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Healthcare, Volume 7, Issue 1 (March 2019)

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Cover Story (view full-size image) Effective strategies to manage obesity are urgently required. Evidence of the effectiveness of [...] Read more.
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Open AccessArticle
Characterization and Adsorption Behavior of Strontium from Aqueous Solutions onto Chitosan-Fuller’s Earth Beads
Received: 21 January 2019 / Revised: 12 March 2019 / Accepted: 21 March 2019 / Published: 26 March 2019
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Abstract
Fuller’s earth spherical beads using chitosan as a binder were prepared for the removal of strontium ions from aqueous solution. The adsorbents were characterized by scanning electron microscopy (SEM) and transmission electron microscopy (TEM), which revealed the porous nature of the beads. The [...] Read more.
Fuller’s earth spherical beads using chitosan as a binder were prepared for the removal of strontium ions from aqueous solution. The adsorbents were characterized by scanning electron microscopy (SEM) and transmission electron microscopy (TEM), which revealed the porous nature of the beads. The Brunauer–Emmett–Teller (BET) surface area of the beads was found to be 48.5 m2/g. The adsorption capacities of the beads were evaluated under both batch and dynamic conditions. The adsorption capacity was found to be ~29 mg/g of adsorbent at 298 K when the equilibrium concentration of strontium in the solution was 925 mg/L at pH 6.5. The X-ray photoelectron spectroscopy (XPS) data suggest that strontium uptake by the beads occurs mainly through an ion-exchange process. Kinetic data indicate that the sorption of strontium onto the beads follows anomalous diffusion. Thermodynamic data suggest that the ion-exchange of Sr2+ on the bead surface was feasible, spontaneous and endothermic in nature. Full article
(This article belongs to the Special Issue Water Quality and Public Health)
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Open AccessArticle
Alarming and/or Alerting Device Effectiveness in Reducing Falls in Long-Term Care (LTC) Facilities? A Systematic Review
Received: 15 February 2019 / Revised: 17 March 2019 / Accepted: 21 March 2019 / Published: 25 March 2019
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Abstract
Perceptions against the use of alarming devices persist in long-term care environments as they are seen as annoying, costly, and a waste of time to the staff involved. Ascertaining whether these perceptions are true or false via the literature was a focus of [...] Read more.
Perceptions against the use of alarming devices persist in long-term care environments as they are seen as annoying, costly, and a waste of time to the staff involved. Ascertaining whether these perceptions are true or false via the literature was a focus of this study. Proper information to educate staff and to work past these perceptions can be a positive effector for resident safety. Many facilitators for the use of alarming devices were found, as well as many barriers to their use as well. New technology is changing the perceptions regarding these types of devices as time passes. Education is a key component for staff, residents, and families. There are “traditional” issues with the use of alarms such as alarm fatigue by caregivers, high costs of implementation, and issues with proper implementation of alarms. Alarms are perceived as intrusive and the noise from them can be a potential cause of falls. However, alarming devices can be a key intervention in the safety of those residents who are prone to falls. This requires proper implementation and education for all parties involved, and proper oversight surrounding use of the devices. Full article
(This article belongs to the Special Issue Aging, Chronic Disease, and the Impact of Long Term Care)
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Open AccessReview
Impacts of Salinity Intrusion in Community Health: A Review of Experiences on Drinking Water Sodium from Coastal Areas of Bangladesh
Received: 3 January 2019 / Revised: 17 March 2019 / Accepted: 17 March 2019 / Published: 22 March 2019
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Abstract
Increasing salt intake has substantial negative impacts on human health and well-being. This article focused on the construction of Driver-Pressure-State-Impact-Response (DPSIR) framework for drinking water sodium (DWS) followed by a review on the published studies regarding salinity intrusion, DWS, and their effects on [...] Read more.
Increasing salt intake has substantial negative impacts on human health and well-being. This article focused on the construction of Driver-Pressure-State-Impact-Response (DPSIR) framework for drinking water sodium (DWS) followed by a review on the published studies regarding salinity intrusion, DWS, and their effects on health perspectives in Bangladesh. Saline water is an important factor for hypertension or high blood pressure in the coastal areas. DWS can also lead women, especially pregnant women, to an increased risk of (pre)eclampsia, hypertension, as well as infant mortality. Several interventions, such as rainwater harvesting, pond sand filter (PSF) system, managed aquifer recharge (MAR), and pilot scale solar-powered desalination plants, such as reverse osmosis (RO), were reviewed on the context of their effectiveness in controlling drinking water sodium. Although rainwater consumption has the positive impact of low or no sodium intake, it still possesses negative impacts from not having vital minerals. A steady increment in sodium concentration through the span of the dry season was observed in MAR. It is, subsequently, important to increase awareness on DWS intake by providing and adopting correct technological interventions and training communities on the maintenance of the adaptive measures. Full article
(This article belongs to the Special Issue Water Quality and Public Health)
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Open AccessArticle
A Review of Age Friendly Virtual Assistive Technologies and their Effect on Daily Living for Carers and Dependent Adults
Received: 14 February 2019 / Revised: 16 March 2019 / Accepted: 17 March 2019 / Published: 21 March 2019
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Abstract
Many barriers exist in the lives of older adult’s, including health, transport, housing, isolation, disability and access to technology. The appropriate integration of technology within age-friendly communities continues to offer possible solutions to these barriers and challenges. Older adults and disabled people continue [...] Read more.
Many barriers exist in the lives of older adult’s, including health, transport, housing, isolation, disability and access to technology. The appropriate integration of technology within age-friendly communities continues to offer possible solutions to these barriers and challenges. Older adults and disabled people continue to be affected and marginalized due to lack of access to the digital world. Working collaboratively with planners, policy makers and developers, social and living spaces in the future will ensure that residents are equipped to live in an era that continues to be led by, and is dependent upon, access to technology. This review paper uniquely draws together the small volume of literature from the fields of gerontology, gerontechnology, human computer interaction (HCI), and disability. This paper examines the national and international age-friendly frameworks regarding older adults who are carers of dependent people with disabilities. Full article
(This article belongs to the Special Issue Creating Age-friendly Communities: Housing and Technology)
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Open AccessReview
The Effect of Preoperative Education on Psychological, Clinical and Economic Outcomes in Elective Spinal Surgery: A Systematic Review
Received: 21 January 2019 / Revised: 18 March 2019 / Accepted: 19 March 2019 / Published: 21 March 2019
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Abstract
Psychosocial factors related to different degrees of clinical impairment and quality of life in the preoperative period may influence outcomes from elective spine surgery. Patients have expressed a need for individualized information given in sufficient quantities and at the appropriate time. Therefore, this [...] Read more.
