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Protocol for pragmatic randomised trial: integrating electronic health record-based behavioural economic 'nudges into the electronic health record to reduce preoperative testing for patients undergoing cataract surgery

Por: Ahmadi · A. · Sorensen · A. · Villaflores · C. W. A. · Mafi · J. N. · Vangala · S. S. · Hofer · I. S. · Bartlett · J. D. · Cheng · E. M. · Duval · V. F. · Damberg · C. · Elashoff · D. · Goldstein · N. J. · Ladapo · J. A. · Moore · J. M. · Pessegueiro · A. M. · Shu · S. B. · Skootsky · S
Introduction

Robust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory.

Methods and analysis

This pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings.

Ethics and dissemination

The study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country.

Trial registration number

ClinicalTrials.gov identifier: NCT04104256.

Transcultural adaptation and validation of Italian Selfcare diabetic foot questionnaire

Abstract

The Italian Selfcare diabetic foot questionnaire, (SDFQ-IT) is considered a diabetic foot self-care evaluation tool with 16 questions for assessing diabetic foot health disorders. To date, SDFQ has been validated in different languages, but an Italian version was lacking. Consequently, the purpose of this study was to translate and validate the Italian version of the SDFQ-IT (SDFQ-IT). A suitable method was developed for the translation protocol and cross-cultural validation from Spanish to Italian. Regarding the total marks from each sub-scale, agreement degrees, and confidence were analysed using the Cronbach's α and intraclass correlation coefficient (ICC), respectively. In addition, the mean ± SD differences between pre and post-tests were calculated and completed using the Bland and Altman distribution plots. Excellent agreement between the two versions based on Cronbach's α was demonstrated. Three sub-scales consisting of knowledge of foot hygiene, the appropriate use of footwear and socks, and podiatric self-care were added together to obtain the total score. Excellent retest reliability was shown for the total score. Test/retest reliability was excellent for the self-care domain, and shock and shoe sub-scales. There were no significant differences among any domain (P > .05). There were no statistically significant differences (P = .000) for the mean ± SDs differences between pre-and post-tests (92.9200 ± 12.914) [89.25-96.59] and 92.9200 ± 13.012 [89.22-96.62] points, respectively). Bland and Altman plots or clinically pertinent variations were not statistically significantly different. The SDFQ-IT is considered a strong and valid questionnaire with adequate repeatability in the Italian community.

Cuidados para el manejo de delirio en Unidades de Paciente Crítico: una revisión integrativa

Objetivo: analizar en la evidencia bibliográfica los aspectos que influyen en el desarrollo del delirio, manejo, evaluación objetiva para su pesquisa y los cuidados relacionados a la promoción y prevención de éste en los usuarios hospitalizados en unidades críticas. Metodología: Se realizó una revisión integrativa, en bases de datos CINAHL; SCOPUS y Scielo. Fueron seleccionados 19 artículos limitados por año (2016-2017). Resultado: Se identificaron cuatro factores que impactan en el delirio: la fisiopatología/factores de riesgo, la prevención y promoción, la evaluación objetiva y el manejo en unidades críticas. Conclusión: La Gestión del Cuidado se encuentra a cargo de Enfermería, por ende, es fundamental no dejar esta temática de lado debido a que su incidencia aumentará los días de hospitalización, días de ventilación mecánica y mortalidad, impactando negativamente en la calidad de los cuidados.

Neutrophil-to-lymphocyte ratio predicts early mortality in females with metastatic triple-negative breast cancer

by Gabriel de la Cruz-Ku, Diego Chambergo-Michilot, J. Smith Torres-Roman, Pamela Rebaza, Joseph Pinto, Jhajaira Araujo, Zaida Morante, Daniel Enriquez, Claudio Flores, Renato Luque, Antonella Saavedra, Maria Lujan, Henry Gomez, Bryan Valcarcel

Background

The aim of this study was to determine the utility of the neutrophil-to-lymphocyte ratio (NLR) as a biomarker for predicting early-mortality ( Methods

We reviewed 118 medical records of females with mTNBC. The cut-off value for the NLR ( Results

The median follow-up was 24 months. Females with NLR ≥2.5 had a poor overall survival compared to females with NLR Conclusion

The NLR is an accessible and reliable biomarker that predicts early mortality among females with mTNBC. Our results suggest that females with high NLR values have poor prognosis despite receiving standard chemotherapy. Health providers should evaluate the possibility to enroll these patients in novel immunotherapy trials.

