Inpatient falls continue to be a significant clinical issue, and while malnutrition is a known risk factors for falls, few studies have investigated its association with inpatient falls. This study aimed to explore the independent association between malnutrition and fall risk as well as harm from falls in hospital inpatients.
Malnutrition identified in annual malnutrition audits was combined with inpatient fall data captured through the electronic patient incident reporting system in the 12 months following audit days. Audit data were available for 1,849 inpatients across 2011–2015, and covariate associations between age, gender, BMI, malnutrition, falls and harmful falls were analysed. The reporting of this paper is in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations (see Appendix S1).
The prevalence of malnutrition was 32.4% (n = 543), and 171 (9.2%) inpatients experienced a fall with 0.7% (n = 13) categorised as harmful. In bivariate analysis, patients who fell were more likely to be older (median 79.0 vs. 70.0 years; p < .0001) or malnourished (40.9% vs. 31.5%; p = .021). Malnutrition (p < .0001) and having a lower BMI (p = .026) were significant predictors of harmful falls. Regression modelling demonstrated that only increasing age increased the likelihood of having an inpatient fall (OR 1.022 95% CI 1.021–1.046; p < .0001). Malnourished inpatients were almost 8 times more likely to have a harmful fall than those not malnourished (OR 7.94 95% CI 1.457–43.338; p = .017), independent of age and BMI.
Malnourished patients are more likely to experience a harmful fall. Assessment of malnutrition should be incorporated into fall risk assessments as a way of highlighting those patients at greater risk and to link to nutritional care pathways.
Verbal autopsy (VA) is a useful tool to ascertain cause of death where no other mechanisms exist. We aimed to assess the utility of VA data to ascertain deaths due to uncontrolled hyperglycaemia and to develop a weighted score (WS) to specifically identify cases. Cases were identified by a study or site physician with training in diabetes. These diagnoses were also compared with diagnoses produced by a standard computer algorithm (InterVA-4).
This study was done using VA data from the Health and Demographic Survey sites in Agincourt in rural South Africa. Validation of the WS was done using VA data from Karonga in Malawi.
All deaths from ages 1 to 49 years between 1992 and 2015 and between 2002 and 2016 from Agincourt and Karonga, respectively. There were 8699 relevant deaths in Agincourt and 1663 in Karonga.
Of the Agincourt deaths, there were 77 study physician classified cases and 58 computer algorithm classified cases. Agreement between study physician classified cases and computer algorithm classified cases was poor (Cohen’s kappa 0.14). Our WS produced a receiver operator curve with area under the curve of 0.952 (95% CI 0.920 to 0.985). However, positive predictive value (PPV) was below 50% when the WS was applied to the development set and the score was dominated by the necessity for a premortem diagnosis of diabetes. Independent validation showed the WS performed reasonably against site physician classified cases with sensitivity of 86%, specificity of 99%, PPV of 60% and negative predictive value of 99%.
Our results suggest that widely used VA methodologies may be missing deaths due to uncontrolled hyperglycaemia. Our WS may offer improved ability to detect deaths due to uncontrolled hyperglycaemia in large populations studies where no other means exist.
The appropriateness of using routinely collected laboratory data combined with administrative data for estimating influenza vaccine effectiveness (VE) is still being explored. This paper outlines a protocol to estimate influenza VE using linked laboratory and administrative data which could act as a companion to estimates derived from other methods.
We will use the test-negative design to estimate VE for each influenza type/subtype and season. Province-wide individual-level records of positive and negative influenza tests at the Provincial Laboratory for Public Health in Alberta will be linked, by unique personal health numbers, to administrative databases and vaccination records held at the Ministry of Health in Alberta to determine covariates and influenza vaccination status, respectively. Covariates of interests include age, sex, immunocompromising chronic conditions and healthcare setting. Cases will be defined based on an individual’s first positive influenza test during the season, and potential controls will be defined based on an individual’s first negative influenza test during the season. One control for each case will be randomly selected based on the week the specimen was collected. We will estimate VE using multivariable logistic regression.
Ethics approval was obtained from the University of Alberta’s Health Research Ethics Board—Health Panel under study ID Pro00075997. Results will be disseminated by public health officials in Alberta.
We compared long-term outcomes in patients with atrial fibrillation (AF) with and without a secondary precipitant.
Retrospective cohort study based on Danish nationwide registries.