Psychosocial factors related to different degrees of clinical impairment and quality of life in the preoperative period may influence outcomes from elective spine surgery. Patients have expressed a need for individualized information given in sufficient quantities and at the appropriate time. Therefore, this review article aims to determine whether a preoperative education session improves clinical, psychological and economic outcomes in elective spinal surgery. PubMed, Cochrane Library, CINAHL Complete, Medline Complete and PsychINFO were searched in July 2018 for randomized clinical trials to evaluate the effects of a preoperative education intervention on psychological, clinical and economic outcomes in spinal surgery. The search yielded 78 results, of which eleven papers (seven studies) were relevant for inclusion. From these results, there is limited, fair-quality evidence that supports the inclusion of a preoperative education session for improving clinical (pain, function and disability), economic (quality-adjusted life years, healthcare expenditure, direct and indirect costs) and psychological outcomes (anxiety, depression and fear-avoidance beliefs) from spinal surgery. Other benefits are reported to be improved patient knowledge, feelings of better preparation, reduced negative thinking and increased levels of physical activity after the intervention. No differences in quality of life, return to work, physical indicators or postoperative complications were reported. From the limited evidence, it is not possible to conclusively recommend that preoperative education should be delivered as a standalone intervention before elective spine surgery; however, given the low risk profile and promising benefits, future research in this area is warranted. Full article
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Open AccessArticle
Parental Life-Limiting Illness: What Do We Tell the Children?
Received: 27 February 2019 / Revised: 18 March 2019 / Accepted: 19 March 2019 / Published: 20 March 2019
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Abstract
Being diagnosed with and having a life-limiting illness is a stressful experience which is compounded when the patient has dependent children. An important aspect of the patient’s psychosocial care should include recognition that their children are also likely to experience severe stress because [...] Read more.
Being diagnosed with and having a life-limiting illness is a stressful experience which is compounded when the patient has dependent children. An important aspect of the patient’s psychosocial care should include recognition that their children are also likely to experience severe stress because of the illness. However, children’s needs are often overlooked during the illness. These needs include information about the illness. Health care professionals have a significant role in supporting patients to communicate with their children. This study aims to increase our understanding of children’s experiences when a parent has a life-limiting illness by exploring bereaved children’s experiences of the support they received when their parent had a life-limiting illness, and professionals’ perspectives of the support offered to children. 7 children (aged between 9 and 24), and 16 health care professionals were interviewed about communication during parental illness. Children report needing open, clear and age appropriate conversations with parents and health care professionals to help them begin to obtain some meaning from the situation. The importance of communication is discussed, with particular reference to the role health care professionals have in supporting these conversations. Full article
(This article belongs to the Special Issue Recent Advances in Palliative Care)
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Open AccessArticle
Presence of Babesia odocoilei and Borrelia burgdorferi Sensu Stricto in a Tick and Dual Parasitism of Amblyomma inornatum and Ixodes scapularis on a Bird in Canada
Received: 11 February 2019 / Revised: 12 March 2019 / Accepted: 13 March 2019 / Published: 20 March 2019
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Abstract
Wild birds transport ticks into Canada that harbor a diversity of zoonotic pathogens. However, medical practitioners often question how these zoonotic pathogens are present in their locality. In this study, we provide the first report of an Amblyomma inornatum tick cofeeding with a [...] Read more.
Wild birds transport ticks into Canada that harbor a diversity of zoonotic pathogens. However, medical practitioners often question how these zoonotic pathogens are present in their locality. In this study, we provide the first report of an Amblyomma inornatum tick cofeeding with a blacklegged tick, Ixodes scapularis, which parasitized a Veery, Catharus fuscescens—a neotropical songbird. Using the flagellin (flaB) gene of the Lyme disease bacterium, Borrelia burgdorferi sensu lato, and the 18S rRNA gene of the Babesia piroplasm, a malaria-like microorganism, we detected Borrelia burgdorferi sensu stricto and Babesia odocoilei, respectively, in an I. scapularis nymph. After the molt, these ticks can bite humans. Furthermore, this is the first documentation of B. odocoilei in a tick parasitizing a bird. Our findings substantiate the fact that migratory songbirds transport neotropical ticks long distances, and import them into Canada during northward spring migration. Health care practitioners need to be aware that migratory songbirds transport pathogen-laden ticks into Canada annually, and pose an unforeseen health risk to Canadians. Full article
(This article belongs to the Special Issue Lyme Disease and Related Tickborne Infections)
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Open AccessArticle
Adverse Event Circumstances and the Case of Drug Interactions
Received: 15 February 2019 / Revised: 15 March 2019 / Accepted: 18 March 2019 / Published: 19 March 2019
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Abstract
Adverse events are a common and for the most part unavoidable consequence of therapeutic intervention. Nevertheless, available tomes of such data now provide us with an invaluable opportunity to study the relationship between human phenotype and drug-induced protein perturbations within a patient system. [...] Read more.
Adverse events are a common and for the most part unavoidable consequence of therapeutic intervention. Nevertheless, available tomes of such data now provide us with an invaluable opportunity to study the relationship between human phenotype and drug-induced protein perturbations within a patient system. Deciphering the molecular basis of such adverse responses is not only paramount to the development of safer drugs but also presents a unique opportunity to dissect disease systems in search of novel response biomarkers, drug targets, and efficacious combination therapies. Inspired by the potential applications of this approach, we first examined adverse event circumstances reported in FAERS and then performed a molecular level interrogation of cancer patient adverse events to investigate the prevalence of drug-drug interactions in the context of patient responses. We discuss avoidable and/or preventable cases and how molecular analytics can help optimize therapeutic use of co-medications. While up to one out of three adverse events in this dataset might be explicable by iatrogenic, patient, and product/device related factors, almost half of the patients in FAERS received multiple drugs and one in four may have experienced effects attributable to drug interactions. Full article
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Open AccessArticle
Attitudes of Doctors and Nurses toward Patient Safety within Emergency Departments of a Saudi Arabian Hospital: A Qualitative Study
Received: 10 February 2019 / Revised: 11 March 2019 / Accepted: 13 March 2019 / Published: 18 March 2019
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Abstract
Background: The attitudes of doctors and nurses toward patient safety representa significant contributing factor to hospital safety climates and medical error rates. Yet, there are very few studies of patient safety attitudes in Saudi hospitals and none conducted in hospital emergency departments. Aims [...] Read more.
