Catalyzing Collaboration Among Interprofessional Birth Transfer Teams Through Simulation

INTRODUCTION

Planned home or birth center births sometimes require emergency transfers to a hospital. Poor communication among members of the birth care team during a transfer can lead to unfavorable outcomes for the birthing person and newborn. To improve the quality of birth transfers in Utah, the Utah Women and Newborns Quality Collaborative partnered with the LIFT Simulation Design Lab to develop and pilot an interprofessional birth transfer simulation training.

METHODS

We engaged community stakeholders to identify learning objectives and co-design the simulation trainings using principles of participatory design. We conducted 5 simulation trainings featuring birth transfers during a postpartum hemorrhage. The LIFT Lab evaluated the trainings to determine if they were feasible, acceptable, and effective. Measures included a post-training form asking participants to evaluate the quality of the training and a 9-question pre- and post-training survey measuring changes in participants' self-efficacy regarding components of birth transfer. The changes were assessed for significance using a paired t test.

RESULTS

A total of 102 participants attended the 5 trainings; all health care provider groups were well represented. Most participants felt the simulations were similar to real situations and would benefit others in their professions. All participants said the trainings were a good use of their time. Following the training, participants had significantly higher levels of self-efficacy regarding their ability to manage birth transfers.

DISCUSSION

Birth transfer simulation trainings are an acceptable, feasible, and effective method for training interprofessional birth care teams.

071 Actigraphy-Derived Sleep Metrics are Not Related to Central Hemodynamics or Arterial Stiffness in Healthy Adults

Introduction

Insufficient sleep is an emerging risk factor for cardiovascular disease. To evaluate the hypothesis that decrements in vascular function, due to poor sleep, may serve as a mechanistic link between sleep and cardiovascular disease, we explored relationships of actigraphy-derived sleep metrics with central hemodynamics and arterial stiffness in healthy young adults.

Methods

A total of 23 women and 27 men (23±5 yrs), free of known cardiovascular, metabolic, and renal disease, and not using sleep medication, participated in this study. ActiGraph GT9X wrist-worn accelerometers were used to measure sleep efficiency, total sleep time, wake after sleep onset, and number of awakenings over a seven-day period. Vascular health measures including central pressures and augmentation index at a heart rate of 75 beats per minute (AIx@75) were quantified via pulse wave analysis, and carotid femoral pulse wave velocity (cf-PWV) was assessed using applanation tonometry. Gender-specific z-scores for each of the sleep metrics were summed to assign each participant a “sleep score” (higher score = better sleep), and relationships between sleep scores and vascular health measures were explored using Pearson correlation coefficients.

Results

In men, sleep score (range: -4.92 to 9.10) was not related (P>0.05) to central systolic (114±15 mmHg, r=-0.26) or diastolic (72±7 mmHg, r=-0.21) pressures. Similarly, in women, sleep score (range: -5.02 to 5.34) was not related (P>0.05) to central systolic (103±11 mmHg, r=-0.09) or diastolic (72±10 mmHg, r=-0.21) pressures. Sleep score also failed to predict (P>0.05) indices of arterial stiffness, AIx@75 (men = 3.1±12.3, r=0.04; women = 5.2±9.5, r=-0.25) and cf-PWV (men = 6.2±0.8 m/s, r=-0.12; women = 5.7±0.5 m/s, r=-0.10).

Conclusion

In young healthy individuals, actigraphy-derived sleep characteristics were not related to central hemodynamics or non-invasive indices of arterial stiffness. Previously documented relationships between sleep and vascular function may be limited to less healthy populations, poorer sleepers, or only for certain sleep metrics.

Support (if any):

Laboratory and Benchtop Performance of a Mealtime Insulin-Delivery System

BACKGROUND

A basal bolus insulin regimen requires multiple daily insulin injections, which might discourage patient adherence. As a potential solution, a mealtime insulin-delivery system-a 3-day wearable bolus-only patch-was designed to manually administer mealtime insulin discreetly by actuating buttons through clothing, without the need for multiple needle sticks.

METHOD

Extensive functional testing of the patch included dose accuracy (from initial fill of the device to empty), pressure-vacuum leak testing, last-dose lockout and occlusion detection (safety alert features that lock the dosing buttons when no insulin is delivered), assessments of insulin drug stability, toxicological risk (including chemical testing), and system biocompatibility.

RESULTS

Dosing accuracy was 2 units ±10% (with U-100 insulin) over a range of environmental conditions, with ≥95% reliability and confidence. The fluid seal performance and the safety alert features performed with ≥95% reliability and ≥95% confidence. The system met acceptable standards for insulin (U-100 lispro and aspart) stability for its intended 3-day use, in addition to the operational requirements. The toxicological risk assessment and demonstrated biocompatibility suggested that the patch is safe for human use.

CONCLUSIONS

Benchtop performance showed that the bolus-only patch is a safe, accurate, and reliable device for mealtime insulin delivery.

