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Introduction The purpose of this study was to explain the process and results of implementing a bundle of two cardiopulmonary resuscitation (CPR) programs in Gwang-ju metropolitan city and to determine whether the use of these programs improved the clinical outcomes for out-of-hospital cardiac arrest (OHCA) patients. Methods This was a before- and after-intervention study of the implementation of a bundle of two CPR programs in Gwang-ju. The main intervention was a multi-tier response (MTR) system, with an emphasis on prolonged on-scene resuscitation. The primary outcome was good neurological recovery, and secondary outcomes were survival to discharge and prehospital return of spontaneous circulation (ROSC). A multivariable logistic regression model was used to estimate the association between the study period and outcomes, after adjusting for potential confounders. Interaction analysis was conducted to determine whether the location of arrest and witness status modified the effect of the study period on the study outcomes. Results The adjusted odds ratios (AORs) for the intervention were 1.35 (0.96–1.90) for pre-hospital ROSC, 1.19 (0.49–2.86) for survival to discharge, and 3.45 (1.01–11.80) for good CPC. The AORs for good neurological recovery of the after-intervention period were 2.93 (0.73–11.77) for a private place, 4.82 (1.04–22.39) for a public place, 5.88 (1.47–23.57) for a witnessed arrest, and 1.49 (0.28–7.86) for a non-witnessed arrest. Conclusions OHCA patients treated in the after-intervention period with the bundle of CPR programs including MTR and prolonged on-scene resuscitation showed better clinical outcomes, especially pre-hospital ROSC, and neurological recovery at hospital discharge than those treated in the before-intervention period.

Study objective Rapid point-of-care (POC) SARS-CoV-2 detection with Abbott ID NOW™ COVID-19 test has been implemented in our Emergency Department (ED) for several months. We aimed to evaluate the operational impact and potential benefits of this innovative clinical pathway. Methods We conducted a prospective, descriptive, interventional, non-randomized study, before-after trial with the comparison of patient cohorts from two consecutive periods of seven weeks (observational pre-POC period vs interventional POC period). Results In 2020, throughout weeks 37 to 50, 3333 patients were assessed for eligibility and among them 331 (9.9%) were positive for SARS-CoV-2 infections. Among the included patients, 136 (9.2%) were positive for SARS-CoV-2 infection in the pre-POC period and 195 (10.5%) in the POC period. Among positive patients for SARS-CoV-2 related infection in-hospital mortality rate was similar between the two groups but the hospitalization rate was higher in the POC group (81.6% vs. 65.4%; p

IntroductionOn September 2, 2019, Rotterdam’s first inner-city outdoor smoke-free zone encompassing the Erasmus MC, a large university hospital in the Netherlands, the Erasmiaans high school, the Rotterdam University of Applied Sciences and the public road in between, was implemented.Aims and MethodsWe aimed to assess spatiotemporal patterning of smoking before and after implementation of this outdoor smoke-free zone. We performed a before–after observational field study. We systematically observed the number of smokers, and their locations and characteristics over 37 days before and after implementation of the smoke-free zone.ResultsBefore implementation of the smoke-free zone, 4098 people smoked in the area every weekday during working hours. After implementation, the daily number of smokers was 2241, a 45% reduction (p = .007). There was an increase of 432 smokers per day near and just outside the borders of the zone. At baseline, 31% of the smokers were categorized as employee, 22% as student and 3% as patient. Following implementation of the smoke-free zone, the largest decreases in smokers were observed among employees (–67%, p value .004) and patients (–70%, p value .049). Before and after implementation, 21 and 20 smokers were visibly addressed and asked to smoke elsewhere.ConclusionsImplementation of an inner-city smoke-free zone was associated with a substantial decline in the number of smokers in the zone and an overall reduction of smoking in the larger area. Further research should focus on optimizing implementation of and compliance with outdoor smoke-free zones.ImplicationsA smoke-free outdoor policy has the potential to denormalize and discourage smoking, support smokers who want to quit, and to protect people from secondhand smoke exposure. Implementation of an inner-city smoke-free zone encompassing a large tertiary hospital and two educational institutions was associated with a substantial decline in the number of smokers in the zone, as well as in the larger area. Voluntary outdoor smoke-free zones can help reduce the number of smokers in the area and protect people from secondhand smoke. There is a need to explore effectiveness of additional measures to further improve compliance.