Background: The attitudes of doctors and nurses toward patient safety representa significant contributing factor to hospital safety climates and medical error rates. Yet, there are very few studies of patient safety attitudes in Saudi hospitals and none conducted in hospital emergency departments. Aims: The current study aims to investigate and compare the patient safety attitudes of doctors and nurses in a Saudi hospital emergency department. Materials and Method: The study employed a qualitative research design via semi-structured interviews with Saudi and non-Saudi doctors and nurses working in a Saudi hospital emergency department to determine their attitudes and experiences about the patient safety climate. Results: Findings revealed doctors and nurses held some similar safety attitudes; however, nurses reported issues with doctors with respect to their teamwork, communication, and patient safety attitudes. Moreover, several barriers to the patient safety climate were identified, including limits to resources, teamwork, communication, and incident reporting. Conclusion: The findings provide one of the few research contributions to knowledge regarding the patient safety attitudes of Saudi and non-Saudi doctors and nurses and suggest the application of such knowledge would enhance positive patient outcomes in emergency departments. Full article
Open AccessArticle
Making Homes More Dementia-Friendly through the Use of Aids and Adaptations
Received: 25 February 2019 / Revised: 12 March 2019 / Accepted: 14 March 2019 / Published: 16 March 2019
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Abstract
The majority of people with dementia live in their own homes, often supported by a family member. While this is the preferred option for most, they often face multiple challenges due to a deterioration in their physical and cognitive abilities. This paper reports [...] Read more.
The majority of people with dementia live in their own homes, often supported by a family member. While this is the preferred option for most, they often face multiple challenges due to a deterioration in their physical and cognitive abilities. This paper reports on a pilot study that aimed to explore the impacts of aids and adaptations on the wellbeing of people with dementia and their families living at home. Quantitative data were collected using established measures of wellbeing at baseline, 3 months and 9 months. In-depth case studies were carried out with a sample of participants. Findings from the pilot suggest that relatively inexpensive aids can contribute towards the maintenance of wellbeing for people with dementia in domestic settings. The project also increased the skills and confidence of professionals involved in the project and strengthened partnerships between the collaborating organisations across health, housing and social care. Providing aids that can help people with dementia to remain living at home with a good quality of life, often with the support of a family member, is an important element in the development of age-friendly communities. Full article
(This article belongs to the Special Issue Creating Age-friendly Communities: Housing and Technology)
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Open AccessArticle
An Increasing Neutrophil-to-Lymphocyte Ratio Trajectory Predicts Organ Failure in Critically-Ill Male Trauma Patients. An Exploratory Study
Received: 10 December 2018 / Revised: 11 March 2019 / Accepted: 12 March 2019 / Published: 14 March 2019
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Abstract
Background: Although the association of neutrophil proportions with mortality in trauma patients has recently been shown, there is a paucity of research on the association with other outcomes. We sought to investigate the association of neutrophil proportions with organ failure in critically-ill trauma [...] Read more.
Background: Although the association of neutrophil proportions with mortality in trauma patients has recently been shown, there is a paucity of research on the association with other outcomes. We sought to investigate the association of neutrophil proportions with organ failure in critically-ill trauma patients. Methods: We reviewed a randomly-selected group of trauma patients admitted to our level-1 trauma intensive care unit between July 2007 and December 2016. Data collected included demographics, injury mechanism and severity (ISS), neutrophil-to-lymphocyte ratio (NLR) at admission and at 24 and 48 hours and organ failure data. NLR patterns during the first 48 hours were divided into two trajectories identified by applying factor and cluster analysis to longitudinal measures. Logistic regression was performed for the association between NLR trajectories and any organ failure; negative binomial regression was used to model the number of organ failures and stage of kidney failure measured by KDIGO classification. Results: 207 patients had NLR data at all three time points. The average age was 44.9 years with mean ISS of 20.6. Patients were 72% male and 23% had penetrating trauma. The 74 patients (36%) with Trajectory 1 had a mean NLR at admission of 3.6, which increased to 14.7 at 48 hours. The 133 (64%) patients in Trajectory 2 had a mean NLR at admission of 8.5 which decreased to 6.6 at 48 hours. Mean NLR was different between the two groups at all three time points (all p < 0.01). There was no significant difference in ISS, age or gender between the two trajectory groups. Models adjusted for age, gender and ISS showed that relative to those with trajectory 2, patients with the trajectory 1 were more likely to have organ failure OR 2.96 (1.42–6.18; p < 0.01), higher number of organ failures IRR 1.50 (1.13–2.00, p < 0.01), and degree of AKI IRR 2.06 (1.04–4.06, p = 0.04). In all cases, the estimated associations were higher among men vs. women, and all were significant among men, but not women. Conclusions: Trauma patients with an increasing NLR trajectory over the first 48 hours had increased risk, number and severity of organ failures. Further research should focus on the mechanisms behind this difference in outcome. Full article
(This article belongs to the Special Issue The Outcome of Sepsis)
Open AccessArticle
Quality Is in the Eye of the Beholder—A Focus Group Study from the Perspective of Ambulance Clinicians, Physicians, and Managers
Received: 28 January 2019 / Revised: 27 February 2019 / Accepted: 8 March 2019 / Published: 13 March 2019
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Abstract
Quality within all areas of healthcare should be systemically monitored and ensured. However, the definition of quality is complex and diverse. In the ambulance service (AS), quality has traditionally been defined as response time, but this measurement eliminates the possibility of addressing other [...] Read more.
