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Bekelman DB, Feser W, Morgan B, Welsh CH, Parsons EC, Paden G, Baron A, Hattler B, McBryde C, Cheng A, Lange AV, Au DH. Nurse and Social Worker Palliative Telecare Team and Quality of Life in Patients With COPD, Heart Failure, or Interstitial Lung Disease: The ADAPT Randomized Clinical Trial. JAMA 2024; 331:212-223. [PMID: 38227034 PMCID: PMC10792473 DOI: 10.1001/jama.2023.24035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 11/01/2023] [Indexed: 01/17/2024]
Abstract
Importance Many patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. Palliative care approaches may benefit this population prior to end of life. Objective Determine the effect of a nurse and social worker palliative telecare team on quality of life in outpatients with COPD, HF, or ILD compared with usual care. Design, Setting, and Participants Single-blind, 2-group, multisite randomized clinical trial with accrual between October 27, 2016, and April 2, 2020, in 2 Veterans Administration health care systems (Colorado and Washington), and including community-based outpatient clinics. Outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life participated. Intervention The intervention involved 6 phone calls with a nurse to help with symptom management and 6 phone calls with a social worker to provide psychosocial care. The nurse and social worker met weekly with a study primary care and palliative care physician and as needed, a pulmonologist, and cardiologist. Usual care included an educational handout developed for the study that outlined self-care for COPD, ILD, or HF. Patients in both groups received care at the discretion of their clinicians, which could include care from nurses and social workers, and specialists in cardiology, pulmonology, palliative care, and mental health. Main Outcomes and Measures The primary outcome was difference in change in quality of life from baseline to 6 months between the intervention and usual care groups (FACT-G score range, 0-100, with higher scores indicating better quality of life, clinically meaningful change ≥4 points). Secondary quality-of-life outcomes at 6 months included disease-specific health status (Clinical COPD Questionnaire; Kansas City Cardiomyopathy Questionnaire-12), depression (Patient Health Questionnaire-8) and anxiety (Generalized Anxiety Disorder-7) symptoms. Results Among 306 randomized patients (mean [SD] age, 68.9 [7.7] years; 276 male [90.2%], 30 female [9.8%]; 245 White [80.1%]), 177 (57.8%) had COPD, 67 (21.9%) HF, 49 (16%) both COPD and HF, and 13 (4.2%) ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% (intervention, 117 of 154; usual care, 116 of 152) at 6 months for both groups. Mean (SD) length of intervention was 115.1 (33.4) days and included a mean of 10.4 (3.3) intervention calls per patient. In the intervention group, 112 of 154 (73%) patients received the intervention as randomized. At 6 months, mean FACT-G score improved 6.0 points in the intervention group and 1.4 points in the usual care group (difference, 4.6 points [95% CI, 1.8-7.4]; P = .001; standardized mean difference, 0.41). The intervention also improved COPD health status (standardized mean difference, 0.44; P = .04), HF health status (standardized mean difference, 0.41; P = .01), depression (standardized mean difference, -0.50; P < .001), and anxiety (standardized mean difference, -0.51; P < .001) at 6 months. Conclusions and Relevance For adults with COPD, HF, or ILD who were at high risk of death and had poor quality of life, a nurse and social worker palliative telecare team produced clinically meaningful improvements in quality of life at 6 months compared with usual care. Trial Registration ClinicalTrials.gov Identifier: NCT02713347.
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Affiliation(s)
- David B. Bekelman
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - William Feser
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora
| | - Brianne Morgan
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
| | - Carolyn H. Welsh
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Elizabeth C. Parsons
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
| | - Grady Paden
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Anna Baron
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora
| | - Brack Hattler
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Connor McBryde
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Andrew Cheng
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Allison V. Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - David H. Au
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
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He K, Crouch T, Kaitz J, Oien AD, De Paul N, Palen BN, Parsons EC. Improving adherence to PAP therapy: A brief PAP coaching intervention for health care providers. PEC Innov 2023; 3:100230. [PMID: 37929052 PMCID: PMC10624969 DOI: 10.1016/j.pecinn.2023.100230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/02/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Abstract
Objectives To evaluate a training program for non-specialist health care providers in a brief coaching intervention to improve positive airway pressure (PAP) usage in Veterans with sleep apnea. Methods We conducted a national webinar training designed for non-specialist providers to implement a brief telephone coaching intervention to improve PAP adherence. The curriculum was crafted by experts in sleep medicine and behavioral sleep medicine based on principles of PAP desensitization. Providers who participated in this training were asked to complete evaluations at 30 days and 1 year. Results Provider surveys indicated that most respondents had incorporated the intervention into their clinical practice and felt comfortable counseling patients about sleep apnea and adherence to PAP. Provider feedback suggested that future training programs should include refresher trainings, more training on PAP equipment specifics, and facilitated collaboration with local sleep medicine staff. Conclusions This pilot training program demonstrated that a webinar format was a feasible method to increase training in PAP adherence among non-specialist health care providers. Innovation Non-specialists can be trained as PAP coaches in webinar format, improving patients' access to effective strategies and support to be successful with PAP therapy.
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Affiliation(s)
- Ken He
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, 4545 Roosevelt Way NE Suite 400, Seattle, WA 98105, USA
| | - Tara Crouch
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
- Veterans Affairs Puget Sound Health Care System, Psychology, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Jenesse Kaitz
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Angela D. Oien
- Veterans Affairs Puget Sound Health Care System, Health Services Research and Development Center for Innovation, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Nicola De Paul
- Veterans Affairs Sierra Nevada Health Care System, Mental Health, 975 Kirman Ave, Mail stop 116, Reno, NV 89502, USA
| | - Brian N. Palen
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, 4545 Roosevelt Way NE Suite 400, Seattle, WA 98105, USA
| | - Elizabeth C. Parsons
- Veterans Affairs Puget Sound Health Care System, Sleep Medicine, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, 4545 Roosevelt Way NE Suite 400, Seattle, WA 98105, USA
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Wagner AM, Richards A, Chiros C, Thuras P, Parsons EC, Oien AD, Schenck CH, Irfan M. A Retrospective Pilot Study of Imagery Rehearsal Therapy Enhanced with Narrative Therapy Principles for the Treatment of Nightmares in US Military Veterans. Sleep Sci 2023; 16:e439-e445. [PMID: 38197021 PMCID: PMC10773522 DOI: 10.1055/s-0043-1776796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 02/14/2023] [Indexed: 01/11/2024] Open
Abstract
Introduction Chronic nightmares are a common and disabling feature of posttraumatic stress disorder (PTSD) for which broadly effective treatments are still lacking. While imagery rehearsal therapy (IRT) demonstrates benefits for patients with idiopathic nightmares and some patients with PTSD-related nightmares, research indicates it may be less beneficial for veterans. Narrative therapy (NT) is a form of psychotherapy which is client-centered and value-focused and has demonstrated benefits for PTSD patients. The application of NT principles to IRT may provide a valuable therapeutic approach for treatment in veterans. Objective To perform a retrospective chart review of veteran clients participating in a novel, brief intervention developed by the first author consisting of IRT enhanced with NT principles (N-IRT) for the treatment of nightmares. The primary outcomes were nightmare frequency and intensity, and the secondary outcome was the impact of the intervention on nightmare distress and coping, subjective sleep quality, and overall PTSD symptoms. Materials and Methods We conducted retrospective chart reviews for eight veterans referred to the first author for the treatment of nightmares, who completed N-IRT, including baseline and end-of-treatment measures. The protocol involved a single 60-minute NT-enhanced rescripting session and assigned homework to rehearse the revised dream script, and a follow-up evaluation 4 weeks later. The subjects completed a sleep and nightmare interview developed by the first author and the PTSD Checklist at baseline and after the intervention at the follow-up evaluation. Paired t -tests were conducted to test for pre-to-post differences. Results In the statistical analysis, we observed a statistically significant and clinically meaningful reduction in the frequency ( p = 0.04) and intensity of nightmares ( p = 0.001) from pretreatment to the 1-month follow-up. Measures of nightmare-associated emotional distress, the ability to cope with nightmares, sleep duration and sleep efficiency, as well as overall PTSD symptoms also demonstrated significant improvements. Conclusion These pilot data provide compelling preliminary evidence that a single-session IRT intervention modified with NT (N-IRT) is effective in reducing nightmare frequency and intensity, reducing nightmare distress, improving the act of coping with nightmares, and improving sleep quality and overall PTSD symptoms in veterans. Further investigation of this method with gold-standard clinical trial designs and larger sample sizes is indicated to confirm effectiveness and to better understand the possible mechanisms of treatment effect.