Operations require collaboration between surgeons, anaesthetia professionals, and nurses. The aim of this study was to determine whether intraoperative briefings influence patient outcomes.In a before-and-after controlled trial (9 months baseline; 9 months intervention), intraoperative briefings were introduced in four general surgery centres between 2015 and 2018. During the operation, the responsible surgeon (most senior surgeon present) briefed the surgical team using the StOP? protocol about: progress of the operation (Status), next steps (Objectives), possible problems (Problems), and encouraged asking questions (?). Differences between baseline and intervention were analysed regarding surgical-site infections (primary outcome), mortality, unplanned reoperations, and duration of hospital stay (secondary outcomes), using inverse probability of treatment (IPT) weighting based on propensity scores.In total, 8256 patients underwent surgery in the study. Endpoint data were available for 7745 patients (93.8 per cent). IPT-weighted and adjusted intention-to-treat analyses showed no differences in surgical-site infections between baseline and intervention (9.8 versus 9.6 per cent respectively; adjusted difference (AD) -0.15 (95 per cent c.i. -1.45 to 1.14) per cent; odds ratio (OR) 0.92, 95 per cent c.i. 0.83 to 1.15; P = 0.797), but there were reductions in mortality (1.6 versus 1.1 per cent; AD -0.54 (-1.04 to -0.03) per cent; OR 0.60, 0.39 to 0.92; P = 0.018), unplanned reoperations (6.4 versus 4.8 per cent; AD -1.66 (-2.69 to -0.62) per cent; OR 0.72, 0.59 to 0.89; P = 0.002), and fewer prolonged hospital stays (21.6 versus 19.8 per cent; AD -1.82 (-3.48 to -0.15) per cent; OR 0.87, 0.77 to 0.98; P = 0.024).Short intraoperative briefings improve patient outcomes and should be performed routinely.Outcomes of surgery depend on patient characteristics and surgeon expertise, but also on teamwork, notably communication. The present study introduces the StOP? protocol, in which the surgeon informs the team about the current status (St), objectives regarding next steps (O), and potential problems (P), and encourages the team to ask questions and raise concerns (?). The results suggest an effect of the StOP? intervention on patient mortality, risk of unplanned reoperation, and duration of hospital stay, but not on surgical-site infections. The study is promising regarding the effect of structured intraoperative communication on important patient outcomes. The study compared patient outcomes at baseline and after implementation of the StOP? protocol, which enhances exchange of structured information within the interdisciplinary surgical team during the course of the operation. The intention-to-treat analyses in this multicentre before-and-after study of 8256 patients undergoing general surgery showed no differences between baseline and intervention for surgical-site infections, but revealed reduced mortality and unplanned reoperations, and fewer prolonged hospital stays during the intervention period.

Poor medical outcomes often result from series of minor events. The present study assessed events related to airway management to determine whether targeted changes to departmental strategies for airway management can reduce the incidence.This prospective before-and-after study was performed with ethics committee approval and written informed consent from patients. Major and minor events related to airway management were prospectively recorded for 9 weeks. After implementation of changes to departmental strategies for airway management, events were again prospectively recorded over 9 weeks. Primary outcome was number of cases with events. Secondary outcomes were various predefined events.At study baseline, 3668 cases and at follow-up 3786 cases were assessed. Cases with events decreased from 566 (15.4%) to 433 (11.4%) (risk ratio [RR]=0.74; 95% confidence interval [CI], 0.66-0.83; P0.01). As secondary outcomes, the following events decreased: Cormack-Lehane grade 3 or 4 (4.3-2.9%; RR=0.67; 95% CI, 0.52-0.85; P0.01); difficult bag-mask ventilation (3.8-2.7%; RR=0.69; 95% CI, 0.54-0.89; P0.01); hypoxaemia (3.8-2.9%; RR=0.75; 95% CI, 0.59-0.96; P=0.03); unplanned use of special equipment (3.2-2.0%; RR=0.62; (95% CI, 0.47-0.83; P0.01); oesophageal intubation (1.3-0.8%; RR=0.61; 95% CI, 0.39-0.96; P=0.03); bleeding (0.8-0.2%; RR=0.30; 95% CI, 0.14-0.63; P0.01); insufficient spontaneous breathing (0.3-0.0%; RR=0.09; 95% CI, 0.01-0.68; P0.01); communication errors (0.1-0.0%; RR=0; 95% CI, 0-NA; P=0.03).Implementation of changes to departmental strategies for airway management significantly reduced cases with events related to airway management. Analysis of events and implementation of strategies that specifically target identified issues might be key to improving airway management.NCT02743767.