Quality within all areas of healthcare should be systemically monitored and ensured. However, the definition of quality is complex and diverse. In the ambulance service (AS), quality has traditionally been defined as response time, but this measurement eliminates the possibility of addressing other characteristics of quality, such as the care provided. This study aimed to explore what constitutes quality in the context of the ambulance service as experienced by ambulance clinicians, physicians, and managers. A focus group study was conducted with 18 participants. The three focus groups were analyzed with the focus group method developed by Kreuger and Casey. The participants highlighted patient involvement, information and care, as well as adherence to policies, regulations, and their own standards as representing quality in the AS. This study demonstrates that quality is in the eye of the beholder. As quality seems to be viewed similarly by patients and ambulance clinicians, physicians, and managers, stakeholders should aim for a paradigm shift where patients’ experience of the care is just as important as various time measures. Full article
Open AccessArticle
Health Insurance Coverage Better Protects Blacks than Whites against Incident Chronic Disease
Received: 23 December 2018 / Revised: 18 February 2019 / Accepted: 19 February 2019 / Published: 10 March 2019
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Abstract
Although the protective effect of health insurance on population health is well established, this effect may vary based on race/ethnicity. This study had two aims: (1) to test whether having health insurance at baseline protects individuals over a 10-year period against incident chronic [...] Read more.
Although the protective effect of health insurance on population health is well established, this effect may vary based on race/ethnicity. This study had two aims: (1) to test whether having health insurance at baseline protects individuals over a 10-year period against incident chronic medical conditions (CMC) and (2) to explore the race/ethnic variation in this effect. Midlife in the United States (MIDUS) is a national longitudinal study among 25–75 year-old American adults. The current study included 3572 Whites and 133 Blacks who were followed for 10 years from 1995 to 2004. Race, demographic characteristics (age and gender), socioeconomic status (educational attainment and personal income), and health insurance status were measured at baseline. Number of CMC was measured in 1995 and 2005. Linear regression models were used for data analysis. In the overall sample, having health insurance at baseline was inversely associated with an increase in CMC over the follow up period, net of covariates. Blacks and Whites differed in the magnitude of the effect of health insurance on CMC incidence, with a stronger protective effect for Blacks than Whites. In the U.S., health insurance protects individuals against incident CMC; however, the health return of health insurance may depend on race/ethnicity. This finding suggests that health insurance may better protect Blacks than Whites against developing more chronic diseases. Increasing Blacks’ access to health insurance may be a solution to eliminate health disparities, given they are at a relative advantage for gaining health from insurance. These findings are discussed in the context of Blacks’ diminished returns of socioeconomic resources. Future attempts should test replicability of these findings. Full article
(This article belongs to the Special Issue Feature Papers in Healthcare in 2018)
Open AccessArticle
A Proactive Environmental Approach for Preventing Legionellosis in Infants: Water Sampling and Antibiotic Resistance Monitoring, a 3-Years Survey Program
Received: 27 January 2019 / Revised: 2 March 2019 / Accepted: 6 March 2019 / Published: 8 March 2019
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Abstract
A proactive environmental monitoring program was conducted to determine the risk and prevent nosocomial waterborne infections of Legionella spp. in infants. Sink taps in a neonatal intensive care unit (NICU) and two obstetric clinics were monitored for Legionella spp. A total of 59 [...] Read more.
A proactive environmental monitoring program was conducted to determine the risk and prevent nosocomial waterborne infections of Legionella spp. in infants. Sink taps in a neonatal intensive care unit (NICU) and two obstetric clinics were monitored for Legionella spp. A total of 59 water samples were collected during a 3-year period and 20 of them were found colonized with Legionella pneumophila. Standard culture, molecular, and latex agglutination methods were used for the detection and identification of Legionella bacteria. Hospital personnel also proceeded with remedial actions (hyperchlorination and thermal shock treatment) in the event of colonization. The minimal inhibitory concentration (MIC) values of erythromycin, ciprofloxacin was determined for Legionella isolates using the e-test method. Our data indicate that the majority of neonatal sink-taps were colonized at least once during the study with Legionella spp. Among 20 isolates, 5 were considered as low-level resistant, 3 in erythromycin and 2 in ciprofloxacin, while no resistant strains were detected. Environmental surveillance in neonatal and obstetric units is suggested to prevent waterborne infections, and thus to reduce the risk of neonatal nosocomial infections. Full article
(This article belongs to the Special Issue Water Quality and Public Health)
Open AccessArticle
Integrating Local Knowledge into a National Programme: Evidence from a Community-Based Diabetes Prevention Education Programme
Received: 1 February 2019 / Revised: 1 March 2019 / Accepted: 4 March 2019 / Published: 7 March 2019
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Abstract
Type 2 diabetes prevention is a major priority for healthcare services and public health. This study aimed to evaluate how a local authority in England piloted a diabetes prevention programme. The South Gloucestershire Diabetes Prevention (Pilot) Programme (SGDPP) comprised a group health education [...] Read more.
Type 2 diabetes prevention is a major priority for healthcare services and public health. This study aimed to evaluate how a local authority in England piloted a diabetes prevention programme. The South Gloucestershire Diabetes Prevention (Pilot) Programme (SGDPP) comprised a group health education course over six weeks with subsequent support provision up to six months post-enrolment. Of the 300 patients invited onto the programme, 32% enrolled and 29% completed the full six-month programme. There was an attendance rate of 84% throughout group sessions and at a six-month follow-up. There were significant improvements across most measures at six months, including a 4 kg mean weight loss and a 3.45 mmol/mol mean HbA1c reduction. Clear goals, high quality organization and personal qualities of educators were identified as central for the programme’s success. The unit costs were similar to pilots of other healthy lifestyle programmes. The evaluation found evidence of reduced type 2 diabetes risk markers, positive impacts for dietary and physical activity, and potential cost-effectiveness for this format of group-based diabetes prevention intervention. Feedback from multiple stakeholders provided insight on how to successfully embed and scale-up delivery of diabetes prevention work. This evidence enables the integration of learning in local service delivery and provides a basis to support development of the national diabetes prevention programme. Full article
(This article belongs to the Special Issue Feature Papers in Healthcare in 2018)
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Open AccessReview
The Interlinked Rising Epidemic of Insufficient Sleep and Diabetes Mellitus
Received: 2 January 2019 / Revised: 26 February 2019 / Accepted: 28 February 2019 / Published: 5 March 2019
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Abstract
For healthy existence, humans need to spend one-third of their time sleeping. Any qualitative or quantitative disturbances in sleep would result in an increased prevalence of obesity, metabolic disorders, diabetes, cardiovascular diseases, and hypertension. The paper aims to highlight the growing global problem [...] Read more.