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Affiliation(s)
- Ann Marie Wagner
- Mental Health Services, Minneapolis Veteran's Affairs (VA) Health Care System, Minneapolis, MN, United States of America
| | - Anne Richards
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States of America
- Mental Health Services, San Francisco Veteran's Affairs (VA) Health Care System, San Francisco, CA, United States of America
| | - Christine Chiros
- Mental Health Services, Minneapolis Veteran's Affairs (VA) Health Care System, Minneapolis, MN, United States of America
| | - Paul Thuras
- Mental Health Services, Minneapolis Veteran's Affairs (VA) Health Care System, Minneapolis, MN, United States of America
| | - Elizabeth C. Parsons
- Pulmonary and Critical Care, Puget Sound Veteran's Affairs (VA) Health Care System, Seattle, WA, United States of America
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Angela D. Oien
- Pulmonary and Critical Care, Puget Sound Veteran's Affairs (VA) Health Care System, Seattle, WA, United States of America
| | - Carlos H. Schenck
- Department of Psychiatry, Minnesota Regional Sleep Disorders Center, Minneapolis, MN, United States of America
| | - Muna Irfan
- Pulmonary, Allergy, Critical Care and Sleep, Minneapolis Veteran's Affairs (VA) Health Care System, Minneapolis, MN, United States of America
- Department of Neurology, Medical School, University of Minnesota, Minneapolis, MN, United States of America
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Mattox EA, Yantsides KE, Germani MW, Parsons EC. Utilizing the RE-AIM framework for a multispecialty Veterans Affairs Extension for Community Healthcare Outcomes (VA-ECHO) program 2018-2022. Front Health Serv 2023; 3:1217172. [PMID: 37780401 PMCID: PMC10533985 DOI: 10.3389/frhs.2023.1217172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/16/2023] [Indexed: 10/03/2023]
Abstract
VA-ECHO (Veterans Affairs -Extension for Community Healthcare Outcomes) provides live, synchronous, continuing education accredited, case-based learning. Sessions deliver up-to-date, evidence-based, practice-relevant, Veteran-focused learning to healthcare team members. The primary goal of VA-ECHO is to increase Veterans' access to high quality care by improving knowledge and skills among VA care providers. Utilizing the RE-AIM framework, descriptive statistics for 23 VA-ECHO programs regarding program effectiveness, adoption, implementation, and maintenance during a five-year period (2018-2022) are reported. VA-ECHO offered 1,462 sessions and 157,238 contact hours, engaging 17,642 participants from 837 VA-based sites (20% rural-based sites). Effectiveness includes information on number and diversity of programs, as well as reported impact on participants' practice. Adoption includes descriptive statistics, including comparison of growth and change compared to prior years. Implementation describes change in the program over time, including the number of specialties offered, and types of continuing education offered. Maintenance includes a narrative regarding sustainability. The discussion focuses on implementation and maintenance strategies the program has used to address participant and VA needs within the RE-AIM framework, including adjustments to the program, iterative qualitative improvement, sustainment strategies, and opportunities for future evaluation.
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Affiliation(s)
- Elizabeth A. Mattox
- Pulmonary, Critical Care and Sleep Medicine Section, Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
| | - Konstantina E. Yantsides
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
| | - Maureen Wylie Germani
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
| | - Elizabeth C. Parsons
- Pulmonary, Critical Care and Sleep Medicine Section, Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, WA, United States
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Donovan LM, Parsons EC, McCall CA, He K, Sharma R, Gamache J, Pannick AP, McDowell JA, Pai J, Epler E, Duan KI, Spece LJ, Feemster LC, Kapur VK, Au DH, Palen BN. Impact of mail-based continuous positive airway pressure initiation on treatment usage and effectiveness. Sleep Breath 2023; 27:303-308. [PMID: 35347655 PMCID: PMC8960106 DOI: 10.1007/s11325-022-02608-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/15/2022] [Accepted: 03/22/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE In-person visits with a trained therapist have been standard care for patients initiating continuous positive airway pressure (CPAP). These visits provide an opportunity for hands-on training and an in-person assessment of mask fit. However, to improve access, many health systems are shifting to remote CPAP initiation with equipment mailed to patients. While there are potential benefits of a mailed approach, relative patient outcomes are unclear. Specifically, many have concerns that a lack of in-person training may contribute to reduced CPAP adherence. To inform this knowledge gap, we aimed to compare treatment usage after in-person or mailed CPAP initiation. METHODS Our medical center shifted from in-person to mailed CPAP dispensation in March 2020 during the COVID-19 pandemic. We assembled a cohort of patients with newly diagnosed obstructive sleep apnea (OSA) who initiated CPAP in the months before (n = 433) and after (n = 186) this shift. We compared 90-day adherence between groups. RESULTS Mean nightly PAP usage was modest in both groups (in-person 145.2, mailed 140.6 min/night). We did not detect between-group differences in either unadjusted or adjusted analyses (adjusted difference - 0.2 min/night, 95% - 27.0 to + 26.5). CONCLUSIONS Mail-based systems of CPAP initiation may be able to improve access without reducing CPAP usage. Future work should consider the impact of mailed CPAP on patient-reported outcomes and the impact of different remote setup strategies.
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Affiliation(s)
- Lucas M Donovan
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA.
- University of Washington, Seattle, WA, USA.
| | - Elizabeth C Parsons
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
| | - Catherine A McCall
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
| | - Ken He
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
| | - Rahul Sharma
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
| | - Justina Gamache
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
| | - Anna P Pannick
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
| | - Jennifer A McDowell
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
| | - James Pai
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
| | - Eric Epler
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
| | - Kevin I Duan
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
| | - Laura J Spece
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
| | - Laura C Feemster
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
| | | | - David H Au
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
| | - Brian N Palen
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- University of Washington, Seattle, WA, USA
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Yang PL, Chaytor NS, Burr RL, Kapur VK, McCurry SM, Vitiello MV, Hough CL, Parsons EC. Rest-Activity Rhythm Fragmentation and Weaker Circadian Strength Are Associated With Cognitive Impairment in Survivors of Acute Respiratory Failure. Biol Res Nurs 2023; 25:5-13. [PMID: 35759356 DOI: 10.1177/10998004221109925] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Survivors of acute respiratory failure (ARF) experience long-term cognitive impairment and circadian rhythm disturbance after hospital discharge. Although prior studies in aging and neurodegenerative diseases indicate actigraphy-estimated rest-activity circadian rhythm disturbances are risk factors for cognitive impairment, it is unclear if this applies to ARF survivors. This study explored the relationships of actigraphy-estimated rest-activity circadian rhythms with cognitive functioning in ARF survivors at 3 months after discharge. Methods: 13 ARF survivors (mean age 51 years and 69% males) completed actigraphy and sleep diaries for 9 days, followed by at-home neuropsychological assessment. Principal component factor analysis created global cognition and circadian rhythm variables, and these first components were used to examine the global relationships between circadian rhythm and cognitive measure scores. Results: Global circadian function was associated with global cognition function in ARF survivors (r = .70, p = .024) after adjusting for age, education, and premorbid cognition. Also, greater fragmented rest-activity circadian rhythm (estimated by intradaily variability, r = .85, p = .002), and weaker circadian strength (estimated by amplitude, r = .66, p = .039; relative strength, r = .70, p = .024; 24-h lag serial autocorrelation, r = .67, p = .035), were associated with global cognition and individual cognitive tests. Conclusions: These results suggest circadian rhythm disturbance is associated with poorer global cognition in ARF survivors. Future prospective research with larger samples is needed to confirm these results and increase understanding of the relationship between disrupted circadian rhythms and cognitive impairment among ARF survivors.
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Affiliation(s)
- Pei-Lin Yang
- School of Nursing, 106177National Defense Medical Center, Taipei, Taiwan
| | - Naomi S Chaytor
- Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, 6760Washington State University, Spokane, WA, USA
| | - Robert L Burr
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, 16181University of Washington, Seattle, WA, USA.,Office of Nursing Research, School of Nursing, 16181University of Washington, Seattle, WA, USA
| | - Vishesh K Kapur
- Division of Pulmonary, Critical Care and Sleep Medicine, 205280University of Washington, Seattle, WA, USA
| | - Susan M McCurry
- School of Nursing, 16181University of Washington, Seattle, WA, USA
| | - Michael V Vitiello
- Department of Psychiatry & Behavioral Sciences, 7284University of Washington, WA, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, 89020Oregon Health and Science University School of Medicine, Portland, USA
| | - Elizabeth C Parsons
- Division of Pulmonary, Critical Care and Sleep Medicine, 205280University of Washington, Seattle, WA, USA.,Pulmonary and Critical Care Section, VA Puget Sound Health Care System, Seattle, WA, USA
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Mattox EA, Yantsides KE, Borgerding J, Beste LA, Parsons EC, Fleet M, Palen BN, O'Hearn D, Germani MW, Chang MF. Participant Characteristics and Attendance Patterns for a Multispecialty Veterans Affairs ECHO Program 2012-2018. Telemed J E Health 2022; 28:1633-1641. [PMID: 35325561 DOI: 10.1089/tmj.2021.0626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: The Veteran Integrated Service Network (VISN) 20 Veterans Affairs-Extension for Community Healthcare Outcomes (VA-ECHO) program connects specialty and primary care providers (PCPs) across large geographic areas, utilizing video-teleconferencing with the intention of increasing access to care among underserved and isolated populations. No previously published work describes participation patterns of a multispecialty ECHO program. We describe the development of VISN 20 VA-ECHO program to inform the design and evaluation of ECHO programs. Methods: The participant cohort included VA-affiliated licensed health care professionals, including trainees, who attended at least one VISN 20 VA-ECHO session between April 2012 and December 2018. Participant characteristics reported include gender, clinical location, clinical specialty, discipline, and rurality. Results: Over the 6-year time frame, VISN 20 VA-ECHO offered 945 sessions in 14 clinical specialties and recorded 17,893 hours of attendance. The cohort included 1,346 participants, 74.3% of whom were female, 85.2% employed in medical centers, and 40.7% affiliated with primary care. Most participants (62.3%) attended one specialty exclusively; among all participants, 40% attended five or more sessions. Discussion: Although VA-ECHO was implemented to develop single specialty expertise among PCPs, our participant cohort represented a more diverse audience from a range of disciplines and specialties. Our experience may be valuable to other teams implementing ECHO programs. Conclusions: Through adaptability and strategies that actively promoted inclusion of a diverse audience, VISN 20 VA-ECHO expanded to include multiple clinical specialties and successfully engaged an audience across a large geographic area and beyond PCPs.