El empoderamiento político de la enfermería

¿A qué nos referimos cuando hablamos de la competencia política enfermera? Estos últimos años, escuchamos una voz cada vez más clara que insta a la responsabilidad profesional de la enfermería a involucrarse de forma activa en la toma de decisiones en materia de salud. Ahora más que nunca, debemos mantener nuestro perfil competencial en constante desarrollo abriendo nuevas puertas, como la política, que de la mano de la investigación promuevan cambios dirigidos a mejorar la eficiencia de la atención sanitaria y la salud de la población. 

Cross‐cultural adaptation, translation, and validation of the Spanish Foot and Ankle Outcome Score questionnaire

Abstract

The Spanish Foot and Ankle Outcome Score questionnaire (FAOS‐S) may be considered a health evaluation tool with 42 questions for assessing foot health disorders. To date, FAOS has been validated in different languages, but a Spanish version was lacking. Consequently, the purpose of this study was to translate and validate the Spanish version of the FAOS (FAOS es). A suitable method was developed for the translation protocol and cross‐cultural validation from Swedish to Spanish. Regarding the total marks from each domain, agreement degrees and confidence were analysed using the Cronbach's α and intraclass correlation coefficient, respectively. In addition, the mean ± SD differences between pretest and posttests were calculated and completed using of the Bland and Altman distribution plots. Excellent agreement between the two versions based on Cronbach's α was demonstrated. Five domains consisting of pain, symptoms of foot disorders, activities of daily living, sports and recreation, and foot and ankle quality of life were added together to obtain the total score. Excellent retest reliability was shown for the total score. Test/retest reliability was excellent for the pain, stiffness, other foot disorder‐related symptoms, and quality of life domains. There were no significant differences among any domain (P > .05). There were no statistically significant differences (P = .000) for the mean ± SD differences between pretest and posttests (56.2524 ± 19.064 [51.98–60.52] and 57.45 ± 21.02 [52.74–62.16] points, respectively). Bland and Altman plots or clinically pertinent variations were not statistically significantly different. The FAOS is considered a strong and valid questionnaire with adequate repeatability in the Spanish community.

Mentors' self‐assessed competence in mentoring nursing students in clinical practice: A systematic review of quantitative studies

Abstract

Aims and objectives

To examine registered nurses' self‐evaluation of their competence in mentoring nursing students in clinical practice.

Background

Clinical mentors have significant roles and responsibility for nursing students' clinical learning. Moreover, the mentors' role is becoming increasingly important internationally, as the role of nurse teachers in mentoring students in clinical practice has declined. However, in most EU countries there are no specific educational requirements for clinical mentors, although they need targeted education to increase their competence in mentoring nursing students.

Design

The systematic review of quantitative studies was designed according to guidelines of the Centre for Reviews and Dissemination and PRISMA protocol.

Methods

Studies published during 2000–2019 that met inclusion criteria formulated in PiCOS format were systematically reviewed by three independent reviewers. CINAHL (Ebsco), PubMed (MEDLINE), Scopus, ERIC and Medic databases were used to retrieve the studies. Three independent reviewers conducted the systematic review process. The studies were tabulated, thematically compared and narratively reported.

Results

In total, 16 peer‐reviewed studies met the inclusion criteria. The studies identified various dimensions of mentors´ competence and associated environmental factors. Generally, participating mentors rated competences related to the clinical environment, mentoring, supporting students' learning processes and relevant personal characteristics fairly high. They also rated organisational practices in their workplaces, resources in the clinical environment and their mentor–student and mentor–stakeholder pedagogical practices, as respectable or satisfactory.

Conclusion

The results indicate considerable scope for improving mentors' competence, particularly through enhancing organisational mentoring practices and relevant resources in clinical environments.

Relevance for clinical practice

Pedagogical practices of mentors in relations with both students and stakeholders should be enhanced to improve future nurses' learning. This systematic review addresses a gap in knowledge of mentors' self‐evaluated competence that could assist the formulation of effective educational programmes for mentors internationally and improving clinical environments.

Predictive model to identify the risk of losing protective sensibility of the foot in patients with diabetes mellitus

Abstract

Diabetic neuropathy is defined as the presence of symptoms and signs of peripheral nerve dysfunction in diabetics. The aim of this study is to develop a predictive logistic model to identify the risk of losing protective sensitivity in the foot. This descriptive cross‐sectional study included 111 patients diagnosed with diabetes mellitus. Participants completed a questionnaire designed to evaluate neuropathic symptoms, and multivariate analysis was subsequently performed to identify an optimal predictive model. The explanatory capacity was evaluated by calculating the R 2 coefficient of Nagelkerke. Predictive capacity was evaluated by calculating sensitivity, specificity, and estimation of the area under the receiver operational curve. Protective sensitivity loss was detected in 19.1% of participants. Variables associated by multivariate analysis were: educational level (OR: 31.4, 95% CI: 2.5‐383.3, P = .007) and two items from the questionnaire: one related to bleeding and wet socks (OR: 28.3, 95% CI: 3.7‐215.9, P = .001) and the other related to electrical sensations (OR: 52.9, 95% CI: 4.3‐643.9, P = .002), which were both statistically significant. The predictive model included the variables of age, sex, duration of diabetes, and educational level, and it had a sensitivity of 81.3% and a specificity of 95.5%. This model has a high predictive capacity to identify patients at risk of developing sensory neuropathy.