For healthy existence, humans need to spend one-third of their time sleeping. Any qualitative or quantitative disturbances in sleep would result in an increased prevalence of obesity, metabolic disorders, diabetes, cardiovascular diseases, and hypertension. The paper aims to highlight the growing global problem of insufficient sleep and its significant impact on the rising incidence of diabetes mellitus. An extensive literature search was done in all major databases for “insufficient sleep” and “Diabetes Mellitus” for this review. Shorter (<6 h) and longer (>9 h) durations of sleep have been adversely related to insulin resistance. Though the relation between insufficient sleep and diabetes mellitus is more or less understood, little is known about how oversleeping or hypersomnia (10–12 h) increases the risk of diabetes. The relationship between sleep disturbances and diabetes is dual-sided, as chronic sleep disturbances would elevate the risk of developing insulin resistance, while diabetes would worsen the quality of sleep. Both the qualitative and quantitative disturbances in sleep significantly increase the risk of developing diabetes, which is supported by numerous community-based and hospital-based epidemiological studies discussed in this review. Obstructive sleep apnea is one of the most common sleep disorders and is characterized by chronic intermittent hypoxia and increased sympathetic activity, thus leading to a higher prevalence of diabetes. Sleep therapy may serve as a low-cost method for fighting against the rising epidemic of diabetes. Full article
(This article belongs to the Special Issue Feature Papers in Healthcare in 2018)
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Open AccessArticle
Impact of The Affordable Care Act’s Elimination of Cost-Sharing on the Guideline-Concordant Utilization of Cancer Preventive Screenings in the United States Using Medical Expenditure Panel Survey
Received: 13 November 2018 / Revised: 30 January 2019 / Accepted: 26 February 2019 / Published: 1 March 2019
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Abstract
Currently available evidence regarding the association of the Affordable Care Act’s (ACA) elimination of cost-sharing and the utilization of cancer screenings is mixed. We determined whether the ACA’s zero cost-sharing policy affected the guideline-concordant utilization of cancer screenings, comparing adults (≥21 years) from [...] Read more.
Currently available evidence regarding the association of the Affordable Care Act’s (ACA) elimination of cost-sharing and the utilization of cancer screenings is mixed. We determined whether the ACA’s zero cost-sharing policy affected the guideline-concordant utilization of cancer screenings, comparing adults (≥21 years) from 2009 with 2011–2014 data from the Medical Expenditure Panel Survey. Study participants were categorized as: 21–64 years with any private insurance, ≥65 years with Medicare only, and 21–64 years uninsured, with a separate sample for each type of screening test. Adjusted weighted prevalence and prevalence ratios (PR (95%CI)) were estimated. In 2014 (vs. 2009), privately-insured women reported 2% (0.98 (0.97–0.99)) and 4% (0.96 (0.93–0.99)) reduction in use of Pap tests and mammography, respectively. Privately-insured non-Hispanic Asian women had 16% (0.84 (0.74–0.97)) reduction in mammography in 2014 (vs. 2009). In 2011 (vs. 2009), privately-insured and Medicare-only men reported 9% (1.09 (1.03–1.16)) and 13% (1.13 (1.02–1.25)) increases in colorectal cancer (CRC) screenings, respectively. Privately-insured women reported a 6–7% rise in 2013–2014 (vs. 2009), and Hispanic Medicare beneficiaries also reported 40–44%, a significant rise in 2011–2014 (vs. 2009), in the utilization of CRC screenings. While the guideline-concordant utilization of Pap tests and mammography declined in the post-ACA period, the elimination of cost-sharing appeared to have positively affected CRC screenings of privately-insured males, females, and Hispanic Medicare-only beneficiaries. Greater awareness about the zero cost-sharing policy may help in increasing the uptake of cancer screenings. Full article
(This article belongs to the Special Issue Feature Papers in Healthcare in 2018)
Open AccessReview
COPD: The Annual Cost-Of-Illness during the Last Two Decades in Italy, and Its Mortality Predictivity Power
Received: 29 December 2018 / Revised: 19 February 2019 / Accepted: 20 February 2019 / Published: 1 March 2019
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Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive pathological condition characterized by a huge epidemiological and socioeconomic impact worldwide. In Italy, the actual annual cost of COPD was assessed for the first time in 2002: the mean cost per patient per year was [...] Read more.
Chronic obstructive pulmonary disease (COPD) is a progressive pathological condition characterized by a huge epidemiological and socioeconomic impact worldwide. In Italy, the actual annual cost of COPD was assessed for the first time in 2002: the mean cost per patient per year was €1801 and ranged from €1500 to €3912, depending on COPD severity. In 2008, the mean annual cost per patient was €2723.7, ranging from €1830.6 in mild COPD up to €5451.7 in severe COPD. In 2015, it was €3291, which is 20.8% and 82.7% higher compared to the costs estimated in 2008 and 2002, respectively. In all these studies, the major cost component was direct costs, in particular hospitalization costs due to exacerbations, which corresponded to 59.9% of the total cost and 67.2% of direct costs, respectively. When the annual healthcare expenditure per patient is related to the length of survival by means of the PRO-BODE Index (PBI, which is the implementation of the well-known BODE Index with costs due to annual exacerbations and/or hospitalizations), the annual cost of care proved much more strictly and inversely proportional to patients’ survival at three years, with the highest regression coefficient (r = −0.58) of all the multidimensional indices presently available, including the BODE Index (r = −021). In Italy, even though tobacco smoking has progressively declined by up to 21% in the general population, the economic impact of COPD has shown relentless progression over the last two decades, confirming that the present national health system organization is still insufficient for facing the issue of chronic diseases, in particular COPD, effectively. The periodic assessment of costs is an effective instrument for care providers in predicting COPD mortality, and for decision makers for updating and planning their social, economic, and political strategies. Full article
(This article belongs to the Special Issue Chronic Obstructive Pulmonary Disease: Updates in Lung Health)
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Open AccessReview
Impact of the Gastro-Intestinal Bacterial Microbiome on Helicobacter-Associated Diseases
Received: 31 January 2019 / Revised: 18 February 2019 / Accepted: 20 February 2019 / Published: 22 February 2019
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Abstract
Helicobacter pylori is a bacterium that selectively infects the gastric epithelium of half of the world population. The microbiome, community of microorganisms gained major interest over the last years, due to its modification associated to health and disease states. Even if most of [...] Read more.
