Patient engagement study to identify and improve surgical experience.

BACKGROUND: Patient engagement is the establishment of active partnerships between patients, families, and health professionals to improve healthcare delivery. The objective of this project was to conduct a series of patient engagement workshops to identify areas to improve the surgical experience and develop strategies to address areas identified as high priority. METHODS: Faculty surgeons and patients were invited to participate in three in-person meetings. Evaluation included identifying and developing strategies for three priority areas to improve the surgical experience and level of engagement achieved at each meeting. RESULTS: Sixteen faculty surgeons and 32 patients participated. Some 63 themes to improve the surgical experience were identified; the three highest-priority themes were physician communication, discharge process, and expectations at home after discharge. Individual improvement strategies for these three prioritized themes (12, 36 and 6 respectively) were used to develop a formal strategic plan, and included a physician communication survey, discharge process worksheet and video, and guideline regarding what to expect at home after discharge. Overall, the level of engagement achieved was considered high by over 85 per cent of the participants. CONCLUSION: A high level of patient engagement was achieved. Priorities were identified with patients and surgeons to improve surgical experience, and strategies were developed to address these areas.

IgM ANCA in healthy individuals and in patients with ANCA-associated vasculitis.

Low levels of IgM auto-antibodies have been reported in health and disease. IgM anti-neutrophil cytoplasmic antibodies (ANCA) have been reported in patients with ANCA-associated vasculitis (AAV). We sought to investigate if healthy individuals may have IgM ANCA in their sera. The first aim of the study was to determine whether IgM ANCA was present in healthy individuals and in patients with ANCA-associated vasculitis. The second aim was to determine what happens to IgM ANCA levels over time. The third aim was to determine whether bacterial infections affected IgM ANCA levels in non-AAV patients. Sera from healthy individuals and patients with AAV were tested for IgM ANCA by immunofluorescence on fixed neutrophils, immunoprecipitation, Western blot and ELISA. Peripheral blood mononuclear cells were isolated and tested by ELISpot for circulating IgM ANCA B cells. To determine whether infection affected IgM ANCA levels, we studied non-AAV patients with bacterial endocarditis or Staphylococcus aureus bacteraemia and measured IgM ANCA levels over time. IgM ANCA is detectable in both healthy individuals and patients with AAV and the titres decreased with increasing age. Circulating IgM ANCA B cells were identified by ELISpot. In the presence of infection, we could not find a significant change in IgM ANCA levels. We report the presence of low-level specific IgM ANCA in the sera of healthy individuals and in patients with ANCA-associated vasculitis. Bacterial infection did not affect the level of IgM ANCA in this small study.

Improving the appropriateness of antipsychotic prescribing in nursing homes: a mixed-methods process evaluation of an academic detailing intervention.

BACKGROUND: In 2014, nursing home administration and government officials were facing increasing public and media scrutiny around the variation of antipsychotic medication (APM) prescribing across Ontario nursing homes. In response, policy makers partnered to test an academic detailing (AD) intervention to address appropriate prescribing of APM in nursing homes in a cluster-randomized trial. This mixed-methods study aimed to explore how and why the AD intervention may have resulted in changes in the nursing home context. The objectives were to understand how the intervention was implemented, explore contextual factors associated with implementation, and examine impact of the intervention on prescribing. METHODS: Administrative data for the primary outcome of the full randomized trial will not be available for a minimum of 1 year. Therefore, this paper reports the findings of a planned, quantitative interim trial analysis assessed mean APM dose and prescribing prevalence at baseline and 3 and 6 months across 40 nursing homes (18 intervention, 22 control). Patient-level administrative data regarding prescribing were analyzed using generalized linear mixed effects regression. Semi-structured interviews were conducted with nursing home staff from the intervention group to explore opinions and experiences of the AD intervention. Interviews were analyzed using the framework method, with constructs from the Consolidated Framework for Implementation Research (CFIR) applied as pre-defined deductive codes. Open coding was applied when emerging themes did not align with CFIR constructs. Qualitative and quantitative findings were triangulated to examine points of divergence to understand how the intervention may work and to identify areas for future opportunities and areas for improvement. RESULTS: No significant differences were observed in prescribing outcomes. A total of 22 interviews were conducted, including four academic detailers and 18 nursing home staff. Constructs within the CFIR domains of Outer Setting, Inner Setting, and Characteristics of Individuals presented barriers to antipsychotic prescribing. Intervention Source, Evidence Strength and Quality, and Adaptability explained participant engagement in the AD intervention; nursing homes that exhibited a Tension for Change and Leadership Engagement reported positive changes in processes and communication. CONCLUSIONS: Participants described their experiences with the intervention against the backdrop of a range of factors that influence APM prescribing in nursing homes that exist at the system, facility, provider, and resident levels. In this context, the perceived credibility and flexibility of the intervention were critical features that explained engagement with and potential impact of the intervention. Development of a common language across the team to enable communication was reported as a proximal outcome that may eventually have an effect on APM prescribing rates. Process evaluations may be useful during early stages of evaluation to understand how the intervention is working and how it might work better. Qualitative results suggest the lack of early changes observed in prescribing may reflect the number of upstream factors that need to change for APM rates to decrease. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02604056.