A nationwide shortage of oxytocin in Canada resulted in a temporary switch from oxytocin to carbetocin for all postpartum women at our institution. This change offered a unique opportunity to conduct a pragmatic comparative assessment of the efficacy of carbetocin and oxytocin.In a retrospective before-after study, we reviewed the medical records from 641 women in the carbetocin group and 752 women in the oxytocin group . The standard carbetocin dosing was 100 µg iv following vaginal and intrapartum Cesarean delivery, while for elective Cesarean delivery it was 50 µg, with an additional 50 µg if required. The standard oxytocin dosing was 5 IU iv followed by 2.4 IU·hrThe incidence of additional uterotonic use was not different between the carbetocin and oxytocin groups (12.0% vs 8.8%; P = 0.05; odds ratio, 1.39; 95% confidence interval, 0.97 to 2.00). The incidence of postpartum hemorrhage was higher in the carbetocin group than in the oxytocin group (10.3% vs 6.6%; P = 0.01). Blood transfusion was more common in the carbetocin group (1.4% vs 0.3%; P = 0.02).There was no difference in the use of additional uterotonics when carbetocin or oxytocin were used in a cohort of women undergoing vaginal deliveries and both elective and emergency Cesarean deliveries.RéSUMé: OBJECTIF: Une pénurie nationale d’ocytocine au Canada a entraîné l’utilisation temporaire de la carbétocine en remplacement de l’ocytocine pour toutes les femmes en post-partum dans notre établissement. Grâce à cette substitution, nous avons bénéficié d’une occasion unique de mener une évaluation comparative pragmatique de l’efficacité de la carbétocine et de l’ocytocine. MéTHODE: Dans une étude rétrospective avant-après, nous avons examiné les dossiers médicaux de 641 femmes dans le groupe carbétocine et de 752 femmes dans le groupe ocytocine. Le dosage standard de carbécotine était de 100 μg iv après un accouchement vaginal et pendant un accouchement par césarienne intrapartum, tandis que pour un accouchement par césarienne élective, le dosage était de 50 μg, avec 50 μg supplémentaires au besoin. Le dosage standard d’ocytocine était de 5 UI iv suivi de 2,4 UI·h

Behavioural and psychological symptoms of dementia (BPSD) are common and have significant implications for patients and caregivers. Non‐pharmacological interventions (NPI) have shown to be effective in the management of BPSD. However, the use of antipsychotics to treat BPSD remains ubiquitous. This retrospective, before–after study aimed to examine whether a nurse mentoring programme promoting NPI for BPSD management had a significant association with the use of antipsychotics in older adults with major neurocognitive disorders residing in different settings. Results obtained from the medical files of 134 older adults having benefitted from the mentoring programme demonstrate that this intervention significantly reduced BPSD. The effect on antipsychotics use was modest: a 10% reduction in the use of antipsychotics has been observed among patients for which the NPI were effective. However, the use of antipsychotics remained widespread despite the nursing recommendations of the mentoring team of the Center of Excellence on Aging in Quebec (CEVQ).

Intravenous (IV) milrinone, in combination with induced hypertension, has been proposed as a treatment option for cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). However, data on its safety and efficacy are scarce. This was a controlled observational study conducted in an academic hospital with prospectively and retrospectively collected data. Consecutive patients with cerebral vasospasm following aSAH and treated with both IV milrinone (0.5 µg/kg/min−1, as part of a strict protocol) and induced hypertension were compared with a historical control group receiving hypertension alone. Multivariable analyses aimed at minimizing potential biases. We assessed (1) 6-month functional disability (defined as a score between 2 and 6 on the modified Rankin Scale) and vasospasm-related brain infarction, (2) the rate of first-line or rescue endovascular angioplasty for vasospasm, and (3) immediate tolerance to IV milrinone. Ninety-four patients were included (41 and 53 in the IV milrinone and the control group, respectively). IV milrinone infusion was independently associated with a lower likelihood of 6-month functional disability (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.10–0.77]) and vasospasm-related brain infarction (aOR = 0.19, 95% CI 0.04–0.94). Endovascular angioplasty was less frequent in the IV milrinone group (6 [15%] vs. 28 [53%] patients, p = 0.0001, aOR = 0.12, 95% CI 0.04–0.38). IV milrinone (median duration of infusion, 5 [2–8] days) was prematurely discontinued owing to poor tolerance in 12 patients, mostly (n = 10) for “non/hardly-attained induced hypertension” (mean arterial blood pressure