Helicobacter pylori is a bacterium that selectively infects the gastric epithelium of half of the world population. The microbiome, community of microorganisms gained major interest over the last years, due to its modification associated to health and disease states. Even if most of these descriptions have focused on chronic disorders, this review describes the impact of the intestinal bacterial microbiome on host response to Helicobacter associated diseases. Microbiome has a direct impact on host cells, major barrier of the gastro-intestinal tract, but also an indirect impact on immune system stimulation, by enhancing or decreasing non-specific or adaptive response. In microbial infections, especially in precancerous lesions induced by Helicobacter pylori infection, these modifications could lead to different outcome. Associated to data focusing on the microbiome, transcriptomic analyses of the eukaryote response would lead to a complete understanding of these complex interactions and will allow to characterize innovative biomarkers and personalized therapies. Full article
(This article belongs to the Special Issue Human Health and Bacteria)
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Open AccessArticle
Modifying a Paediatric Rational Prescribing Tool (POPI) for Use in the UK
Received: 4 January 2019 / Revised: 4 February 2019 / Accepted: 14 February 2019 / Published: 20 February 2019
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Abstract
Rational prescribing tools can be used by individual prescribers, organisations, and researchers to evaluate the quality of prescribing for research and quality improvement purposes. A literature search showed that there is only one tool for evaluating rational prescribing for paediatric patients in hospital [...] Read more.
Rational prescribing tools can be used by individual prescribers, organisations, and researchers to evaluate the quality of prescribing for research and quality improvement purposes. A literature search showed that there is only one tool for evaluating rational prescribing for paediatric patients in hospital and outpatient settings. The Pediatrics: Omission of Prescriptions and Inappropriate Prescriptions (POPI) tool was developed in France and comprises 105 criteria. The aim of this study was to modify this tool to facilitate its use in paediatric practice in the United Kingdom (UK). POPI criteria were compared to relevant UK clinical guidelines from the National Institute for Health and Care Excellence, the Scottish Intercollegiate Guideline Network and the British National Formulary for Children. Where guidelines differed, criteria were modified to reflect UK guidance. If there were no relevant guidelines or directly contradictory guidelines, criteria were removed. Overall, no change was made to 49 criteria. There were 29 modified to concord with UK guidelines. Four criteria were reduced to two criteria due to being linked in single guidelines. Twenty-three criteria were omitted, due to the absence of relevant UK guidance or directly conflicting UK practice, including one entire clinical category (mosquitos). One category title was amended to parallel UK terminology. The modified POPI (UK) tool comprises of eighty criteria and is the first rational prescribing tool for the evaluation of prescribing for children in hospital and outpatient settings in the UK. Full article
(This article belongs to the Special Issue Rational Use of Medicines in Children)
Open AccessArticle
Development and Use of the ‘SENS’-Structure to Proactively Identify Care Needs in Early Palliative Care—An Innovative Approach
Received: 9 December 2018 / Revised: 20 January 2019 / Accepted: 15 February 2019 / Published: 20 February 2019
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Abstract
Anticipatory planning for end of life requires a common language for discussion among patients, families, and professionals. Studies show that early Palliative Care (PC) interventions based on a problem-oriented approach can improve quality of life, support decision-making, and optimize the timing of medical [...] Read more.
Anticipatory planning for end of life requires a common language for discussion among patients, families, and professionals. Studies show that early Palliative Care (PC) interventions based on a problem-oriented approach can improve quality of life, support decision-making, and optimize the timing of medical treatment and transition to hospice services. The aim of this quality-improvement project was to develop a pragmatic structure meeting all clinical settings and populations needs. Based on the Medical Research Council (MRC) framework, a literature review identifying approaches commonly used in PC was performed. In addition, more than 500 hospital-based interprofessional consultations were analyzed. Identified themes were structured and compared to published approaches. We evaluated the clinical usefulness of this structure with an online survey among professionals. The emerged ‘SENS’-structure stands for: Symptoms patients suffer from; End-of-life decisions; Network around the patient delivering care; and Support for the carer. Evaluation among professionals has confirmed that the ‘SENS’-structure covers all relevant areas for anticipatory planning in PC. ‘SENS’ is useful in guiding patient-centered PC conversations and pragmatic anticipatory planning, alongside the regular diagnosis-triggered approach in various settings. Following this approach, ‘SENS’ may facilitate systematic integration of PC in clinical practice. Depending on clearly defined outcomes, this needs to be confirmed by future randomized controlled studies. Full article
(This article belongs to the Special Issue Recent Advances in Palliative Care)
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Open AccessArticle
Two-Year Use of Care Robot Zora in Dutch Nursing Homes: An Evaluation Study
Received: 20 December 2018 / Revised: 5 February 2019 / Accepted: 14 February 2019 / Published: 19 February 2019
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Abstract
The use of the Zora robot was monitored and evaluated in 14 nursing care organizations (15 locations). The Zora robot, a Não robot with software, is designed as a social robot and used for pleasure and entertainment or to stimulate the physical activities [...] Read more.
The use of the Zora robot was monitored and evaluated in 14 nursing care organizations (15 locations). The Zora robot, a Não robot with software, is designed as a social robot and used for pleasure and entertainment or to stimulate the physical activities of clients in residential care. In the first year, the aim was to monitor and evaluate how the care robot is used in daily practice. In the second year, the focus was on evaluating whether the use of Zora by care professionals can be extended to more groups and other type of clients. Interviews, questionnaires and observations were used as instruments to reveal the progress in the use of the robot and to reveal the facilitators and barriers. Care professionals experienced several barriers in the use of the robot (e.g., start-up time and software failures). The opportunity they had to discuss their experience during project team meetings was seen as a facilitator in the project. Furthermore, they mentioned that the Zora robot had a positive influence on clients as it created added value for the care professionals in having fun at work. Full article
(This article belongs to the Special Issue Creating Age-friendly Communities: Housing and Technology)
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Open AccessReview
The Role of Palliative Care in the Cardiac Intensive Care Unit
Received: 30 December 2018 / Revised: 4 February 2019 / Accepted: 8 February 2019 / Published: 19 February 2019
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Abstract
In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients that were admitted to cardiac intensive care units (CICU). Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic [...] Read more.