Patient Perceptions and Preferences for a Mealtime Insulin Delivery Patch

INTRODUCTION

A basal-bolus insulin regimen is needed to achieve glycated hemoglobin A1c (HbA1c) below 7.0% in people with type 1 (T1D) or type 2 (T2D) diabetes who have significant loss of beta-cell function. Nonadherence to therapy is common and negatively affects the ability to reach treatment goals. We examined patient assessment of a new, wearable mealtime insulin-delivery system (patch) relative to their current mealtime insulin-delivery system (syringe, pen, or pump). The patch is designed to deliver only boluses of fast-acting insulin (no basal insulin), mechanically controlled by the patient.

METHODS

Adults (n = 101) with T1D or T2D assessed their current mealtime insulin-delivery system and then assessed simulated (no active medication) patch use over a 3-day period. Participants evaluated mealtime insulin-delivery systems using eight measures from five domains (convenience, interference with daily activities, diabetes-related worry, psychological well-being, and overall satisfaction/preference) on the self-administered Insulin Delivery System Rating Questionnaire. User ratings of their current insulin-delivery systems (syringe, pen, pump) were compared with those for the patch by repeated measure analysis of variance and one-sample t tests.

RESULTS

Participants had significant (p < 0.05) preference for patch over syringe in all eight comparisons, and over pen in five out of eight comparisons, with no significant preference for pen. Although there was a preference for patch over pump in six out of eight comparisons, only one showed a significant preference for patch, and one for pump. Significantly more participants reported that they would like to switch to the patch than continue using a syringe (78% vs 22%) or pen (76% vs 24%) but this difference was not significant for the group using a pump (52% vs 48%).

CONCLUSIONS

Participants preferred using the patch over pens and syringes. Its ease of use and discreet method of insulin delivery may contribute to improved patient adherence to mealtime insulin regimens among people currently using injection devices.

FUNDING

Calibra Medical.

Use of preoperative erythrocyte sedimentation rate (ESR) to predict overall survival in localized renal cell carcinoma following radical nephrectomy

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Background: Systemic inflammation has been associated with increased tumor grade and disease progression in renal cell carcinoma (RCC). Erythrocyte sedimentation rate (ESR) reflects systemic inflammation in other disease states. However, the relationship between ESR and survival remains unclear in localized RCC following potentially curative nephrectomy. We hypothesized that preoperative ESR would be a prognostic indicator of overall survival in localized RCC following radical nephrectomy.

Methods: 167 patients undergoing nephrectomy for localized RCC had ESR measured preoperatively. Receiver operating characteristics (ROC) curves were constructed and used to determine the area under the curve (AUC) and relative sensitivity and specificity of preoperative ESR in predicting overall survival. From this curve, cut-offs for low risk (0.0-20.0 mm/hr), intermediate risk (20.1-50.0 mm/hr), and high risk (> 50.0 mm/hr) groups were created. Kaplan-Meier analysis was conducted to assess the univariate impact of these ESR-based risk groups on overall survival. Finally, univariate and multivariate Cox regression analysis was conducted to assess the potential of these groups to predict overall survival, adjusting for other patient and tumor characteristics.

Results: 55.2%, 27.0% and 17.8% were in the low, intermediate, and high risk groups, respectively. Median (95% CI) survivals for these groups were 44.1 (42.6-45.5), 35.5 (32.3-38.8), and 32.1 (25.5-38.6) months, respectively. After controlling for patient age, race, gender, Charlson Comorbidity Index, T-Stage, Fuhrman Nuclear grade, and tumor size, intermediate risk and high risk groups experienced a 4.5-fold (HR: 4.509, 95% CI: 0.735-27.649) and 18.5-fold (HR: 18.531, 95% CI: 2.117-162.228) increased risk of overall mortality, respectively.

Conclusions: Preoperative ESR values represent a robust categorical predictor of overall survival following nephrectomy in localized renal cell carcinoma in this cohort. Clinicians may consider including ESR measurements in counseling patients before nephrectomy, as well as managing patients according to their ESR-based risk category.

No significant financial relationships to disclose.

Using surface force apparatus, diffusion and velocimetry to measure slip lengths

Determining the slip lengths for liquids flowing close to smooth walls is challenging. The reason lies in the fact that the scales that must be addressed range between a few and hundreds of nanometres. Several techniques have been used over the last few years. Here, we consider three of them based on surface force apparatus, diffusion and velocimetry, respectively. The descriptions offered here incorporate recent instrumental progress made in the field.

Boundary slip on smooth hydrophobic surfaces: intrinsic effects and possible artifacts

We report an accurate determination of the hydrodynamic boundary condition of simple liquids flowing on smooth hydrophobic surfaces using a dynamic surface force apparatus equipped with two independent subnanometer resolution sensors. The boundary slip observed is well defined and does not depend on the scale of investigation from one to several hundreds of nanometers, nor on shear rate up to 5 x 10(3)s(-1). The slip length of 20 nm is in good agreement with theory and numerical simulations concerning smooth nonwetting surfaces. These results disagree with previous data in the literature reporting very high boundary slip on similar systems. We discuss possible origins of large slip length on smooth hydrophobic surfaces due to their contamination by hydrophobic particles.