Patients with AF with and without secondary precipitants (1996–2015) were matched 1:1 according to age, sex, calendar year, CHA2DS2-VASc score and oral anticoagulation therapy (OAC), resulting in a cohort of 39 723 patients with AF with a secondary precipitant and the same number of patients with AF without a secondary precipitant. Secondary precipitants included alcohol intoxication, thyrotoxicosis, myocardial infarction, surgery and infection in conjunction with AF.
The primary outcome in this study was thromboembolic events. Secondary outcomes included AF rehospitalisation and death. Long-term risks of outcomes were examined by multivariable Cox regression analysis.
The most common precipitants were infection (55.0%), surgery (13.2%) and myocardial infarction (12.0%). The 5-year absolute risk of thromboembolic events (taking death into account as a competing risk) in patients with AF grouped according to secondary precipitants were 8.3% (alcohol intoxication), 8.5% (thyrotoxicosis), 12.1% (myocardial infarction), 11.6% (surgery), 12.2% (infection), 10.1% (>1 precipitant) and 12.3% (no secondary precipitant). In the multivariable analyses, AF with a secondary precipitant was associated with the same or an even higher thromboembolic risk than AF without a secondary precipitant. One exception was patients with AF and thyrotoxicosis: those not initiated on OAC therapy carried a lower thromboembolic risk the first year of follow-up than matched patients with AF without a secondary precipitant and no OAC therapy.
In general, AF with a secondary precipitant was associated with the same thromboembolic risk as AF without a secondary precipitant. Consequently, this study highlights the need for more research regarding the long-term management of patients with AF associated with a secondary precipitant.
To determine the cost-effectiveness of selective digestive decontamination (SDD) as compared to selective oropharyngeal decontamination (SOD) in intensive care units (ICUs) with low levels of antimicrobial resistance.
Post-hoc analysis of a previously performed individual patient data meta-analysis of two cluster-randomised cross-over trials.
24 ICUs in the Netherlands.
12 952 ICU patients who were treated with ≥1 dose of SDD (n=6720) or SOD (n=6232).
SDD versus SOD.
The incremental cost-effectiveness ratio (ICER; ie, costs to prevent one in-hospital death) was calculated by comparing differences in direct healthcare costs and in-hospital mortality of patients treated with SDD versus SOD. A willingness-to-pay curve was plotted to reflect the probability of cost-effectiveness of SDD for a range of different values of maximum costs per prevented in-hospital death.
The ICER resulting from the fixed-effect meta-analysis, adjusted for clustering and differences in baseline characteristics, showed that SDD significantly reduced in-hospital mortality (adjusted absolute risk reduction 0.0195, 95% CI 0.0050 to 0.0338) with no difference in costs (adjusted cost difference 62 in favour of SDD, 95% CI –1079 to 935). Thus, SDD yielded significantly lower in-hospital mortality and comparable costs as compared with SOD. At a willingness-to-pay value of 33 633 per one prevented in-hospital death, SDD had a probability of 90.0% to be cost-effective as compared with SOD.
In Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD. These data support the implementation of SDD in settings with low levels of antimicrobial resistance.
To assess the three key issues for congenital anomalies (CAs) prevention and care, namely, CA prevalence, risk factor prevalence and survival, in a longitudinal cohort in Riyadh, Saudi Arabia.
Tertiary care centre, Riyadh, Saudi Arabia.
Saudi women enrolled during pregnancy over 3 years and their 28 646 eligible pregnancy outcomes (births, stillbirths and elective terminations of pregnancy for foetal anomalies). The nested case-control study evaluated the CA risk factor profile of the underlying cohort. All CA cases (1179) and unaffected controls (1262) were followed through age 2 years. Referred mothers because of foetal anomaly and mothers who delivered outside the study centre and their pregnancy outcome were excluded.
Prevalence and pattern of major CAs, frequency of CA-related risk factors and survival through age 2 years.
The birth prevalence of CAs was 412/10 000 births (95% CI 388.6 to 434.9), driven mainly by congenital heart disease (148 per 10 000) (95% CI 134 to 162), renal malformations (113, 95% CI 110 to 125), neural tube defects (19, 95% CI 25.3 to 38.3) and chromosomal anomalies (27, 95% CI 21 to 33). In this study, the burden of potentially modifiable risk factors included high rates of diabetes (7.3%, OR 1.98, 95% CI 1.04 to 2.12), maternal age >40 years (7.0%, OR 2.1, 95% CI 1.35 to 3.3), consanguinity (54.5%, OR 1.5, 95% CI 1.28 to 1.81). The mortality for live births with CAs at 2 years of age was 15.8%.