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Affiliation(s)
- Elizabeth A Mattox
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Konstantina E Yantsides
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Joleen Borgerding
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Lauren A Beste
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- General Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of General Internal Medicine, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Elizabeth C Parsons
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Margaret Fleet
- Nephrology Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Brian N Palen
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel O'Hearn
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Maureen Wylie Germani
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Michael F Chang
- Gastroenterology and Hepatology Service, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
- Gastroenterology and Hepatology Division, Oregon Health & Sciences University, Portland, Oregon, USA
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Palen BN, Mattox EA, He K, Beste LA, Borgerding J, Patel S, Au DH, Chang MF, Parsons EC. Impact of Sleep Telementorship in Primary Care: Sleep VA-ECHO (Veterans Affairs-Extension for Community Healthcare Outcomes). Int J Environ Res Public Health 2021; 18:ijerph18189914. [PMID: 34574837 PMCID: PMC8464697 DOI: 10.3390/ijerph18189914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/13/2021] [Accepted: 09/15/2021] [Indexed: 11/16/2022]
Abstract
Sleep VA-ECHO (Veterans Affairs-Extension for Community Healthcare Outcomes) is a national telementorship program intended to improve knowledge about sleep disorders among non-specialty providers. The project goal was to describe the characteristics of Sleep VA-ECHO participants from primary care and their use of program-obtained knowledge in practice. Sleep VA-ECHO consisted of 10 voluntary, 75-min teleconference sessions combining didactics and case discussion. Out of 86 participants, 21 self-identified as primary care team members and completed a program evaluation. Participants self-reported their application of knowledge gained, including changes to practice as a result of program participation. These 21 participants represented 18 sites in 11 states and attended a median of 5.0 sessions. They included physicians (29%), nurse practitioners (24%), and registered nurses (24%). Nearly all participants (95%) reported using acquired knowledge to care for their own patients at least once a month; 67% shared knowledge with colleagues at least once a month. Eighty-five percent reported improved quality of sleep care for their patients, and 76% reported an expanded clinical skillset. The greatest self-reported change in practice occurred in patient education about sleep disorders (95%) and non-pharmacologic management of insomnia (81%).
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Affiliation(s)
- Brian N. Palen
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA; (K.H.); (D.H.A.); (E.C.P.)
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA 98195, USA
- Correspondence: (B.N.P.); (E.A.M.)
| | - Elizabeth A. Mattox
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA; (K.H.); (D.H.A.); (E.C.P.)
- Correspondence: (B.N.P.); (E.A.M.)
| | - Ken He
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA; (K.H.); (D.H.A.); (E.C.P.)
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA 98195, USA
| | - Lauren A. Beste
- General Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA;
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA;
| | - Joleen Borgerding
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA;
| | - Sarah Patel
- Department of Medicine, University of Arizona, Tucson, AZ 85721, USA;
- Sonoran Sleep Center, Glendale, AZ 85306, USA
| | - David H. Au
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA; (K.H.); (D.H.A.); (E.C.P.)
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA 98195, USA
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA;
| | - Michael F. Chang
- Gastroenterology and Hepatology Service, Veterans Affairs Portland Health Care System, Portland, OR 97239, USA;
- Gastroenterology and Hepatology Division, Oregon Health & Sciences University, Portland, OR 97239, USA
| | - Elizabeth C. Parsons
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA; (K.H.); (D.H.A.); (E.C.P.)
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA 98195, USA
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9
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Donovan LM, Mog AC, Blanchard KN, Magid KH, Syed AS, Kelley LR, Palen BN, Parsons EC, McCall CC, Thompson W, Charlton M, Spece LJ, Kirsh S, Au DH, Sayre GG. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med 2021; 17:1645-1651. [PMID: 33755010 DOI: 10.5664/jcsm.9266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The field of sleep medicine has been an avid adopter of telehealth, particularly during the COVID-19 pandemic. The goal of this study was to assess patients' experiences receiving sleep care by telehealth. METHODS From June 2019 to May 2020, the authors recruited a sample of patients for semi-structured interviews, including patients who had 1 of 3 types of telehealth encounters in sleep medicine: in-clinic video, home-based video, and telephone. Two analysts coded transcripts using content analysis and identified themes that cut across patients and categories. RESULTS The authors conducted interviews with 35 patients and identified 5 themes. (1) Improved access to care: Patients appreciated telehealth as providing access to sleep care in a timely and convenient manner. (2) Security and privacy: Patients described how home-based telehealth afforded them greater feelings of safety and security due to avoidance of anxiety-provoking triggers (eg, crowds). Patients also noted a potential loss of privacy with telehealth. (3) Personalization of care: Patients described experiences with telehealth care that either improved or hindered their ability to communicate their needs. (4) Patient empowerment: Patients described how telehealth empowered them to manage their sleep disorders. (5) Unmet needs: Patients recognized specific areas where telehealth did not meet their needs, including the need for tangible services (eg, mask fitting). CONCLUSIONS Patients expressed both positive and negative experiences, highlighting areas where telehealth can be further adapted. As telehealth in sleep medicine continues to evolve, the authors encourage providers to consider these aspects of the patient experience. CITATION Donovan LM, Mog AC, Blanchard KN, et al. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med. 2021;17(8):1645-1651.
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Affiliation(s)
- Lucas M Donovan
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,University of Washington, Seattle, Washington
| | - Ashley C Mog
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,University of Washington, Seattle, Washington
| | - Kelly N Blanchard
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - Kate H Magid
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - Adnan S Syed
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - Lynette R Kelley
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - Brian N Palen
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,University of Washington, Seattle, Washington
| | - Elizabeth C Parsons
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,University of Washington, Seattle, Washington
| | - Catherine C McCall
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,University of Washington, Seattle, Washington
| | - William Thompson
- University of Washington, Seattle, Washington.,Veterans Affairs Boise Medical Center, Boise, Idaho
| | - Matthew Charlton
- University of Washington, Seattle, Washington.,Veterans Affairs Boise Medical Center, Boise, Idaho
| | - Laura J Spece
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,University of Washington, Seattle, Washington
| | - Susan Kirsh
- Office of Veterans Access to Care, Department of Veterans Affairs, Washington, DC
| | - David H Au
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,University of Washington, Seattle, Washington
| | - George G Sayre
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,University of Washington, Seattle, Washington
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10
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Palen BN, He K, Redinger J, Parsons EC. A Change of Heart. J Clin Sleep Med 2020; 15:1543-1545. [PMID: 31596222 DOI: 10.5664/jcsm.7998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Brian N Palen
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care & Sleep Medicine, University of Washington
| | - Ken He
- Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Jeff Redinger
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Elizabeth C Parsons
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care & Sleep Medicine, University of Washington
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11
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Yang PL, Ward TM, Burr RL, Kapur VK, McCurry SM, Vitiello MV, Hough CL, Parsons EC. Sleep and Circadian Rhythms in Survivors of Acute Respiratory Failure. Front Neurol 2020; 11:94. [PMID: 32117040 PMCID: PMC7033606 DOI: 10.3389/fneur.2020.00094] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/27/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Little is known about sleep and circadian rhythms in survivors of acute respiratory failure (ARF) after hospital discharge. Objectives: To examine sleep and rest-activity circadian rhythms in ARF survivors 3 months after hospital discharge, and to compare them with a community-dwelling population. Methods: Sleep diary, actigraphy data, and insomnia symptoms were collected in a pilot study of 14 ARF survivors. Rest-activity circadian rhythms were assessed with wrist actigraphy and sleep diary for 9 days, and were analyzed by cosinor and non-parametric circadian rhythm analysis. Results: All participants had remarkable actigraphic sleep fragmentation, 71.5% had subclinical or clinical insomnia symptoms. Compared to community-dwelling adults, this cohort had less stable rest-activity circadian rhythms (p < 0.001), and weaker circadian strength (p < 0.001). Conclusion: Insomnia and circadian disruption were common in ARF survivors. Sleep improvement and circadian rhythm regularity may be a promising approach to improve quality of life and daytime function after ARF.