Objective: Is the level of shared decision-making (SDM) higher after introduction of a SDM package (including encounter decision aids on treatment options for heavy menstrual bleeding and training for clinicians) than before?. Methods: This before-after study, performed in OB-GYN practice, compared consultations before and after introduction of a SDM package. The target sample size was 25 patients per group. Women seeking treatment for heavy menstrual bleeding were eligible. After their appointments, patients filled out a three-item patient-reported SDM measure. Treatment discussions were audio-recorded and rated for SDM using Observer OPTION 5. Consultation transcripts in the ‘after’ group were checked for adherence to the steps required for intended use of decision aids. Results: 16 gynaecologists participated. 25 patients participated before introduction of the decision aids and 28 after. The proportion of women reporting optimal SDM was higher after introduction (75 %) than before (50 %;p < 0.001). The mean observer-rated level of SDM was also significantly higher after than before (MD = 12.50,95 % CI 5.53–19.47). Conclusion: The level of SDM was higher after the introduction of the package than before. Practice implications: This study was conducted in a real-life setting in three clinics, both large academic and small rural, offering opportunities for implementation in different type of organizations.

Oncologic, urinary, and sexual outcomes are important to patients receiving prostate cancer surgery. The objective of this study was to determine if providing surgical report cards (SuReps) to surgeons resulted in improved patient outcomes.A prospective before-and-after study was conducted at The Ottawa Hospital. A total of 422 consecutive patients undergoing radical prostatectomy were enrolled. The intervention was provision of report cards to surgeons. The control cohort was patients treated before report card feedback (pre-SuRep), and the intervention cohort was patients treated after report card feedback (post-SuRep). The primary outcomes were postoperative erectile function, urinary continence, and positive surgical margins.Baseline characteristics were similar between groups. Almost all patients (99%) were continent and the majority (59%) were potent prior to surgery. Complete 1-year followup was available for 400 patients (95%). Nerve sparing surgery increased from 70% pre-SuRep to 82% post-SuRep (p=0.01). There was a nonstatistically significant increase in the proportion of patients with a positive surgical margin post-SuRep (31% pre-SuRep vs 39% post-SuRep, p=0.08). There was no difference in postoperative erectile function (17% vs 18%, p=0.7) and a decrease in continence (75% vs 65%, p=0.02) at 1 year postoperatively.The SuRep platform allows accurate reporting of surgical outcomes that can be used for patient counseling. However, the provision of surgical report cards did not improve functional or oncologic outcomes. Longer durations of feedback, report card modifications, or targeted interventions are likely necessary to improve outcomes.

Background The coronavirus disease 2019 (COVID-19) pandemic affected almost 1.6 billion students or more than 90% of learners globally. However, the effect of school closures during COVID-19 pandemic on adolescent sleep duration remains unclear. Methods We undertook a cross-sectional electronic survey in six junior and senior high schools in Shanghai, China from late June to early July 2020. We evaluated the changes of sleep duration on weekdays by comparing sleep duration hours and insufficient sleep ( Results A total of 3265 students completed the survey, the mean age was 14.56 ± 1.99 years, 1567 (47.99%) were girls and 1344 (41.17%) were in grades 10–12. The overall sleep duration decreased from 8.88 h in school closures to 7.77 h after school reopening, and the change (difference: − 1.11 h; 95%CI: − 1.16, − 1.07; P P Conclusion Results of this study revealed that sleep duration was longer and percentage of sufficient sleep was higher during COVID-19 school closures in adolescent students.