Narrativas sobre morbilidad materna extrema en sobrevivientes a esta experiencia en México

Objetivo: analizar las narrativas que sobre morbilidad materna extrema han desarrollado mujeres sobrevivientes a esta experiencia en san luis potosí, méxico. Metodología: estudio biográfico-narrativo en el que mediante muestreo intencional inicial y teórico posteriormente, fueron seleccionadas 20 mujeres para recuperar sus relatos sobre la experiencia. Las narrativas compartidas fueron sometidas a análisis paradigmático de contenido. Resultados principales: con marco en la antropología del riesgo, se identificó que las narrativas que prevalecen sobre morbilidad materna extrema son: a) como sinónimo de muerte, b) como evento fortuito y efímero, y c) como una situación ilegítima o inventada. Conclusión: las narrativas que las mujeres han construido sobre su experiencia de morbilidad materna extrema son diversas, sostenidas en emociones que van desde el miedo, hasta la aceptación e incredulidad; sin embargo, ninguna de estas narrativas aporta al desarrollo de una agencia real para prevenir un riesgo obstétrico futuro.

Selecting and quantifying low‐value nursing care in clinical practice: A questionnaire survey

Abstract

Aims and objectives

To evaluate the opinion of hospital nurses on a group of recommendations aimed at reducing low‐value nursing care and, based on these results, to detect low‐value practices probably existing in the hospital.

Background

Low‐value nursing care refers to clinical practices with poor or no benefit for patients that may be harmful and a waste of resources. Detecting these practices and understanding nurses' perceptions are essential to developing effective interventions to reduce them.

Methods

We conducted a survey in a tertiary hospital. STROBE guidelines were followed. The questionnaire appraised nurses' agreement, subjective adherence and perception of usefulness of a group of recommendations to reduce low‐value nursing care from Choosing Wisely and other initiatives. Practices described in recommendations with an agreement over 70% and a subjective adherence under 70% were categorised as low‐value practices probably existing in the hospital.

Results

A total of 265 nurses from eight areas of care participated in the survey. The response rate by area ranged between 2%–55%. From the 38 recommendations evaluated, agreement was 96% (95% confidence interval [95%CI], 95%–97%), median subjective adherence was 80% (95%CI, 80%–85%), and usefulness was 90% (95%CI, 89%–92%). Based on these results, we detected seven (0–15) low‐value practices probably existing in our hospital, mostly on general practice, pregnancy care and wound care.

Conclusions

We found a great understanding of low‐value care between nurses, given the high agreement to recommendations and perception of usefulness. However, several low‐value practices may be present in nursing care, requiring actions to reduce them, for instance, reviewing institutional protocols and involving patients in de‐implementation.

Relevance to clinical practice

Hospitals and other settings should be aware of low‐value practices and take actions to identify and reduce them. A survey may be a simple and helpful way to start this process.

Efecto de la intervención psicoeducativa “Reconociéndome” para el manejo de la incertidumbre en personas con diabetes tipo 2

Introducción: Dentro de los determinantes que constituyen el desarrollo de la Diabetes tipo 2 se encuentra el consumo de alcohol que representa altos costos para la salud y conduce a problemas agudos y crónicos, como traumatismos intencionales, accidentales, trastornos mentales, cáncer, enfermedades cardiovasculares e hipertensión; afectando la salud física y mental de la persona además de inferir con responsabilidades sociales y familiares, causando tensión por vivir en ambientes donde se generan sentimientos de preocupación, impotencia e incertidumbre. Material y métodos: Se plantea un diseño cuasi experimental, longitudinal y prospectivo. La captación del estudio se realizará en las Unidades de Especialidades Médicas, Enfermedades Crónicas de la Secretaría de Salud de Culiacán, Sinaloa. El muestreo será estratificado, el tamaño de mínimo de muestra será de n=66 población finita, para cada grupo. Los datos se recogerán mediante cuestionarios. Utilidad práctica: Se espera que mediante la intervención psicoeducativa las personas con Diabetes tipo 2 que consumen se obtengan un efecto positivo y disminuya el nivel de incertidumbre.