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Affiliation(s)
- Pei-Lin Yang
- School of Nursing, University of Washington, Seattle, WA, United States
| | - Teresa M. Ward
- School of Nursing, University of Washington, Seattle, WA, United States
| | - Robert L. Burr
- School of Nursing, University of Washington, Seattle, WA, United States
| | - Vishesh K. Kapur
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States
| | - Susan M. McCurry
- School of Nursing, University of Washington, Seattle, WA, United States
| | - Michael V. Vitiello
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Catherine L. Hough
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States
| | - Elizabeth C. Parsons
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States
- VA Puget Sound Health Care System, Seattle, WA, United States
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12
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Donovan LM, Fernandes LA, Williams KM, Parsons EC, O'Hearn DJ, He K, McCall CA, Johnson KA, Kennedy MW, Syed AS, Thompson WH, Spece LJ, Feemster LC, Kirsh S, Au DH, Palen BN. Agreement of sleep specialists with registered nurses' sleep study orders in supervised clinical practice. J Clin Sleep Med 2020; 16:279-283. [PMID: 31992435 DOI: 10.5664/jcsm.8182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Incorporating registered nurses (RN-level) into obstructive sleep apnea (OSA) management decisions has the potential to augment the workforce and improve patient access, but the appropriateness of such task-shifting in typical practice is unclear. METHODS Our medical center piloted a nurse triage program for sleep medicine referrals. Using a sleep specialist-designed decision-making tool, nurses triaged patients referred for initial sleep studies to either home sleep apnea test (HSAT) or in-laboratory polysomnography (PSG). During the first 5 months of the program, specialists reviewed all nurse triages. We compared agreement between specialists and nurses. RESULTS Of 280 consultations triaged by nurses, nurses deferred management decisions to sleep specialists in 6.1% (n = 17) of cases. Of the remaining 263 cases, there was 88% agreement between nurses and specialists (kappa 0.80, 95% confidence interval 0.74-0.87). In the 8.8% (n = 23) of cases where supervising specialists changed sleep study type, specialists changed from HSAT to PSG in 16 cases and from PSG to HSAT in 7. The most common indication for change in sleep study type was disagreement regarding OSA pretest probability (n = 14 of 23). Specialists changed test instructions in 3.0% (n = 8) of cases, with changes either related to the use of transcutaneous carbon dioxide monitoring (n = 4) or adaptive servo-ventilation (n = 4). CONCLUSIONS More than 80% of sleep study triages by registered nurses in a supervised setting required no sleep specialist intervention. Future research should focus on how to integrate nurses into the sleep medicine workforce in a manner that maximizes efficiency while preserving or improving patient outcomes.
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Affiliation(s)
- Lucas M Donovan
- Seattle-Denver HSR&D Center for Veteran-Centered and Value-Driven Care, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
| | | | | | | | | | - Ken He
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | | | | | - Adnan S Syed
- VA Eastern Colorado Health Care System, Aurora, Colorado
| | | | - Laura J Spece
- Seattle-Denver HSR&D Center for Veteran-Centered and Value-Driven Care, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
| | - Laura C Feemster
- Seattle-Denver HSR&D Center for Veteran-Centered and Value-Driven Care, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
| | - Susan Kirsh
- VA Office of Veterans Access to Care, Washington, DC
| | - David H Au
- Seattle-Denver HSR&D Center for Veteran-Centered and Value-Driven Care, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
| | - Brian N Palen
- VA Puget Sound Health Care System, Seattle, Washington
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13
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Donovan LM, Coggeshall SS, Spece LJ, Griffith MF, Palen BN, Parsons EC, Todd-Stenberg JA, Glorioso TJ, Carey EP, Feemster LC, Zeliadt SB, Kirsh S, Au DH. Use of In-Laboratory Sleep Studies in the Veterans Health Administration and Community Care. Am J Respir Crit Care Med 2019; 200:779-782. [PMID: 31206308 PMCID: PMC7330508 DOI: 10.1164/rccm.201902-0313le] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Lucas M. Donovan
- Veterans Affairs Puget Sound Health Care
SystemSeattle, Washington
- University of WashingtonSeattle,
Washington
- Veterans Affairs Eastern Colorado Health
Care SystemDenver, Colorado
| | | | - Laura J. Spece
- University of WashingtonSeattle,
Washington
- Veterans Affairs Eastern Colorado Health
Care SystemDenver, Colorado
| | - Matthew F. Griffith
- University of WashingtonSeattle,
Washington
- Veterans Affairs Eastern Colorado Health
Care SystemDenver, Colorado
| | - Brian N. Palen
- University of WashingtonSeattle,
Washington
- Veterans Affairs Eastern Colorado Health
Care SystemDenver, Colorado
| | - Elizabeth C. Parsons
- University of WashingtonSeattle,
Washington
- Veterans Affairs Eastern Colorado Health
Care SystemDenver, Colorado
| | | | | | - Evan P. Carey
- St. Louis UniversitySt. Louis,
Missouri
- Department of Veterans
AffairsWashington, DCand
| | - Laura C. Feemster
- University of WashingtonSeattle,
Washington
- Veterans Affairs Eastern Colorado Health
Care SystemDenver, Colorado
| | - Steven B. Zeliadt
- University of WashingtonSeattle,
Washington
- Veterans Affairs Eastern Colorado Health
Care SystemDenver, Colorado
| | - Susan Kirsh
- VA Health Services Research &
Development Center of Innovation for Veteran-Centered and Value-Driven
CareSeattle, Washington
| | - David H. Au
- University of WashingtonSeattle,
Washington
- Veterans Affairs Eastern Colorado Health
Care SystemDenver, Colorado
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14
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Graney BA, Au DH, Barón AE, Cheng A, Combs SA, Glorioso TJ, Paden G, Parsons EC, Rabin BA, Ritzwoller DP, Stonecipher JJ, Turvey C, Welsh CH, Bekelman DB. Advancing Symptom Alleviation with Palliative Treatment (ADAPT) trial to improve quality of life: a study protocol for a randomized clinical trial. Trials 2019; 20:355. [PMID: 31196156 PMCID: PMC6567600 DOI: 10.1186/s13063-019-3417-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/08/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND People living with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD) suffer impaired quality of life due to burdensome symptoms and depression. The Advancing Symptom Alleviation with Palliative Treatment (ADAPT) trial aims to determine the effect of a multidisciplinary, team-based intervention on quality of life in people with these common diseases. METHODS/DESIGN The ADAPT trial is a two-site, patient-level randomized clinical trial that examines the effectiveness of the ADAPT intervention compared to usual care on patient-reported quality of life at 6 months in veterans with CHF, COPD or ILD with poor quality of life and increased risk for hospitalization or death. The ADAPT intervention involves a multidisciplinary team-a registered nurse, social worker, palliative care specialist, and primary care provider (with access to a pulmonologist and cardiologist)-who meet weekly to make recommendations and write orders for consideration by participants' individual primary care providers. The nurse and social worker interact with participants over six visits to identify and manage a primary bothersome symptom and complete a structured psychosocial intervention and advance care planning. The primary outcome is change in patient-reported quality of life at 6 months as measured by the Functional Assessment of Chronic Illness Therapy-General questionnaire. Secondary outcomes at 6 months include change in symptom distress, depression, anxiety, disease-specific quality of life hospitalizations, and advance care planning communication and documentation. Intervention implementation will be assessed using a mixed-methods approach including a qualitative assessment of participants' and intervention personnel experiences and a quantitative assessment of care delivery, resources, and cost. DISCUSSION The ADAPT trial studies an innovative intervention designed to improve quality of life for veterans with common, burdensome illnesses by targeting key underlying factors-symptoms and depression-that impair quality of life but persist despite disease-specific therapies. Leveraging the skills of affiliate health providers with physician supervision will extend the reach of palliative care and improve quality of life for those with advanced disease within routine outpatient care. The hybrid effectiveness/implementation design of the ADAPT trial will shorten the time to broader dissemination if effective and create avenues for future research. TRIAL REGISTRATION ClinicalTrials.gov, NCT02713347 . Registered March 19, 2016.