This study documented specific opportunities to improve primary prevention and care. Specifically, folic acid fortification (the neural tube defect prevalence was >3 times that theoretically achievable by optimal fortification), preconception diabetes screening and consanguinity-related counselling could have significant and broad health benefits in this cohort and arguably in the larger Saudi population.
This study assesses the competency of maternal and neonatal health (MNH) professionals at district-level and subdistrict-level health facilities in northern Bangladesh in managing maternal and newborn complications using clinical vignettes. The study also examines whether the professional’s characteristics and provision of MNH services in health facilities influence their competencies.
134 MNH professionals in 15 government hospitals were interviewed during August and September 2016 using structured questionnaire with clinical vignettes on obstetric complications (antepartum haemorrhage and pre-eclampsia) and neonatal care (low birthweight and immediate newborn care). Summative scores were calculated for each vignette and median scores were compared across different individual-level and health facility-level attributes to examine their association with competency score. Kruskal-Wallis test was performed to identify the significance of association considering a p value
The competency of MNH professionals was low. About 10% and 24% of the health professionals received ‘high’ scores (>75% of total) in maternal and neonatal vignettes, respectively. Medical doctors had higher competency than nurses and midwives (score=11 vs 8 out of 19, respectively; p=0.0002) for maternal vignettes, but similar competency for neonatal vignettes (score=30.3 vs 30.9 out of 50, respectively). Professionals working in health facilities with higher use of normal deliveries had better competency than their counterparts. Professionals had higher competency in newborn vignettes (significant) and maternal vignettes (statistically not significant) if they worked in health facilities that provided more specialised newborn care services and emergency obstetric care, respectively, in the last 6 months.
Despite the overall low competency of MNH professionals, exposure to a higher number of obstetric cases at the workplace was associated with their competency. Arrangement of periodic skill-based and drill-based in-service training for MNH professionals in high-use neighbouring health facilities could be a feasible intervention to improve their knowledge and skill in obstetric and neonatal care.
To understand family and parent perspectives on newborn care provided at home to infants in the first 28 days of life, in order to inform behavioural interventions for improving care in low-income countries, where the majority of newborn deaths occur.
A comprehensive, qualitative systematic review was conducted. MEDLINE/PubMed, Embase and Cumulative Index of Nursing and Allied Health databases were systematically searched for studies examining the views of parents and family members on newborn care at home. The search period included all studies published from 2006 to 2017. Studies using qualitative approaches or mixed-methods studies with substantial use of qualitative techniques in both the methods and analysis sections were included. Studies meeting the inclusion criteria were extracted and evaluated using Critical Appraisal Skills Programme guidelines. Following the initial selection and appraisal, barriers and facilitators to recommended care practices across several domains were synthesised.
Of 411 results retrieved, 37 met both inclusion and quality appraisal criteria for methodology and reporting. Geographical representation largely reflected that of newborn health outcomes globally, with the majority of studies conducted in the region of Sub-Saharan Africa and South Asia. Specific barriers and facilitators were identified among a range of domains including: cord care, drying and wrapping, thermal control, skin to skin contact, hygiene, breast feeding, care-seeking for illness, and low birthweight recognition. Cross cutting facilitators, common to all domains were evident and included
delivery at a health facility, inclusion of female relatives in care counselling, lower healthcare costs, and exposure to newborn care behaviour change messaging in the community.
When designing behavioural interventions to address newborn mortality at scale, policy-makers and practitioners must include barriers and facilitators important to families in low-income settings.
In 2016, Georgian researchers and policymakers were developing a policy to improve the performance of the national tuberculosis (TB) control programme. The research programme ‘Designing and Evaluating Provider Results-Based Financing for Tuberculosis Care in Georgia: Understanding Costs, Mechanisms of Effect and Impact (Results4TB)’ was initiated to inform the policy formulation phase, document the policy implementation and assess the effectiveness, cost-effectiveness and the processes of change. To achieve this, the research team intends to combine an impact evaluation, a cost-effectiveness study and a realist evaluation (RE) within an overarching theory-informed design. This protocol is the RE component of the programme.
A realist methodological approach will be adopted to guide the research design and evaluation. RE answers the question of ‘what works in which conditions for whom?’ and starts with the development of an initial programme theory (IPT). The IPT will feed into other phases of the realist research cycle (study design, data collection, data analysis and synthesis and theory refinement). Data will be collected in a multiple embedded case study design (five intervention and three control sites) through document reviews, in-depth interviews, non-participant observations and context mapping at facility and national levels. Additional data from other research components (cost-effectiveness and impact evaluation) will aid data triangulation.