Toxic properties of Beauveria pigments on erythrocyte membranes.

The Beauveria pigments, tenellin, bassianin and oosporein, all inhibited total erythrocyte membrane ATPase activity in a dose-dependent manner by as much as 50% at 200 micrograms/ml. These pigments inhibited Ca(2+)-ATPases to a greater extent than Na+/K(+)-ATPase activity. The ATPase inhibitory activity for these pigments was not specific but was probably a consequence of membrane disruption, since pigments all caused alterations in erythrocyte morphology and promoted varying degrees of cell lysis.

What near misses tell us about risk and safety in mental health care.

How service providers and service users view near misses in their daily practice within the rubric of patient safety events is not well understood. Further no studies were located that explored near misses specifically in mental health settings in Canada. In this context, a qualitative study was undertaken to gain insight into how service providers and service users (mental health clients or their family members) experienced and defined near misses. Eight (8) focus groups (n= 88) with service providers and 28 semi-structured interviews with service users were conducted at three mental health care organizations. Content analysis was employed to the dataset that elucidated that near misses were (1) safety threats and vulnerabilities associated with experiencing mental illness; and (2) acts that avert harm and prevent something from happening. Findings are compared to what is currently known about in safety. Implications of findings for practice, research and policy are delineated.

Impact of nursing on hospital patient mortality: a focused review and related policy implications.

Understanding the determinants of patient mortality can lead to the development of strategies that reduce mortality and prevent unnecessary death. This paper synthesizes the body of published research that explores determinants of mortality for patients who have experienced acute care hospitalization. Fifteen research manuscripts were found to meet the selection criteria through an electronic search in MEDLINE and CINAHL (1986-2004). Seven categories of determinants of mortality were found: nurse-physician relationships, nurse staffing characteristics, physician characteristics, professional practice environment, nurse experience, registered nurse educational preparation, and clinical nursing support. Implications and recommendations for improving quality and safety in hospital care are discussed.

The enhancement of the frequency of resistance to N-phosphonoacetyl-L-aspartate and methotrexate by 1-beta-D-arabinofuranosylcytosine: the effect of dipyridamole.

In cultured cells, dipyridamole, in a dose-dependent manner, prevented the enhancement by 1-beta-D-arabinofuranosylcytosine (AraC) of either N-phosphonoacetyl-L-aspartate (PALA)- or methotrexate- resistance frequency. Maximal blockade of enhancement of PALA-resistance frequency occurred if the dipyridamole was added with or within about 20 hr of PALA addition. Thereafter, the effect of dipyridamole decreased. Nitrobenzylthioinosine similarly reduced AraC enhancement of PALA- and methotrexate-resistance frequency. Both dipyridamole and nitrobenzylthioinosine inhibited uridine and thymidine uptake into cells to a similar extent in cells pretreated or not with AraC. Thus, although inhibition of nucleoside uptake would seem a reasonable explanation for the effect on PALA-resistance frequency by dipyridamole, there is no obvious explanation at present of how dipyridamole selectively affects resistance frequency in AraC-pretreated cells.

Nature and control of chloride transport in insect absorptive epithelia.

Insect epithelia most commonly absorb from KCI-rich, low Na+ fluids. This is true of the locust hindgut, which is functionally analogous to vertebrate kidney tubules. Active absorption of Cl- at the apical membrane is the predominant transport process giving rise to a large short-circuit current (Isc) after stimulation by neuropeptides (CTSH, ITP) via cAMP as second messenger. This Cl- transport is not coupled to or driven secondarily by Na+, K+, HCO3-, Ca2+, or Mg2+ movements. An apical V-type H+ ATPase acidifies the hindgut lumen but at a rate that is 10-15% of Cl-dependent Isc. The evidence to date as to whether the resulting large apical proton gradient is used to drive Cl- transport secondarily by an apical H+/Cl- symport is mixed. Thus a primary mechanism of Cl- absorption remains an alternative possibility. The complete primary structure of a large neuropeptide stimulant (ITP: 72 amino acids) of locust ileal Cl- transport has recently been deduced from its cDNA. This is the first putative insect neuropeptide hormone shown to stimulate ion transport across absorptive epithelia for which the primary sequence has been deduced.