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Affiliation(s)
- Bridget A Graney
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA. .,University of Colorado Anschutz Medical Campus, Aurora, USA. .,National Jewish Health, Anschutz Medical Campus, 12700 East 19th Avenue, Research 2, 9th Floor, Box C272, Aurora, CO, 80045, USA.
| | - David H Au
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, WA, USA
| | - Anna E Barón
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew Cheng
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, WA, USA.,Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Sara A Combs
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Thomas J Glorioso
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO, USA
| | - Grady Paden
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, WA, USA.,Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Elizabeth C Parsons
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Borsika A Rabin
- Department of Family Medicine and Public Health, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | | | - Carolyn Turvey
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA.,Center for Access and Delivery Research and Evaluation, Department of Veterans Affairs, Iowa City Health Care System, Iowa City, IA, USA
| | - Carolyn H Welsh
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO, USA
| | - David B Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO, USA
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15
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Donovan LM, Fernandes LA, Williams KM, Parsons EC, O'Hearn DJ, He K, McCall CA, Spece LJ, Feemster LC, Kirsh S, Au DH, Palen BN. 0989 Nurse-led Sleep Study Triage In Typical Practice. Sleep 2019. [DOI: 10.1093/sleep/zsz067.986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | | | | | - Ken He
- VA Pittsburgh Health Care System, Pittsburgh, PA, USA
| | | | | | | | - Susan Kirsh
- VA Office of Veterans Access to Care, Washington, DC, USA
| | - David H Au
- VA Puget Sound Health Care System, Seattle, WA, USA
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16
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Parsons EC, Carter JC, Wrede JE, Donovan LM, Palen BN. Practical implementation of noninvasive ventilation in Amyotrophic Lateral Sclerosis: lessons learned from a clinical case series. Can J Respir Ther 2019; 55:13-15. [PMID: 31297440 PMCID: PMC6591783 DOI: 10.29390/cjrt-2018-020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose Noninvasive ventilation (NIV) may improve survival and quality of life in Amyotrophic Lateral Sclerosis (ALS) patients. There is a surprising paucity of practical guidelines for office-based implementation and management of NIV outside of tertiary ALS centers. We saw the need for a clinical protocol to allow feasible and consistent NIV management in this patient population. Methods We created a clinical protocol for office-based initiation of NIV implemented on consecutive ALS patients referred from our regional ALS multidisciplinary clinic. The protocol provided initial empiric settings using a bilevel device in volume-assured pressure support mode. A respiratory therapist (RT) initiated NIV in an office setting and made adjustments according to patient tolerance and therapy targets outlined in the protocol. Later setting changes were performed at patient or provider request. We evaluated patient adherence and efficacy via device download at 30 days and 1 year. Results We present data from a case series of the first 14 consecutive patients initiated on NIV over a 20-month period. Our protocol underwent iterative modification based on clinical experience and patient feedback. Early challenges included the significant time and resource burden required to coordinate device downloads and patient follow-up. Early 30-day NIV adherence was variable (median 20 out of 30 days), while 1-year NIV adherence was excellent (median 27.5 out of 30 days). Conclusions Our RT-driven clinical NIV protocol was feasible but labor intensive. Achieving real-world adherence of NIV in our ALS patients required iterative protocol adjustment, significant RT provider time, and tele-based follow-up.
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Affiliation(s)
- Elizabeth C Parsons
- Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, WA
| | - John C Carter
- Division of Pulmonary, Critical Care, and Sleep Medicine, Case Western Reserve University School of Medicine and MetroHealth, Cleveland, OH
| | - Joanna E Wrede
- Division of Pulmonary and Sleep Medicine and Division of Neurology, Seattle Children's Hospital, Seattle, WA
| | - Lucas M Donovan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Brian N Palen
- Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, WA
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17
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Donovan LM, Feemster LC, Billings ME, Spece LJ, Griffith MF, Rise PJ, Parsons EC, Palen BN, O'Hearn DJ, Redline S, Au DH, Kapur VK. Risk of Cardiovascular Disease Related to Smoking Is Greater Among Women With Sleep-Disordered Breathing. J Clin Sleep Med 2018; 14:1929-1935. [PMID: 30373694 DOI: 10.5664/jcsm.7496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/01/2018] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVES Although both sleep-disordered breathing (SDB) and smoking are associated with cardiovascular disease (CVD), the potential for an interactive effect on CVD risk has not been explored. Our objective was to determine if smoking-related risk for CVD rises with greater SDB severity. METHODS Polysomnography and smoking history were obtained in 3,852 men and women in the Sleep Heart Health Study without baseline CVD. Fine-Gray proportional hazard models accounting for competing risk were used to calculate risk of incident CVD associated with SDB severity (defined by clinical cutoffs of the apnea-hypopnea index), smoking status (never, former, and current) and their interaction adjusting for potential confounders. RESULTS Over a mean (standard deviation) follow-up period of 10.3 (3.4) years, there were 694 incident CVD events. We found a significant three-way interaction of sex, current smoking, and moderate to severe SDB (P = .039) in the adjusted proportional hazards model. In adjusted analyses, women who were current smokers with moderate to severe SDB had a hazard ratio for incident CVD of 3.5 (95% confidence interval 1.6-8.0) relative to women who were nonsmokers without SDB. No such difference in CVD risk was observed in men or women of other strata of smoking and SDB. CONCLUSIONS In women, smoking-related risk for CVD is significantly higher among individuals with moderate to severe SDB.
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Affiliation(s)
- Lucas M Donovan
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Laura C Feemster
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Martha E Billings
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Laura J Spece
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Matthew F Griffith
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Peter J Rise
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - Elizabeth C Parsons
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Brian N Palen
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Daniel J O'Hearn
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Susan Redline
- Division of Sleep Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David H Au
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Vishesh K Kapur
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
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Wrede JE, Parsons EC, Watson NF. A Novel Treatment for Nasolacrimal Air Regurgitation Into the Eye With CPAP: The Total Face Mask. J Clin Sleep Med 2018; 14:1415-1417. [PMID: 30092899 DOI: 10.5664/jcsm.7286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/12/2018] [Indexed: 11/13/2022]
Abstract
ABSTRACT We present a patient who experienced insufflation of air under the left eyelid when using continuous positive airway pressure (CPAP) via an oronasal mask. The patient had a lacrimal stent in place for many years, which was a predisposing factor for this complication. Lacrimal stents are frequently used in the treatment of epiphora (excessive tearing) secondary to obstruction of the lacrimal drainage system. In this case, we review the pathophysiology of air regurgitation into the eye with CPAP use and methods previously described to address this rare complication. We also present a novel intervention for this rare complication, the total face mask. By additionally covering the eyes, a total face mask allows equalization of pressure on both sides of the lacrimal system. With a total face mask, our patient was able to successfully use CPAP.
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Affiliation(s)
- Joanna E Wrede
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington.,Division of Neurology, Seattle Children's Hospital, Seattle, Washington
| | - Elizabeth C Parsons
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Nathaniel F Watson
- Division of Neurology, University of Washington, Seattle, Washington.,Division of Sleep Medicine, University of Washington, Seattle, Washington
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Parsons EC, Hough CL, Vitiello MV, Palen B, Zatzick D, Davydow DS. Validity of a single PTSD checklist item to screen for insomnia in survivors of critical illness. Heart Lung 2018; 47:87-92. [PMID: 29449026 DOI: 10.1016/j.hrtlng.2017.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND There is no insomnia screening tool validated in intensive care unit (ICU) survivors. OBJECTIVES To examine the validity of a single item from the PTSD checklist-Civilian version (PCL-C) to detect insomnia by Insomnia Severity Index (ISI) METHODS: We performed a secondary analysis of data from a longitudinal investigation in 120 medical-surgical ICU survivors. At 1 year post-ICU, patients completed ISI, PCL-C, and Medical Short-Form 12 (SF-12) by telephone. A single PCL-C item rates difficulty initiating or maintaining sleep over the past month. We compared performance characteristics of this PCL-C item to ISI-defined insomnia (ISI ≥15). RESULTS A score of ≥3 on the PCL-C sleep item exhibited 91% sensitivity and 67% specificity for ISI-defined insomnia (ISI ≥ 15), and it demonstrated construct validity by correlation to related QOL indices. CONCLUSIONS A single PCL-C sleep item score ≥ 3 is a reasonable screen to identify insomnia symptoms in ICU survivors.
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Affiliation(s)
- Elizabeth C Parsons
- VA Puget Sound Health Care System, Seattle, WA; Division of Pulmonary, Critical Care, Sleep Medicine, University of Washington, Seattle, WA.
