise evidence relating to interventions designed to develop the support workforce guided by the programme theories; (3) 'test out' our synthesis findings and refine the programme theories, establish their practical relevance/potential for implementation and (4) formulate recommendations about improvements to current workforce development interventions to contribute to the improvement of care standards in older people's health and social care services, potentially transferrable to other services. ETHICS AND DISSEMINATION: Ethical approval is not required to undertake this review. Knowledge exchange activities through stakeholder engagement and online postings are embedded throughout the lifetime of the project. The main output from this review will be a new theory driven framework for skill development for the support workforce in health and social care for older people. TRIAL REGISTRATION NUMBER: CRD42013006283.

A novel APC gene mutation associated with a severe phenotype in a patient with Turcot syndrome.

Turcot syndrome is a rare inherited condition of colonic polyposis associated with central nervous system tumors. We report a patient with a novel adenomatous polyposis coli gene mutation leading to a severe phenotype including medulloblastoma, low-grade fibromyxoid sarcoma following cranial radiation, pilomatrixomas, colonic adenomas, and abdominal desmoid tumor following colectomy, all of which were successfully treated. Multiple tumors may be seen in patients with Turcot syndrome but the occurrence of sarcomas is rare. This case highlights the importance of close follow-up for patients with Turcot syndrome and the importance of a broad differential diagnosis in evaluating a condition in which multiple tumors are frequently seen.

Implementation of a dietitian-led enteral nutrition support clinic results in quality improvement, reduced readmissions, and cost savings.

BACKGROUND: Enteral access device malfunction and breakage results in significant morbidity and healthcare cost. In many healthcare systems, enteral nutrition care is fragmented and inefficient. We describe the development and validation of an enteral nutrition support clinic (NSC) with a focus on prevention of enteral access complications. A care protocol consisting of pre- and postplacement visits and subsequent weekly visits was developed. Competencies were established for dietitians to staff the NSC. METHODS: A retrospective quality analysis was performed in patients before and after the implementation of an enteral NSC. Enteral access complications, emergency room visits, readmissions, unplanned physician visits, and tube replacements were recorded for 90 days after tube placement. RESULTS: Thirty patients were evaluated in the NSC pilot and compared with 22 baseline patients with adequate follow-up. The NSC resulted in an 88.9% reduction in nutrition-related emergency room visits (P = .016) and 78.1% reduction in readmissions (P = .027). Estimated per-patient cost reductions amounted to $6831. Approximately 30% of patients were seen in the NSC at least once for a clogged tube and 43.3% for tube leakage. Only 1 NSC patient required a procedure for tube reinsertion. CONCLUSION: Implementation of a dietitian-led nutrition support clinic resulted in improved quality, as well as reductions in hospital readmissions, tube-related complications, and healthcare costs

Care for the patient with burns in the trauma rehabilitation setting.

Caring for patients who are recovering from severe burns is not common in most rehabilitation settings. Nursing challenges include patients' physical and psychological changes and their high care demands. Harborview Medical Center, a regional level 1 burn and trauma center in Seattle, Washington, accepted these nursing challenges and developed a successful plan of care consistent with current evidence. This article describes Harborview Medical Center's trauma rehabilitation nursing experiences while caring for patients with burns. Our experiences may assist other rehabilitation units that serve patients with burns. Says one burn survivor: "Nurses make a huge difference in recovery, as they are there 24 hours a day. It is their touch, their caring, and their listening that aid the patient in his journey from fire victim to burn survivor."

Personal digital assistant-based self-monitoring adherence rates in 2 dialysis dietary intervention pilot studies: BalanceWise-HD and BalanceWise-PD.