In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients that were admitted to cardiac intensive care units (CICU). Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic cardiovascular diseases and a high burden of non-cardiovascular comorbid conditions: both increase the susceptibility of patients to developing life-threatening critical conditions. These conditions are associated with a significant symptom burden and mortality rate and an increased length of stay. In this context, palliative care programs, including withholding/withdrawing life support treatments or the deactivation of implanted cardiac devices, are frequently needed, according to the specific guidelines of scientific societies. However, the implementation of these recommendations in clinical practice is still inconsistent. In this review, we analyze the reasons for this gap and the main cultural changes that are required to improve the care of patients with advanced illness. Full article
(This article belongs to the Special Issue Recent Advances in Palliative Care)
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Open AccessArticle
Positive and Negative Factors That Influence Health Care Faculty Intent to Engage in Interprofessional Education (IPE)
Received: 22 January 2019 / Revised: 11 February 2019 / Accepted: 13 February 2019 / Published: 16 February 2019
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Abstract
Background: This study explored the positive and negative factors that influence interprofessional education (IPE) implementation in health care education programs across the United States. Methods: The study sample consisted of 439 (response rate 8.4%) health care faculties from seven health care professions (nursing, [...] Read more.
Background: This study explored the positive and negative factors that influence interprofessional education (IPE) implementation in health care education programs across the United States. Methods: The study sample consisted of 439 (response rate 8.4%) health care faculties from seven health care professions (nursing, medicine, pharmacy, physical therapy, occupational therapy, physician assistant, and social work) who were asked what the positive and negative factors are that influence their decisions to engage in IPE. Results: Three positive categories and two negative categories concerning factors that influence health care faculty (HCF) intent to engage in IPE emerged. The three major categories of positive factors emerged as patient care, which was mentioned by 196 subjects or 54% of the sample, student learning, which was mentioned by 157 subjects or 43% of the sample, and health care teams, which was mentioned by 88 subjects or 24% of the sample. The two major categories of negative factors emerged as scheduling and coordination, which was mentioned by 230 subjects or 63% of the sample, and discipline culture which was mentioned by 103 subjects or 28% of the sample. Conclusion: This study contributes to the body of knowledge concerning the factors that influence effective IPE implementation. Discussion is provided regarding the positive and negative categories that emerged and how they influence effective IPE delivery. Full article
Open AccessReview
Rational Use of Antibiotics in Neonates: Still in Search of Tailored Tools
Received: 12 January 2019 / Revised: 31 January 2019 / Accepted: 14 February 2019 / Published: 16 February 2019
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Abstract
Rational medicine use in neonates implies the prescription and administration of age-appropriate drug formulations, selecting the most efficacious and safe dose, all based on accurate information on the drug and its indications in neonates. This review illustrates that important uncertainties still exist concerning [...] Read more.
Rational medicine use in neonates implies the prescription and administration of age-appropriate drug formulations, selecting the most efficacious and safe dose, all based on accurate information on the drug and its indications in neonates. This review illustrates that important uncertainties still exist concerning the different aspects (when, what, how) of rational antibiotic use in neonates. Decisions when to prescribe antibiotics are still not based on robust decision tools. Choices (what) on empiric antibiotic regimens should depend on the anticipated pathogens, and the available information on the efficacy and safety of these drugs. Major progress has been made on how (beta-lactam antibiotics, aminoglycosides, vancomycin, route and duration) to dose. Progress to improve rational antibiotic use necessitates further understanding of neonatal pharmacology (short- and long-term safety, pharmacokinetics, duration and route) and the use of tailored tools and smarter practices (biomarkers, screening for colonization, and advanced therapeutic drug monitoring techniques). Implementation strategies should not only facilitate access to knowledge and guidelines, but should also consider the most effective strategies (‘skills’) and psychosocial aspects involved in the prescription process: we should be aware that both the decision not to prescribe as well as the decision to prescribe antibiotics is associated with risks and benefits. Full article
(This article belongs to the Special Issue Rational Use of Medicines in Children)
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Open AccessArticle
Comparing the Convergent and Concurrent Validity of the Dynamic Gait Index with the Berg Balance Scale in People with Multiple Sclerosis
Received: 19 October 2018 / Revised: 6 February 2019 / Accepted: 7 February 2019 / Published: 15 February 2019
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Abstract
Background: Recent clinical guidelines for adults with neurological disabilities suggest the need to assess measures of static and dynamic balance using the Berg Balance Scale (BBS) and Dynamic Gait Index (DGI) as core outcome measures. Given that the BBS measures both static and [...] Read more.
Background: Recent clinical guidelines for adults with neurological disabilities suggest the need to assess measures of static and dynamic balance using the Berg Balance Scale (BBS) and Dynamic Gait Index (DGI) as core outcome measures. Given that the BBS measures both static and dynamic balance, it was unclear as to whether either of these instruments was superior in terms of its convergent and concurrent validity, and whether there was value in complementing the BBS with the DGI. Objective: The objective was to evaluate the concurrent and convergent validity of the BBS and DGI by comparing the performance of these two functional balance tests in people with multiple sclerosis (MS). Methods: Baseline cross-sectional data on 75 people with MS were collected for use in this study from 14 physical therapy clinics participating in a large pragmatic cluster-randomized trial. Convergent validity estimates between the DGI and BBS were examined by comparing the partial Spearman correlations of each test to objective lower extremity functional measures (Timed Up and Go (TUG), Six-Minute Walk Test (6MWT), Timed 25-Foot Walk (T25FW) test) and the self-reported outcomes of physical functioning and general health using the 36-Item Short Form Health Survey (SF-36). Concurrent validity was assessed by applying logistic regression with gait disability as the binary outcome (Patient Determined Disease Steps (PDDS) as the criterion measure). The predictive ability of two models, a reduced/parsimonious model including the BBS only and a second model including both the BBS and DGI, were compared using the adjusted coefficient of determinations. Results: Both the DGI and BBS were strongly correlated with lower extremity measures overall as well as across the two PDSS strata with correlations. In PDDS ≤ 2, the difference in the convergence of BBS with TUG and DGI with TUG was −0.123 (95% CI: −0.280, −0.012). While this finding was statistically significant at a type 1 error rate of 0.05, it was not significant (Hommel’s adjusted p-value = 0.465) after accounting for multiple testing corrections to control for the family-wise error rate. The BBS–SF-36 physical functioning correlation was at least moderate and significant overall and across both PDDS strata. However, the DGI–physical functioning score did not have a statistically significant correlation within PDDS ≤ 2. None of the differences in convergent and concurrent validity between the BBS and DGI were significant. The additional variation in 6MWT explained by the DGI when added to a model with the BBS was 7.78% (95% CI: 0.6%, 15%). Conclusions: These exploratory analyses on data collected in pragmatic real-world settings suggest that neither of these measures of balance is profoundly superior to the other in terms of its concurrent and convergent validity. The DGI may not have any utility for people with PDDS ≤ 2, especially if the focus is on mobility, but may be useful if the goal is to provide insight on lower extremity endurance. Further research leveraging longitudinal data from pragmatic trials and quasi-experimental designs may provide more information about the clinical usefulness of the DGI in terms of its predictive validity when compared to the BBS. Full article
(This article belongs to the Special Issue Feature Papers in Healthcare in 2018)
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Open AccessArticle
Comparison of the Effects of Hand Reflexology versus Acupressure on Anxiety and Vital Signs in Female Patients with Coronary Artery Diseases
Received: 2 December 2018 / Revised: 29 January 2019 / Accepted: 2 February 2019 / Published: 11 February 2019
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Abstract
Hospitalization in the cardiac care unit can increase anxiety in patients. This study aimed to compare hand reflexology versus acupressure on anxiety and vital signs in female patients with coronary artery diseases. This double-blinded randomized placebo-controlled trial with a pre- and post-intervention design [...] Read more.