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, Sleep Medicine, University of Washington, Seattle, WA
| | - Michael V Vitiello
- Department of Psychiatry & Behavioral Sciences, University of Washington, Harborview Medical Center, Seattle, WA
| | - Brian Palen
- VA Puget Sound Health Care System, Seattle, WA; Division of Pulmonary, Critical Care, Sleep Medicine, University of Washington, Seattle, WA
| | - Douglas Zatzick
- Department of Psychiatry & Behavioral Sciences, University of Washington, Harborview Medical Center, Seattle, WA
| | - Dimitry S Davydow
- Division of Behavioral Health, CHI Franciscan Health System, Tacoma, WA
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He K, Palen BN, Mattox EA, Parsons EC. Veteran Preferences Regarding Wireless Management of Positive Airway Pressure for Obstructive Sleep Apnea at a Tertiary Health-Care System. Respir Care 2016; 62:357-362. [PMID: 27879382 DOI: 10.4187/respcare.05002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Timely monitoring of obstructive sleep apnea (OSA) therapy can be a challenge amid conflicting pressures of rising patient volume and shortage of sleep medicine providers. Positive airway pressure (PAP) devices with wireless modem technology have the potential to improve patient access to care and streamline work load, yet little is known about patient attitudes toward telehealth integration among veterans with sleep apnea. As part of a larger quality improvement initiative at the Veterans Affairs (VA) Puget Sound Health Care System, we elicited veterans' preferences toward modem versus traditional PAP data download, including patient attitudes and factors affecting those preferences. METHODS We conducted an anonymous survey of veterans without previous CPAP experience presenting for initial device setup and training at VA Puget Sound PAP clinics. Surveys assessed subject demographics, PAP download preferences (modem vs mail), and Likert-type scale ratings of importance placed on factors including convenience and information privacy. Using multinomial logistic regression, we examined the association between convenience rating and download preference, adjusting for information privacy rating, age, and commute time. RESULTS Of 444 surveys analyzed, respondents were primarily male with a mean age of 52 y. Most respondents reported taking ≥ 30 min to commute to the PAP clinic. Convenience was rated as the most important factor affecting download preferences. Veteran preferences regarding PAP download method were mixed, with 47% preferring modem, 38% preferring memory card mail-in, and 15% undecided. A higher rating of convenience was significantly associated with modem preference, both before and after adjustment for information privacy rating, commute time, and veteran age (adjusted relative risk ratio 1.67, P < .001, 95% CI 1.40-1.99). CONCLUSIONS PAP data download preferences were mixed among new veteran users. Veterans placed a high value on the potentially competing concerns of convenience and information privacy. Veterans preferring modem factored convenience as important in their decision making, independent of privacy concerns.
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Affiliation(s)
- Ken He
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Brian N Palen
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington.,Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | | | - Elizabeth C Parsons
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington. .,Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Affiliation(s)
- Brian N Palen
- Division of Pulmonary & Critical Care Medicine, VA Puget Sound Health Care System, Seattle, WA.,Division of Pulmonary & Critical Care Medicine, University of Washington, Seattle, WA
| | - Lucas M Donovan
- Division of Pulmonary & Critical Care Medicine, University of Washington, Seattle, WA
| | - Elizabeth C Parsons
- Division of Pulmonary & Critical Care Medicine, VA Puget Sound Health Care System, Seattle, WA.,Division of Pulmonary & Critical Care Medicine, University of Washington, Seattle, WA
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Parsons EC, Hough CL, Vitiello MV, Zatzick D, Davydow DS. Insomnia is associated with quality of life impairment in medical-surgical intensive care unit survivors. Heart Lung 2015; 44:89-94. [PMID: 25592203 DOI: 10.1016/j.hrtlng.2014.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 11/02/2014] [Accepted: 11/04/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To examine the prevalence of insomnia and its relationship to health-related quality of life (HRQOL) post-intensive care unit (ICU). BACKGROUND The burden of post-ICU insomnia is unknown. METHODS This cross-sectional study examined data from 120 patients with an ICU stay >24 h. Pre-hospital health was assessed in-hospital. Insomnia, HRQOL and post-ICU psychiatric symptoms were assessed at 12 months post-ICU. RESULTS Over one-quarter (28%) of subjects met insomnia criteria at 12 months post-ICU. Post-ICU insomnia was independently associated with worse mental HRQOL (P < 0.01), as well as worse scores on the HRQOL sub-domains of bodily pain (P < 0.001), vitality (P < 0.05) and physical function (P < 0.05). However, these associations were no longer significant after adjusting for post-ICU psychiatric symptoms (P = 0.33). CONCLUSIONS Insomnia is common among ICU survivors. Post-ICU insomnia is significantly associated with mental HRQOL and could identify ICU survivors who may benefit from further psychiatric evaluation.
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Affiliation(s)
- Elizabeth C Parsons
- VA Puget Sound Health Care System, Seattle, WA, USA; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA.
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Michael V Vitiello
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Douglas Zatzick
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Dimitry S Davydow
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, USA
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Parsons EC, Patel K, Tran BT, Littman AJ. Maternal pre-gravid obesity and early childhood respiratory hospitalization: a population-based case-control study. Matern Child Health J 2013; 17:1095-102. [PMID: 22903266 PMCID: PMC3538085 DOI: 10.1007/s10995-012-1092-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Inflammation in utero is linked to childhood respiratory and infectious complications. Obesity is an increasingly common chronic inflammatory state, yet little is known about its role in childhood respiratory illness. We sought to examine the association between maternal pre-gravid BMI and early childhood respiratory hospitalization. We conducted a population-based case-control study using the Washington State Comprehensive Hospital Abstract Reporting System and linked birth certificate data. Cases were children age 0-5 years, born in Washington state, with a respiratory hospitalization between 2003 and 2008. We identified 15,318 cases, frequency matching each case to two controls by birth year (total 31,060 controls). We used logistic regression to estimate the risk (approximated by odds ratios) of early childhood respiratory hospitalization according to maternal pre-gravid body mass index (BMI) category (underweight, normal, overweight, obese), after adjustment for maternal and infant characteristics. An elevated maternal pre-gravid BMI was associated with increased risk of childhood respiratory hospitalization, with an adjusted odds ratio OR [95 % CI] = 1.08 [1.03-1.14] for overweight mothers (BMI 25-29.9 kg/m(2)), and OR = 1.29 [1.22-1.36] for obese mothers (BMI ≥ 30 kg/m(2)). An elevated maternal pre-gravid BMI was associated with higher risk of early childhood respiratory hospitalization. Childhood respiratory illness may be an important complication of excess maternal weight that should be shared with expectant mothers.
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Affiliation(s)
- Elizabeth C Parsons
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
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Parsons EC, Kross EK, Caldwell ES, Kapur VK, McCurry SM, Vitiello MV, Hough CL. Post-discharge insomnia symptoms are associated with quality of life impairment among survivors of acute lung injury. Sleep Med 2012; 13:1106-9. [PMID: 22763017 DOI: 10.1016/j.sleep.2012.05.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 04/04/2012] [Accepted: 05/06/2012] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Sleep disturbance is common during critical illness, yet little is known about its prevalence or role in post-discharge quality of life among high-risk acute lung injury (ALI) patients. METHODS In a prospective cohort of 61 mechanically ventilated ALI patients, we examined the association between insomnia symptoms and quality of life six months after discharge. Subjects completed surveys rating quality of life (MOS SF-36), post-traumatic stress disorder (PCL), and depression (PHQ-9). Using an individual item from the PCL, we defined insomnia symptoms as moderate or greater trouble falling or staying asleep in the past month. We performed multivariable linear regression to examine the association between insomnia symptoms and SF-36 physical and mental component summary scores, adjusting for PTSD and depression. RESULTS Forty subjects (85% of eligible) completed six-month questionnaires; 20 (50%) met criteria for insomnia symptoms. After adjustment for PTSD and depression, insomnia symptoms remained significantly associated with worse physical component summary scores (adjusted mean difference=-8.8; 95% CI: -15.0, -2.5; P<0.01). CONCLUSIONS Post-discharge insomnia symptoms were common and significantly associated with physical quality of life impairment among six-month ALI survivors, even after adjustment for PTSD and depression symptoms. Further studies are needed to validate these results and to characterize sleep disturbance after ALI using sleep-specific metrics.
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Affiliation(s)
- Elizabeth C Parsons
- Health Services Research and Development Northwest Center of Excellence, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA 98101, United States.
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Parsons EC, Hough CL, Seymour CW, Cooke CR, Rubenfeld GD, Watkins TR. Red blood cell transfusion and outcomes in patients with acute lung injury, sepsis and shock. Crit Care 2011; 15:R221. [PMID: 21936902 PMCID: PMC3334766 DOI: 10.1186/cc10458] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 07/25/2011] [Accepted: 09/21/2011] [Indexed: 01/08/2023]
Abstract
Introduction In this study, we sought to determine the association between red blood cell (RBC) transfusion and outcomes in patients with acute lung injury (ALI), sepsis and shock. Methods We performed a secondary analysis of new-onset ALI patients enrolled in the Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment Trial (2000 to 2005) who had a documented ALI risk factor of sepsis or pneumonia and met shock criteria (mean arterial pressure (MAP) < 60 mmHg or vasopressor use) within 24 hours of randomization. Using multivariable logistic regression, we examined the association between RBC transfusion and 28-day mortality after adjustment for age, sex, race, randomization arm and Acute Physiology and Chronic Health Evaluation III score. Secondary end points included 90-day mortality and ventilator-free days (VFDs). Finally, we examined these end points among the subset of subjects meeting prespecified transfusion criteria defined by five simultaneous indicators: hemoglobin < 10.2 g/dL, central or mixed venous oxygen saturation < 70%, central venous pressure ≥ 8 mmHg, MAP ≥ 65 mmHg, and vasopressor use. Results We identified 285 subjects with ALI, sepsis, shock and transfusion data. Of these, 85 also met the above prespecified transfusion criteria. Fifty-three (19%) of the two hundred eighty-five subjects with shock and twenty (24%) of the subset meeting the transfusion criteria received RBC transfusion within twenty-four hours of randomization. We found no independent association between RBC transfusion and 28-day mortality (odds ratio = 1.49, 95% CI (95% confidence interval) = 0.77 to 2.90; P = 0.23) or VFDs (mean difference = -0.35, 95% CI = -4.03 to 3.32; P = 0.85). Likewise, 90-day mortality and VFDs did not differ by transfusion status. Among the subset of patients meeting the transfusion criteria, we found no independent association between transfusion and mortality or VFDs. Conclusions In patients with new-onset ALI, sepsis and shock, we found no independent association between RBC transfusion and mortality or VFDs. The physiological criteria did not identify patients more likely to be transfused or to benefit from transfusion.