Early geriatric involvement is recommended for older trauma patients. We wished to determine the impact of geriatric consultation on mortality, hospital length of stay and discharge disposition in older patients who were admitted to our Level 1 trauma unit. We completed a health records review of trauma unit patients, age ≥ 75 years old with Injury Severity Score (ISS) ≥ 12, before (11/2015–10/2017) and after (11/2017–10/2019) implementation of a geriatric trauma consultation initiative. Primary outcomes were mortality, hospital length of stay and discharge destination. Secondary objectives were adherence to the geriatric trauma consult process and identification of geriatric-specific issues. A multivariable analysis controlling for age, gender, multi-morbidity and ISS was undertaken. 157 patients pre-implementation and 172 post-implementation with mean age 83.8 years and 53.8% females were included. Geriatric consultation had no impact on in-hospital mortality [OR 0.70 (95% CI 0.31–1.58)] or length of stay [s 0.68 (95%CI − 1.35–2.72)]. Patients who received a geriatric consultation were more likely to be discharged home (OR 2.01 (95% CI 1.24–3.24). The adherence to consultation process was 99.4%. Mobility, pain and cognitive impairment were the most common geriatric concerns, identified in 76.6, 61.1 and 50.0% of older trauma patients, respectively. Older trauma patients that receive geriatric trauma consultation are more likely to be discharged home. Collaboration between trauma and geriatric specialists is beneficial and may lead to meaningful improvements in outcomes for older trauma patients.

Background The ongoing COVID-19 pandemic has disrupted the surgical training of residents. There is a real concern that trainees will not be able to meet their training requirements. Low-fidelity surgical simulation appears to be an alternative for surgical training. The educational benefits of repeating ossiculoplasty simulations under a microscope have never been evaluated. With this study we aimed to evaluate the differences in performance scores and on a global rating scale before and after training on an ossiculoplasty simulator. Methods In this quasi-experimental, prospective, single-centre, before-after study with blinded rater evaluation, residents performed five microscopic ossiculoplasty tasks with a difficulty gradient (sliding beads onto rods, the insertion of a partial prosthesis, the insertion of a total prosthesis, and the insertion of a stapedotomy piston under microscopic or endoscopic surgery) before and after training on the same simulator. Performance scores were defined for each task, and total performance scores (score/min) were calculated. All data were collected prospectively. Results Six out of seven intermediate residents and 8/9 novices strongly agreed that the simulator was an effective training device and should be included in the ENT residency program. The mean effect of training was a significant increase in the total performance score (+ 0.52 points/min, [95 % CI, 0.40–0.64], p Conclusions This preliminary study shows that techniques for middle-ear surgery can be acquired using a simulator, avoiding any risk for patients, even under lockdown measures.

ObjectivesTo assess the effectiveness of a workplace intervention reducing psychosocial stressors at work in lowering blood pressure and hypertension prevalence.MethodsThe study design was a quasi-experimental pre–post study with an intervention group and a control group. Post-intervention measurements were collected 6 and 36 months after the midpoint of the intervention. Participants were all white-collar workers employed in three public organisations. At baseline, the intervention and the control groups were composed of 1088 and 1068 workers, respectively. The intervention was designed to reduce psychosocial stressors at work by implementing organisational changes. Adjusted changes in ambulatory blood pressure and hypertension prevalence were examined.ResultsBlood pressure and hypertension significantly decreased in the intervention group while no change was observed in the control group. The differential decrease in systolic blood pressure between the intervention and the control group was 2.0 mm Hg (95% CI: −3.0 to –1.0). The prevalence of hypertension decreased in the intervention group, when compared with the control group (prevalence ratio: 0.85 (95% CI: 0.74 to 0.98)).ConclusionsFindings suggest that psychosocial stressors at work are relevant targets for the primary prevention of hypertension. At the population level, systolic blood pressure reductions such as those observed in the present study could prevent a significant number of premature deaths and disabling strokes.

Objective To analyze the effect of psycho-educational intervention on knowledge of oral hygiene and psychological distress to the parents of children suffering from leukemia. Methods Design of this study was a quasi-experimental pre-posttest control group design. The sample were 70 mothers who had children with leukemia (intervention group = 35 mothers; control group = 35 mothers). The independent variable was psycho-educational, while the dependent variables were oral hygiene knowledge and psychological distress. The instruments used were the knowledge questionnaire and the Depression-Anxiety-Stress Scale (DASS-21). Data were analyzed using the Wilcoxon signed rank test and the Mann Whitney U-test with the significance α =0.05. Results The knowledge most widely known by parents was about how to perform of oral care (37.3%). All parameters of knowledge about oral hygiene have increased after being given a psycho-educational intervention. Psycho-educational interventions had an effect on reducing psychological distress; depression (p=0.000), anxiety (p=0.001) and stress (p=0.000). Conclusion Most parents whose children suffer from cancer experience psychological distress in the form of depression, anxiety and stress with a range of symptoms ranging from mild to moderate. Psycho-educational interventions can increase knowledge about oral hygiene and decrease psychological distress in parents. .