Rheological properties of a highly confined film of a lyotropic lamellar phase

We investigated the rheological properties of a thin film of a lyotropic lamellar phase with a Dynamic Surface Forces Apparatus. The minimum thickness of the film is varied between one to several tens of layers by confining the materials between solid surfaces. The rheometric properties are measured with the application of a small harmonic compression. These properties depend clearly on the smectic order of the material. Whole mechanical properties may be easily described by taking into account interactions between membranes and motion of the dislocation line loops. In particular, it is shown that at the dynamical frequencies investigated in this study, the solvent flows between membranes which remain undeformed. Consequences and perspectives of this study will be discussed.

Pharmaceutical care for elderly patients shared between community pharmacists and general practitioners: a randomised evaluation. RESPECT (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) [ISRCTN16932128]

BACKGROUND

This trial aims to investigate the effectiveness and cost implications of 'pharmaceutical care' provided by community pharmacists to elderly patients in the community. As the UK government has proposed that by 2004 pharmaceutical care services should extend nationwide, this provides an opportunity to evaluate the effect of pharmaceutical care for the elderly.

DESIGN

The trial design is a randomised multiple interrupted time series. We aim to recruit 700 patients from about 20 general practices, each associated with about three community pharmacies, from each of the five Primary Care Trusts in North and East Yorkshire. We shall randomise the five resulting groups of practices, pharmacies and patients to begin pharmaceutical care in five successive phases. All five will act as controls until they receive the intervention in a random sequence. Until they receive training community pharmacists will provide their usual dispensing services and so act as controls. The community pharmacists and general practitioners will receive training in pharmaceutical care for the elderly. Once trained, community pharmacists will meet recruited patients, either in their pharmacies (in a consultation room or dispensary to preserve confidentiality) or at home. They will identify drug-related issues/problems, and design a pharmaceutical care plan in conjunction with both the GP and the patient. They will implement, monitor, and update this plan monthly. The primary outcome measure is the 'Medication Appropriateness Index'. Secondary measures include adverse events, quality of life, and patient knowledge and compliance. We shall also investigate the cost of pharmaceutical care to the NHS, to patients and to society as a whole.

Is Arrhythmia Detection by Automatic External Defibrillator Accurate for Children?

Background —Use of automatic external defibrillators (AEDs) in children aged <8 years is not recommended. The purpose of this study was to develop an ECG database of shockable and nonshockable rhythms from a broad age range of pediatric patients and to test the accuracy of the Agilent Heartstream FR2 Patient Analysis System for sensitivity and specificity.

Methods and Results —Children aged ≤12 years who either developed arrhythmias or were at risk for developing arrhythmias were studied. Two sources were used for the database: children whose rhythms were recorded prospectively via a modified AED and children who had arrhythmias captured on paper and digitized for subsequent analysis. The rhythms were divided into 5-second strips, classified by 3 reviewers, and then assessed by the AED analysis algorithm. A total of 696 five-second rhythm strips from 191 children (81 female and 110 male) aged 1 day to 12 years (median 3.0 years) were analyzed. There was 100% specificity for nonshockable rhythms. Sensitivity for ventricular fibrillation was 96%.

Conclusions —There was excellent AED rhythm analysis sensitivity and specificity in all age groups for ventricular fibrillation and nonshockable rhythms. The high specificity and sensitivity indicate that there is a very low risk of an inappropriate shock and that the AED correctly identifies shockable rhythms, making the algorithm both safe and effective for children.

Wound seeding associated with endometrial cancer

We report a patient with well-differentiated adenocarcinoma of the endometrium who developed a recurrence in the anterior abdominal wall probably secondary to wound seeding at the time of her original surgery. She underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy. She then received 15 mCi of 32P for positive peritoneal washings. She was free of disease until 2 years later when a large lower incision mass developed. She had no evidence for intra-abdominal disease and a radical resection with a myocutaneous flap was undertaken. Radical resection for isolated metastases may be of benefit for patients with endometrial cancer. Patients with positive cytology should be observed closely for incisional recurrence.

The disulfide bond arrangement of leukemia inhibitory factor: homology to oncostatin M and structural implications

Murine leukemia inhibitory factor (LIF) (the fully active recombinant form produced in E. coli) was digested in the unreduced state with trypsin and Staphylococcal V8 protease in 0.05% sodium dodecyl sulfate. Disulfide-bonded peptides were identified by altered mobility on reverse-phase high-performance liquid chromatography in the presence or absence of dithiothreitol and subjected to amino acid sequencing. Peptides containing more than one disulfide bond were subjected to further proteolysis and disulfide-bonded subfragments identified and sequenced. The three disulfide bonds are CYS13-CYS135, CYS19-CYS132 and CYS61-164 and the first and third of these are clearly homologous to the two disulfide bonds in oncostatin M. The spatial organization of the cysteine residues in the predicted four alpha-helical bundle structure of LIF (Bazan, Neuron 7,197;1991) is compatible with these disulfide assignments.