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Affiliation(s)
- Elizabeth C Parsons
- Division of Pulmonary and Critical Care Medicine, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104, USA.
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Dredge DC, Parsons EC, Carter LP, Staley KJ. Anticonvulsant hypersensitivity syndrome treated with intravenous immunoglobulin. Pediatr Neurol 2010; 43:65-9. [PMID: 20682208 DOI: 10.1016/j.pediatrneurol.2010.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 02/16/2010] [Accepted: 03/08/2010] [Indexed: 11/30/2022]
Abstract
Anticonvulsant hypersensitivity syndrome is a severe, potentially life-threatening, reaction to the aromatic anticonvulsant medications. Reported here is a case of anticonvulsant hypersensitivity syndrome secondary to phenobarbital in a 2-year-old boy; he responded to drug withdrawal, corticosteroids, and intravenous immunoglobulin. The literature regarding treatment of this syndrome is reviewed.
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Affiliation(s)
- David C Dredge
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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27
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Spuentrup E, Wiethoff AJ, Parsons EC, Spangenberg P, Stracke CP. High spatial resolution magnetic resonance imaging of experimental cerebral venous thrombosis with a blood pool contrast agent. Eur J Radiol 2009; 74:445-52. [PMID: 19394183 DOI: 10.1016/j.ejrad.2009.03.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Accepted: 03/27/2009] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to investigate the feasibility of clot visualization in small sinus and cortical veins with contrast enhanced MRA in a cerebral venous thrombosis animal model using a blood pool contrast agent, Gadofosveset, and high spatial resolution imaging. MATERIAL AND METHODS For induction of cerebral venous thrombosis a recently developed combined interventional and microsurgical model was used. Cerebral sinus and cortical vein thrombosis was induced in six pigs. Two further pigs died during the procedure. Standard structural, time-of-flight- and phase contrast-angiograms were followed by fast time resolved high resolution 3D MRA (4D MRA) and subsequent high spatial resolution 3D MRA in the equilibrium phase with and without addition of parallel imaging. Visualization of the clots using the different sequences was subjectively compared and contrast-to-noise ratio (CNR) was assessed. RESULTS In the remaining six animals the procedure and MR-imaging protocol including administration of Gadofosveset was successfully completed. The 3D high resolution MRA in the equilibrium phase without the addition of parallel imaging was superior to all the other applied MR measurement techniques in terms of visualization of the clots. Only applying this sequence bridging vein thromboses were also seen as a small filling defect with a high CNR of >18. CONCLUSION Only the non-accelerated high spatial resolution 3D MRA in the equilibrium in conjunction with the blood pool agent Gadofosveset allows for high-contrast visualization of very small clots in the cerebral sinus and cortical veins. STATEMENT CLINICAL IMPACT: Detection of cortical vein thrombosis is of high clinical impact. Conventional MRI sequences often fail to visualize the clot. We could demonstrate that, in contrast to conventional sequences, with high spatial resolution 3D MRA in the equilibrium in conjunction with the blood pool agent Gadofosveset very small clots in the cerebral sinus and cortical veins could be successfully visualized. We think that with the presented approach cortical vein thrombosis might also be sufficiently visualized in patients.
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Affiliation(s)
- E Spuentrup
- Department of Radiology, University Hospital, University of Cologne, Cologne, Germany.
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Spuentrup E, Katoh M, Wiethoff AJ, Buecker A, Botnar RM, Parsons EC, Guenther RW. Molecular coronary MR imaging of human thrombi using EP-2104R, a fibrin-targeted contrast agent: experimental study in a swine model. ROFO-FORTSCHR RONTG 2008; 179:1166-73. [PMID: 17948194 DOI: 10.1055/s-2007-963573] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study was to investigate the use of a fibrin-specific contrast agent (EP-2104R, EPIX Pharmaceuticals, Lexington, Massachusetts, USA) for targeted molecular magnetic resonance (MR) imaging of human clot material removed from patients in a model of coronary thrombosis in swine. MATERIALS AND METHODS Freshly ex vivo engineered clots from human blood and human in situ developed clots removed from patients were delivered into the coronary arteries of nine domestic swine. For MR imaging a navigator-gated, free-breathing, cardiac-triggered 3D inversion recovery black-blood gradient echo sequence was performed prior to clot delivery (baseline), after clot delivery but prior to contrast media administration, and two hours after systemic (i.v.) injection of 4 micromol/kg EP-2104R. MR images were analyzed by two investigators and the contrast-to-noise ratio and Gadolinium (Gd) concentration in the clots were assessed. RESULTS On baseline images and prior to contrast media application no thrombi were visible. Post contrast administration all 10 coronary emboli (five ex vivo engineered clots and five human clots removed from patients) were selectively visualized as white spots with a mean contrast-to-noise ratio to the blood pool and the surrounding tissue of >12 and a mean Gd concentration of >100 microM. CONCLUSION Molecular MR imaging using the fibrin-targeted contrast agent EP-2104R allows selective visualization of human clot material in a model of coronary thrombosis in swine.
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Affiliation(s)
- E Spuentrup
- Department of Diagnostic Radiology, Aachen Technical University, Aachen, Germany.
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Vogt FM, Herborn CU, Parsons EC, Kröger K, Barkhausen J, Goyen M. [Diagnostic performance of contrast-enhanced MR angiography of the aortoiliac arteries with the blood pool agent Vasovist: initial results in comparison to intra-arterial DSA]. ROFO-FORTSCHR RONTG 2007; 179:412-20. [PMID: 17385136 DOI: 10.1055/s-2006-927371] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To prospectively assess the accuracy of contrast-enhanced MR angiography of the aortoiliac arteries using the blood pool agent Vasovist compared to unenhanced time-of-flight MRA. Conventional digital subtraction angiography served as the standard of reference. MATERIALS AND METHODS Twenty-nine patients with suspected or known peripheral arterial occlusive disease (PAOD) were examined by means of contrast-enhanced aortoiliac MR angiography using a dosage of 0.03 mmol/kg bodyweight Vasovist. Unenhanced two-dimensional time-of-flight (TOF) MRA of the same anatomic region was performed immediately prior to injection of the contrast agent. This study was approved by the local Institutional Review Board and informed consent was obtained from all subjects. Both contrast-enhanced and unenhanced MRA images were compared to conventional angiography with respect to the presence of vascular stenosis. Three independent, blinded readers evaluated vessel stenosis and occlusion on the basis of DSA and MR angiographic image readings. Sensitivity, specificity, accuracy, and the area under the receiver operating characteristic curve were analyzed. Correlations between readers of conventional angiograms were calculated and compared to the MR results. RESULTS In the case of pooled readings, unenhanced TOF MR angiography had a sensitivity of 42.6 %, a specificity of 78.4 % and an accuracy of 74.9 % for detection of clinically significant (>50 %) stenosis. Vasovist-enhanced MRA showed significant improvement in sensitivity (83.3 %), specificity (88.8 %) and accuracy (88.3 %) compared to TOF MRA (p<0.01). The areas under the receiver operating characteristic curve for quantitative measurements increased significantly (p<0.01) in the case of Vasovist-enhanced MRA compared to TOF MRA. All readers found fewer images uninterpretable with Vasovist enhancement and the agreement regarding stenosis location and degree of stenosis between MR angiography and DSA improved substantially after Vasovist administration compared to the noncontrast examination. CONCLUSION MR angiography using the blood pool agent Vasovist is a feasible and minimally invasive alternative to DSA and provides angiograms of the aortoiliac region with high sensitivity, specificity, and diagnostic accuracy.
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Affiliation(s)
- F M Vogt
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Uniklinikum Essen, Essen.
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Parsons EC, Chan HM. Organochlorine and trace element contamination in bottlenose dolphins (Tursiops truncatus) from the South China Sea. Mar Pollut Bull 2001; 42:780-786. [PMID: 11585071 DOI: 10.1016/s0025-326x(00)00191-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- E C Parsons
- The Swire Institute of Marine Science, The University of Hong Kong, Cape d'Aguilar.