BACKGROUND: A majority of patients with community-acquired pneumonia (CAP) receive antibiotics. According to the evidence, 5-7 days of treatment should be sufficient for most patients. Many, however, are treated longer than recommended. We have previously conducted a quality improvement study to ensure guideline-conform treatment for CAP. However, the impact of the interventions on antibiotic use has not been investigated.OBJECTIVE: To estimate the impact of an eight-month stewardship program on antibiotic use.METHODS: We conducted a before-after study comparing a four-month baseline period with data from a corresponding follow-up period. We performed univariable and multivariable logistic regression to compare odds for ≤7 days of total antibiotic treatment, ≤3 days of intravenous treatment and the proportion of correct empiric antibiotics. As sensitivity analysis, we repeated the univariable logistic regression on a propensity score-matched cohort by using the same variables we used for adjustments in the multivariable analysis. We also performed subgroup analyses for patients stable ≤72 h of admission.RESULTS: In total, 771 patients were included. Compared to preintervention, the unadjusted odds ratio (OR) for ≤7 days of total antibiotic treatment were 1.84 (95% CI 1.34-2.54) for the whole population and 2.08 (1.41-3.10) for the stable patients. The OR for ≤3 days of intravenous antibiotics were 1.16 (0.87-1.54) and 1.38 (0.87-2.22), respectively. The OR for correct empiric antibiotics were 1.96 (1.45-2.68) and 1.82 (1.23-2.69). Comparable results regarding all outcomes were derived from the other analyses.CONCLUSION: The programme resulted in a significantly lower overall antibiotic exposure and a higher proportion of patients treated with the recommended antibiotics without a the reduction of exposure to intravenous antibiotics significantly.

BACKGROUND: Single disciplinary management of patients with vertigo and dizziness is an important challenge for most physicians in China. OBJECTIVE: To assess the impact of a new paradigm of practice (Clinic for Vertigo and Dizziness, CVD) performed by a multidisciplinary team (MDT) on diagnostic spectrum, medical costs, and patient satisfaction. DESIGN: Retrospective before-after study. PARTICIPANTS: Sample of 29,793 patients with vertigo/dizziness as primary complaint. MEASURES: Changes in diagnostic spectrum, medical costs, and patient satisfaction before and after the establishment of a CVD based on a 4-year database in three tertiary hospitals in northwestern China. KEY RESULTS: The most common diagnoses of patients with vertigo and dizziness were Meniere’s disease (25.77%), cervical disease (25.00%), cerebral vascular disease (13.96%), vestibular syndrome (10.57%), and other etiologies (6.34%) before the CVD establishment. In contrast, after the CVD establishment, the most common diagnoses were BPPV (23.92%), vestibular migraine (15.83%), Meniere’s disease (14.22%), CSD/PPPD (11.61%), and cerebral vascular diseases (4.45%). Extended implementation of a structured questionnaire for vertigo/dizziness and vestibular-oriented examinations (nystagmus, positional tests, HINTS) at the CVD resulted in a remarkable decline in the utility of CT/MRI and X-ray examination (p

BACKGROUND/OBJECTIVE Ineffective interdisciplinary communication has negative impacts on patient outcomes. The use of regular structured interdisciplinary bedside rounds (SIBR), where each patient interaction lasts 3-5 minutes, is a model of care that improves interdisciplinary communication. We evaluated the impact of SIBR on in-hospital falls. DESIGN Prospective before-after study of older people hospitalized with acute illness. SETTING Two side-by-side aged care wards in a university hospital in Sydney, Australia. PARTICIPANTS A total of 3,673 consecutive inpatients of mean age 83.8 ± 7.7 years, with 1,703 before SIBR compared with 1,970 after SIBR. No patients were excluded from potential participation. INTERVENTION Twice-weekly SIBR. MEASUREMENTS Falls data were manually extracted from a mandatory institutional incident reporting database. Medical diagnoses were based on the Australian Refined Diagnosis Related Groups classification system. Injuries due to falls were corroborated using the institutional electronic medical record (Cerner PowerChart). Generalized estimating equations were used to evaluate the incidence rate ratio (IRR) of falls and fall-related injuries. A negative binomial distribution and a logarithmic link function were used to linearize regression equations. RESULTS After SIBR, there were 7.4 falls per 1,000 occupied bed days (OBD), compared with 10.6 falls per 1,000 OBD before SIBR (P