The Institutional Review Boards of the National Centre for Disease Control and Public Health in Georgia (ref. IRB # 2018–019) and the Institute of Tropical Medicine, Antwerp (ref. IRB #- 1240/18) have granted ethical approval to the study.
by M. J. Costa, J. F. Fuentes-Pérez, I. Boavida, J. A. Tuhtan, A. N. PinheiroHydropeaking is the rapid change in the water flow downstream of a hydropower plant, driven by changes in daily electricity demand. These fluctuations may produce negative effects in freshwater fish. To minimize these impacts, previous studies have proposed habitat enhancement structures as potential mitigation measures for salmonids. However, the recommendation of these mitigation measures for cyprinids remains scarce and their effects unknown. In this study, the effects of potential habitat mitigation structures under simulated hydropeaking and base-flow conditions are examined for Iberian barbel (Luciobarbus bocagei) in an indoor flume. Solid triangular pyramids and v-shaped structures were evaluated as potential flow-refuging areas and compared with a configuration without structures. A novel, interdisciplinary approach is applied to investigate individual and group responses to rapidly changing flows, by assessing physiological (glucose and lactate), movement behaviour (structure use, sprints and drifts) and the pressure distribution using a fish-inspired artificial lateral line flow sensor. The major findings of this study are four-fold: 1) Under hydropeaking conditions, the v-shaped structures triggered a lactate response and stimulated individual structure use, whereas solid structures did not elicit physiological adjustments and favoured individual and group structure use. Overall, both solid structures and their absence stimulated sprints and drifts. 2) The hydrodynamic conditions created in hydropeaking did not always reflect increased physiological responses or swimming activity. 3) Each event-structure combination resulted in unique hydrodynamic conditions which were reflected in the different fish responses. 4) The most relevant flow variable measured was the pressure asymmetry, which is caused by the vortex size and shedding frequency of the structures. Considering the non-uniform nature of hydropeaking events, and the observation that the fish responded differently to specific flow event-structure combinations, a diverse set of instream structures should be considered for habitat-based hydropeaking mitigation measures for Iberian barbel.
To evaluate the preliminary effectiveness of the BRief Evaluation of Asthma TH erapy intervention, a 7‐min primary care provider‐delivered shared decision‐making protocol that uses motivational interviewing to address erroneous asthma disease and medication beliefs.
A multi‐centre masked two‐arm group‐randomized clinical trial.
This 2‐year pilot study is funded (September 2016) by the National Institute of Nursing Research. Eight providers will be randomized to one of two arms: the active intervention (N = 4) or a dose‐matched attention control (N = 4). Providers will deliver the intervention to which they were randomized to 10 Black adult patients with uncontrolled asthma (N = 80). Patients will be followed three months postintervention to test the preliminary intervention effects on asthma control (primary outcome) and on medication adherence, lung function, and asthma‐related quality of life (secondary outcomes).
This study will evaluate the preliminary impact of a novel shared decision‐making intervention delivered in a real world setting to address erroneous disease and medication beliefs as a means of improving asthma control in Black adults. Results will inform a future, large‐scale randomized trial with sufficient power to test the intervention's effectiveness.
Shared decision‐making is an evidence‐based intervention with proven effectiveness when implemented in the context of labour‐ and time‐intensive research protocols. Medication adherence is linked with the marked disparities evident in poor and minority adults with asthma. Addressing this requires a novel multifactorial approach as we have proposed. To ensure sustainability, shared decision‐making interventions must be adapted to and integrated into real‐world settings.
Trial registration: Registered at clincialtrials.gov as NCT03036267 and NCT03300752.
The Emergency Management of Severe Burns (EMSB) referral criteria have been implemented for optimal triaging of burn patients. Admission to a burn centre is indicated for patients with severe burns or with specific characteristics like older age or comorbidities. Patients not meeting these criteria can also be treated in a hospital without burn centre. Limited information is available about the organisation of care and referral of these patients. The aims of this study are to determine the burn injury characteristics, treatment (costs), quality of life and scar quality of burn patients admitted to a hospital without dedicated burn centre. These data will subsequently be compared with data from patients with
In this multicentre, prospective, observational study (cohort study), the following two groups of patients will be followed: 1) all patients (no age limit) admitted with burn-related injuries to a hospital without a dedicated burn centre in the Southwest Netherlands or Brabant Trauma Region and 2) all patients (no age limit) with
This study has been exempted by the medical research ethics committee Erasmus MC (Rotterdam, The Netherlands). Each participant will provide written consent to participate and remain encoded during the study. The results of the study are planned to be published in an international, peer-reviewed journal.