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Parsons EC, Overstreet RM, Jefferson TA. Parasites from Indo-Pacific hump-backed dolphins (Sousa chinensis) and finless porpoises (Neophocaena phocaenoides) stranded in Hong Kong. Vet Rec 2001; 148:776-80. [PMID: 11465264 DOI: 10.1136/vr.148.25.776] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Between 1993 and 1998, 28 Indo-Pacific hump-backed dolphins (Sousa chinensis) and 32 finless porpoises (Neophocaena phocoenoides) stranded in Hong Kong territorial waters were examined postmortem for parasites. The nematode Halocercus pingi was discovered in the lungs of one hump-backed dolphin and in 10 finless porpoises, typically within abscesses or granulomata, and they were frequently accompanied by a catarrhal exudate and lesions characteristic of pneumonia. Seven of the 10 finless porpoises were calves with substantial lungworm infections, and three were neonates with visible fetal folds and umbilical remnants, suggesting that H pingi is transferred to the neonate before birth or during lactation. Electron micrographs of H pingi should allow the nematode to be identified by other researchers. An ectoparasitic stalked barnacle (Xenobalanus globicipitis) was recovered from a finless porpoise, the first time that this species of barnacle has been recorded in Hong Kong's territorial waters.
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Affiliation(s)
- E C Parsons
- Department of Parasitology, Gulf Coast Research Laboratory, Ocean Springs, MS 39564, USA
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Gore JC, Anderson AW, Does MD, Gochberg DF, Joers JM, Kennan RP, Parsons EC, Schachter M. The relationship of problems in biomedical MRI to the study of porous media. Magn Reson Imaging 2001; 19:295-300. [PMID: 11445302 DOI: 10.1016/s0730-725x(01)00239-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The NMR methods that are used to characterize inanimate porous media measure relaxation times and related phenomena and material transport, fluid displacement and flow. Biological tissues are comprised of multiple small, fluid-filled compartments, such as cells, that restrict the movement of the bulk solvent water and whose constituents influence water proton relaxation times via numerous interactions with macromolecular surfaces. Several of the methods and concepts that have been developed in one field of application are also of great value in the other, and it may be expected that technical developments that have been spurred by biomedical applications of MR imaging will be used in the continuing study of porous media. Some recent specific studies from our laboratory include the development of multiple quantum coherence methods for studies of ordered water in anisotropic macromolecular assemblies, studies of the degree of restriction of water diffusion in cellular systems, multiple selective inversion imaging to depict the ratios of proton pool sizes and rates of magnetization transfer between proton populations, and diffusion tensor imaging to depict tissue anisotropies. These illustrate how approaches to obtain structural information from biological media are also relevant to porous media. For example, the recent development of oscillating gradient spin echo techniques (OGSE), an approach that extends our ability to resolve apparent diffusion changes over different time scales in tissues, has also been used to compute surface to volume measurements in assemblies of pores. Each of the new methods can be adapted to provide spatially resolved quantitative measurements of properties of interest, and these can be efficiently acquired with good accuracy using fast imaging methods such as echo planar imaging. The community of NMR scientists focused on applications to porous media should remain in close communication with those who use MRI to study problems in biomedicine, to their mutual benefits.
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Affiliation(s)
- J C Gore
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA.
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Affiliation(s)
- E C Parsons
- Perioperative Services, Emory Hospitals, Atlanta, USA
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Abstract
Stranded cetaceans reported from the territorial waters of Hong Kong during the period May 1993 to March 1998 were examined to establish factors that may have contributed to their death. During the current study, 28 Indo-Pacific hump-backed dolphins (Sousa chinensis), 32 finless porpoises (Neophocaena phocaenoides), and four bottlenose dolphins (Tursiops truncatus) were necropsied. Bacteria (15 species) were isolated from nine animals. Of these bacteria, 47% were of possible fecal origin reflecting the high level of sewage contamination in Hong Kong's waters. One finless porpoise displayed wounds caused by a shark attack, and two female finless porpoises presented prolapsed uteri. At least 10 finless porpoises showed evidence of moderate to heavy lungworm infections (Halocercus pingi), and this appears to have been a factor contributing to death in at least six animals. Evidence suggesting blunt traumatic injury (probably caused by boat collisions) was found in six cetaceans (three finless porpoises and three hump-backed dolphins). Signs of fishery-related mortality were detected in at least nine animals (six hump-backed dolphins, two finless porpoises, and one bottlenose dolphin). Of these two human-caused mortality types, pre-existing disease or bacterial infection were detected in 29% of cases. Results indicate that human factors may have played a significant role in the death of at least 15 animals (32% of hump-backed dolphins, 15% of finless porpoises, and 25% of bottlenose dolphins).
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Affiliation(s)
- E C Parsons
- Comparative Pathology Laboratory, University of Miami, FL 33136, USA
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Parsons EC. Trace metal pollution in Hong Kong: implications for the health of Hong Kong's Indo-Pacific hump-backed dolphins (Sousa chinensis). Sci Total Environ 1998; 214:175-184. [PMID: 9646525 DOI: 10.1016/s0048-9697(98)00063-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The territorial waters of Hong Kong are highly contaminated with anthropogenic pollutants, including trace metals. Hong Kong's population of Indo-Pacific hump-backed dolphins (Sousa chinensis) inhabits an area where a high volume of sewage waste discharge and the close proximity of contaminated mud pits mean a considerable potential for trace metal contamination. Trace metal concentrations in the muscle tissue of fish caught from areas of high dolphin abundance are notable. However, in order to gauge the amount of trace metal consumed by dolphins, whole fish must be analysed. Whole fish from areas of high dolphin abundance have considerably higher trace metal loads than muscle tissue alone. Considering the consumption of prey items by dolphins, a daily intake of trace metals was estimated as As, 410-518; Cd, 34-44; Co, 4-5; Cr, 40-50; Cu, 44-56; Hg, 51-66; Mo, 22-27; Ni, 19-24; Pb, 320-403; Se, 99-125 and Zn, 388-490 (microgram kg-1 body wt. per day). Concentrations of arsenic, chromium, lead, molybdenum and nickel in dolphin tissues were an order of magnitude lower than in prey items, suggesting these elements may be excreted by this species. Mercury concentrations in dolphin tissues were, however, an order of magnitude higher than in prey items and could be considered potentially health threatening (max: 906 micrograms kg-1 dry wt.). Hong Kong's Indo-Pacific hump-backed dolphin population has a high dietary intake of trace metals which may, especially in the case of mercury, be a cause for concern.
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Affiliation(s)
- E C Parsons
- Swire Institute of Marine Science, Shek O, Hong Kong
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Abstract
The requirement to verify and ensure the competency of staff members to perform their assigned duties is here to stay. This article describes a model for decision making about competency assessment frequency. Implementation of the model should be accompanied by a systematic review of learning needs and performance improvement data. Education sessions designed to address identified learning needs or to support performance improvement activities should occur before or concurrent with competency assessment. The result is a cost-effective, efficient use of resources to accomplish the goal of ongoing assessment and improvement of staff competency. When staff member competency improves, the likelihood of a positive patient outcome increases. Our model provides a structured, defensible mechanism to link competency assessment with improvements in patient care quality.
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Affiliation(s)
- E C Parsons
- Intraoperative Services, Crawford Long Hospital, Atlanta, USA
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Dilmanian FA, Wu XY, Parsons EC, Ren B, Kress J, Button TM, Chapman LD, Coderre JA, Giron F, Greenberg D, Krus DJ, Liang Z, Marcovici S, Petersen MJ, Roque CT, Shleifer M, Slatkin DN, Thomlinson WC, Yamamoto K, Zhong Z. Single-and dual-energy CT with monochromatic synchrotron x-rays. Phys Med Biol 1997; 42:371-87. [PMID: 9044419 DOI: 10.1088/0031-9155/42/2/009] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We explored the potential for clinical research of computed tomography (CT) with monochromatic x-rays using the preclinical multiple energy computed tomography (MECT) system at the National Synchrotron Light Source. MECT has a fixed, horizontal fan beam with a subject apparatus rotating about a vertical axis; it will be used for imaging the human head and neck. Two CdWO4-photodiode array detectors with different spatial resolutions were used. A 10.5 cm diameter acrylic phantom was imaged with MECT at 43 keV and with a conventional CT (CCT) at 80 kVp: spatial resolution approximately equal to 6.5 line pairs (lp)/cm for both; slice height, 2.6 mm for MECT against 3.0 mm for CCT; surface dose, 3.1 cGy for MECT against 2.0 cGy for CCT. The resultant image noise was 1.5 HU for MECT against 3 HU for CCT. Computer simulations of the same images with more precisely matched spatial resolution, slice height and dose indicated an image-noise ratio of 1.4:1.0 for CCT against MECT. A 13.5 cm diameter acrylic phantom imaged with MECT at approximately 0.1 keV above the iodine K edge and with CCT showed, for a 240 micrograms I ml-1 solution, an image contrast of 26 HU for MECT and 13 and 9 HU for the 80 and 100 kVp CCT, respectively. The corresponding numbers from computer simulation of the same images were 26, 12, and 9 HU, respectively. MECT's potential for use in clinical research is discussed.
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Affiliation(s)
- F A Dilmanian
- Brookhaven National Laboratory, Upton, NY 11973-5000, USA
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Affiliation(s)
- E C Parsons
- Surgical Services Division, Crawford W. Long Hospital of Emory University, Atlanta
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