Hospitalization in the cardiac care unit can increase anxiety in patients. This study aimed to compare hand reflexology versus acupressure on anxiety and vital signs in female patients with coronary artery diseases. This double-blinded randomized placebo-controlled trial with a pre- and post-intervention design was conducted on 135 female patients with coronary artery diseases. Female patients hospitalized in a cardiac care unit were randomly divided into three groups of hand reflexology, acupressure and placebo (n = 45 patients in each group) using blocking and a table of random numbers. Data was collected using the Spielberger anxiety inventory. Also, their vital signs were measured before, immediately after and half an hour after the intervention. Data analysis was performed using descriptive and analytical statistics. Before the intervention, there was no statistically significant difference in anxiety levels between the groups (p > 0.05). Also, the effects of hand reflexology and acupressure immediately and half an hour later on the reduction of anxiety and vital signs were equal (p < 0.05). Implementation of hand reflexology and acupressure can have positive effects on anxiety and vital signs in patients with coronary artery diseases. They can reduce patients’ anxiety with an equal effectiveness. Full article
(This article belongs to the Special Issue Feature Papers in Healthcare in 2018)
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Open AccessProject Report
Addressing the Gaps in Post-Stroke Sexual Activity Rehabilitation: Patient Perspectives
Received: 6 January 2019 / Revised: 31 January 2019 / Accepted: 31 January 2019 / Published: 5 February 2019
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Abstract
Sexual dysfunction is common but often under-recognised or neglected after stroke. This study sought to identify the existing methods for providing information and discussion on post-stroke sexual activity, and perceived gaps from the patient perspective. A sample of 1265 participants who had been [...] Read more.
Sexual dysfunction is common but often under-recognised or neglected after stroke. This study sought to identify the existing methods for providing information and discussion on post-stroke sexual activity, and perceived gaps from the patient perspective. A sample of 1265 participants who had been admitted to any of the four major public hospitals in Tasmania, Australia, with stroke (International Classification of Diseases (ICD-10) group B70) were mailed a survey assessing their experiences with, and opinions about, receipt of post-stroke sexual activity education. One hundred and eighty-three participants (14.5%) responded; of these, 65% were male and the mean age was 69.1 years. The results indicated that, whilst over 30% or participants wanted to receive information related to post-stroke sexual activity, only a small proportion of participants (8.2%) had received this. In terms of the method of receiving this information, participants preferred to receive this from a doctor in a private discussion with or without their partner present. The delivery of post-stroke sexual activity information and education is inconsistent and fails to meet patient needs within major Tasmanian hospitals, highlighting the importance of developing sound, routine, post-stroke education and information processes. Full article
Open AccessArticle
Examination of EMS Decision Making in Determining Suitability of Patient Diversion to Urgent Care Centers
Received: 12 January 2019 / Revised: 29 January 2019 / Accepted: 1 February 2019 / Published: 2 February 2019
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Abstract
Widespread use of Emergency Medicine Services (EMS) for non-emergency care has increased recently, causing overcrowding of the Emergency Department (ED). The increased availability of urgent care centers (UCCs), with their ability to see large numbers of unscheduled patients with more acute presentations, may [...] Read more.
Widespread use of Emergency Medicine Services (EMS) for non-emergency care has increased recently, causing overcrowding of the Emergency Department (ED). The increased availability of urgent care centers (UCCs), with their ability to see large numbers of unscheduled patients with more acute presentations, may offer a viable option for many EMS systems to divert non-emergent cases. Using a survey-based study combined with retrospective chart review, EMS provider ability to determine patient suitability for diversion to UCCs was assessed. Results indicated a rate of inappropriate diversion of 11.6%. UCCs may be an alternative option for EMS transport, however strict protocols with medical direction are needed. Full article
Open AccessArticle
Negative Behaviors among Healthcare Professionals: Relationship with Patient Safety Culture
Received: 18 December 2018 / Revised: 21 January 2019 / Accepted: 29 January 2019 / Published: 1 February 2019
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Abstract
Behaviors that undermine a culture of safety within hospitals threaten overall wellbeing of healthcare workers as well as patient outcomes. Existing evidence suggests negative behaviors adversely influence patient outcomes, employee satisfaction, retention, productivity, absenteeism, and employee engagement. Our objective was to examine the [...] Read more.
Behaviors that undermine a culture of safety within hospitals threaten overall wellbeing of healthcare workers as well as patient outcomes. Existing evidence suggests negative behaviors adversely influence patient outcomes, employee satisfaction, retention, productivity, absenteeism, and employee engagement. Our objective was to examine the presence of negative behaviors within a healthcare system and the influence of negative behaviors among healthcare workers on perceptions of patient safety culture. Using a cross-sectional design, the negative behaviors in healthcare survey (NBHC) and selected composites of the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS) were combined within an electronic survey which was administered to physicians, clinical and managerial staff. Exposure to contributing factors of negative behaviors was moderately correlated with elements of HSOPS, including perceptions of teamwork within units, management response to error, and overall patient safety grade. Use of aggression and fear of retaliation were moderately correlated with HSOPS management response to error. Reducing healthcare worker exposure to contributing factors of negative behavior may result in increased perceptions of teamwork within a hospital unit, while addressing use of staff aggression and fear of retaliation potentially positively influences management response to error. Full article
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