 

Abstract

Introduction: Among the determinants that constitute the development of Type 2 Diabetes is the consumption of alcohol that represents high health costs and leads to acute and chronic problems, such as intentional, accidental trauma, mental disorders, cancer, cardiovascular diseases and hypertension; affecting the physical and mental health of the person as well as inferring with social and family responsibilities, causing tension by living in environments where feelings of concern, helplessness and uncertainty are generated.Material and methods: A quasi experimental, longitudinal and prospective design is proposed. The capture of the study will be carried out in the Units of Medical Specialties, Chronic Diseases of the Secretariat of Health of Culiacán, Sinaloa. The sampling will be stratified, the minimum sample size will be n = 66 finite population, for each group. The data will be collected through questionnaires. Practical Utility: It is expected that through psychoeducational intervention people with Type 2 Diabetes who consume will obtain a positive effect and decrease the level of uncertainty. 

Ser mujer indígena, vivir con VIH y violencia de pareja: una triple vulneración frente al derecho a la salud

Introducción: La epidemia del VIH/Sida se ha reconfigurado en la última década, su tendencia a la feminización y ruralización se ha asociado de manera estrecha con la violencia de género y la discriminación racial. Objetivo: Analizar desde el marco del cuidado enfermero, el impacto de la violencia de pareja en la vida de una mujer indígena que vive con VIH. Metodología: Se trató de una aproximación desde el enfoque biográfico, la información recuperada se procesó mediante análisis crítico del discurso. Resultados: Los relatos recuperan las experiencias de una mujer indígena que contrajo VIH, y cómo la trayectoria de la enfermedad ha estado enmarcada por la violencia de pareja y la discriminación social. Conclusiones: La violencia de pareja contribuye a la vulnerabilidad de las mujeres indígenas frente al VIH/sida, la trayectoria de la enfermedad recrudece las formas de violencia que en general, viven estas mujeres.

Estudio semi-cuantitativo de la idoneidad del uso de abreviaturas en la Unidad de Cuidados Intensivos del Hospital Universitario de Torrevieja (Alicante)

Objetivo principal: Identificar el número y tipo de abreviaturas estandarizadas utilizadas al elaborar los registros de enfermería en la Unidad de Cuidados Intensivos (UCI) del Hospital Universitario de Torrevieja. Metodología: Estudio descriptivo transversal realizado con una muestra de 641 registros de enfermería de 25 Historias Clínicas. Resultados principales: El glosario de abreviaturas, siglas y acrónimos fue filtrado en bases terminológicas para comprobar si existía una estandarización a las mismas. De la muestra de los 641 registros se identificaron un total de 3.445 abreviaturas, siglas y acrónimos, siendo 247 diferentes entre sí. Los vocablos identificados están reconocidos en un 45,5 %, en el primero de los diccionarios, aumentando el porcentaje  al 51,2 % en la base segunda base terminológica. Conclusión principal: El uso de las abreviaturas, siglas y acrónimos puede generar problemas de comprensión e  interferir en la seguridad de los pacientes, aconsejándose la protocolización de su uso para no deteriorar la calidad asistencial.

Characterisation of impaired wound healing in a preclinical model of induced diabetes using wide‐field imaging and conventional immunohistochemistry assays

Major complications of diabetes lead to inflammation and oxidative stress, delayed wound healing, and persistent ulcers. The high morbidity, mortality rate, and associated costs of management suggest a need for non‐invasive methods that will enable the early detection of at‐risk tissue. We have compared the wound‐healing process that occurs in streptozotocin (STZ)‐treated diabetic rats with non‐diabetic controls using contrast changes in colour photography (ie, Weber Contrast) and the non‐invasive optical method Spatial Frequency Domain Imaging (SFDI). This technology can be used to quantify the structural and metabolic properties of in‐vivo tissue by measuring oxyhaemoglobin concentration (HbO2), deoxyhaemoglobin concentration (Hb), and oxygen saturation (StO2) within the visible boundaries of each wound. We also evaluated the changes in inducible nitric oxide synthase (iNOS) in the dermis using immunohistochemistry. Contrast changes in colour photographs showed that diabetic rats healed at a slower rate in comparison with non‐diabetic control, with the most significant change occurring at 7 days after the punch biopsy. We observed lower HbO2, StO2, and elevated Hb concentrations in the diabetic wounds. The iNOS level was higher in the dermis of the diabetic rats compared with the non‐diabetic rats. Our results showed that, in diabetes, there is higher level of iNOS that can lead to an observed reduction in HbO2 levels. iNOS is linked to increased inflammation, leading to prolonged wound healing. Our results suggest that SFDI has potential as a non‐invasive assessment of markers of wound‐healing impairment.

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