OBJECTIVE: The dialysis dietary regimen is complicated, and computer-based dietary self-monitoring may be useful for helping dialysis patients manage their dietary regimen. In this report, we describe dietary self-monitoring rates among study participants randomized to the intervention arms of 2 pilot studies. METHODS: Both studies tested similar interventions involving dietary counseling paired with personal digital assistant-based self-monitoring. One study was performed in hemodialysis (HD) and one in peritoneal dialysis (PD) patients. RESULTS: HD intervention participants entered an average of 244.9 meals (median = 288; interquartile range [IQR]: 186 to 342) over the 16-week intervention, 2.2 meals per day (median = 2.6; IQR: 1.7 to 3.1), and 73% of expected meals (median = 86; IQR: 55 to 102), assuming intake of 3 meals per day. At least some meals were entered in 87% of the observed weeks (median = 100%; IQR: 81 to 100). PD intervention participants entered an average of 212.1 meals (median = 203; IQR: 110 to 312) over the 16-week intervention, 1.9 meals per day (median = 1.8; IQR: 1 to 2.8), and 63% of expected meals (median = 60; IQR: 33 to 93), assuming 3 meals per day. At least some meals were entered in 80% of the observed weeks (median = 94; IQR: 50 to 100). CONCLUSION: These HD and PD patients demonstrated excellent rates of self-monitoring. Additional research with a larger sample is required to confirm these findings.

Nutritional Intake in Adult Hemodialysis Patients.

BACKGROUND: Research pertaining to the nutritional intake of hemodialysis patients is limited. PURPOSE: Describe the nutritional quality of foods consumed by hemodialysis patients and variation by day of the week. METHODS: Dietary recalls were obtained from 22 hemodialysis patients and analyzed using the Nutrition Data System for Research. RESULTS: Few statistically significant differences were found by day of the week, but several dietary deficits were noted. CONCLUSION: The data suggest poor intake of calories, protein, and several vitamins and minerals, as well as excess sodium consumption, but little variation by day of the week. Additional research is needed.

A PDA-based dietary self-monitoring intervention to reduce sodium intake in an in-center hemodialysis patient.

OBJECTIVE: The purpose of the BalanceWise-hemodialysis study is to determine the efficacy of a dietary intervention to reduce dietary sodium intake in patients receiving maintenance, in-center hemodialysis (HD). Personal digital assistant (PDA)-based dietary self-monitoring is paired with behavioral counseling. The purpose of this report is to present a case study of one participant's progression through the intervention. METHODS: The PDA was individually programmed with the nutritional requirements of the participant. With 25 minutes of personalized instruction, the participant was able to enter his meals into the PDA using BalanceLog((R)) software. Nutritional counseling was provided based on dietary sodium intake reports generated by BalanceLog((R)). RESULTS: : At initiation of the study the participant required 4 HD treatments per week. The participant entered 342 meals over 16 weeks (>/=3 meals per day). BalanceLog((R)) revealed that the participant consumed restaurant/fast food on a regular basis, and consumed significant amounts of corned beef as well as canned foods high in sodium. The study dietitian worked with the participant and his wife to identify food alternatives lower in sodium. Baseline sodium consumption was 4,692 mg, and decreased at a rate of 192 mg/week on average. After 11 weeks of intervention, interdialytic weight gains were reduced sufficiently to permit the participant to reduce HD treatments from 4 to 3 per week. Because of a low serum albumin at baseline (2.9 g/dL) the study dietitian encouraged the participant to increase his intake of high quality protein. Serum albumin level at 16 weeks was unchanged (2.9 g/dL). Because of intense pruritis and a high baseline serum phosphorus (6.5 mg/dL) BalanceLog((R)) electronic logs were reviewed to identify sources of dietary phosphorus and counsel the participant regarding food alternatives. At 16 weeks the participant's serum phosphorus fell to 5.5 mg/dL. CONCLUSIONS: Self-monitoring rates were excellent. In a HD patient who was willing to self-monitor his dietary intake, BalanceLog((R)) allowed the dietitian to target problematic foods and provide counseling that appeared to be effective in reducing sodium intake, reducing interdialytic weight gain, and alleviating hyperphosphatemia and hyperkalemia. Additional research is needed to evaluate the efficacy of the intervention.

Wound care for burn patients in acute rehabilitation settings.

Caring for patients who are recovering from severe burns is not common in most inpatient rehabilitation settings. Nursing challenges include patients' physical and psychological changes and their high care demands. Harborview Medical Center (HMC), a regional Level 1 burn and trauma center in Seattle, WA, accepted these nursing challenges and developed a successful plan of care consistent with current evidence. This article describes HMC's nursing experiences while caring for patients with burns. Our experiences may assist other rehabilitation units that serve burn patients. Says one burn survivor: "Nurses make a huge difference in recovery, as they are there 24 hours a day. It is their touch, their caring, and their listening that aids the patient in his journey from fire victim to burn survivor."