BACKGROUND This study determined spousal involvement and the effect of community-based spousal engagement on cervical cancer screening-related discussions and uptake in a rural Nigerian community. METHODS A before-after mixed methods study was conducted among 245 married men in a rural Nigerian community. Spousal engagement involved advocacy to men groups, awareness creation, and monthly meeting-based announcements/reminders about screening. Three months post-intervention, uptake was determined from facility registers. Thematic analysis and SPSS were used for data analysis. RESULTS A large minority of respondents were aged 29-39 years (95/245, 38.8%). At baseline, respondents generally had poor spousal involvement. Post-intervention, inter-spousal discussion on screening increased from 17.2% to 46.9% (p

Background With the growing opioid epidemic and recent focus on the quantity of opioids prescribed at discharge after surgery, enhanced recovery pathways provide another tool to counteract this epidemic. The aim of this current study is to analyze the differences in opioid requirements and pain scores in the immediate postoperative period for patients who underwent laparoscopic colectomies before and after the implementation of enhanced recovery after surgery (ERAS) protocols. Materials and Methods This study is a retrospective review of patients and was conducted at an academically affiliated tertiary care hospital. In patients undergoing elective laparoscopic colectomies before December 1, 2013-July 31, 2015 and after September 1, 2015-May 31, 2018, the implementation of enhanced recovery pathways was included. The primary end point was opioid consumption from the end of surgery until 48 hours after surgery. Secondary end points included pain scores, surgery length of time, and hospital length of stay after surgery. Results A total of 242 patients (122 pre- and 120 postimplementation) were analyzed. Patient characteristics were similar between groups. Pain scores were higher in the preimplementation patients for postoperative day (POD) 0 scores ( P = .019). There was a decrease in the morphine milligram equivalents (MME) on POD 0-2 for the postimplementation patients. This decrease resulted in a 61% reduction in opioid requirements after implementation of ERAS protocols (32 vs. 12.5 MME, P < .0001). Discussion Enhanced recovery after surgery protocols can reduce opioid requirements after elective laparoscopic colectomies without negatively affecting pain scores.

BACKGROUND: Epilepsy is a neurological disorder affecting both children and adults. Epileptic seizures are the result of excessive and abnormal cortical cell electrical activity in the brain. In response to criticism that epilepsy care for children has little impact on long‐term outcomes, healthcare professionals and administrators have developed various service models and strategies to address perceived inadequacies. This is an updated version of a Cochrane Review previously published in 2018. OBJECTIVES: To assess the effects of any specialised or dedicated intervention for epilepsy versus usual care in children and adolescents with epilepsy and their families. SEARCH METHODS: We searched the following databases on 14 January 2020: the Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to 13 January 2020), PsycINFO (1887 to 14 January 2020), CINAHL Plus (1937 to 14 January 2020), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The Cochrane Register of Studies (CRS Web) includes the Cochrane Epilepsy Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL). We also contacted experts in the field seeking information on unpublished and ongoing studies and checked the websites of epilepsy organisations and the reference lists of included studies. SELECTION CRITERIA: We included randomised controlled trials recruiting children and adolescents with epilepsy. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion and extracted the relevant data. We assessed the following outcomes: 1. Seizure frequency and severity; 2. Appropriateness and volume of medication prescribed (including evidence of drug toxicity); 3. Participants' reported knowledge of information and advice received from professionals; 4. Participants' reports of health and quality of life; 5. Objective measures of general health status; 6. Objective measures of social or psychological functioning (including the number of days spent on sick leave/absence from school or work, and employment status); and 7. Costs of care or treatment. The results of the data extraction and quality assessment for each study were presented in structured tables and as a narrative summary. All summary statistics were extracted for each outcome. MAIN RESULTS: We included nine studies of eight interventions in the review, reporting on seven distinct self‐management programmes for educating or counselling children with epilepsy and their parents, and one new model of care. Based largely on self‐reported outcomes, each programme showed some benefits for the well‐being of children with epilepsy; however, all of the included studies had methodological flaws. No single programme was evaluated with different study samples, and in no instance was the same outcome measured and reported in the same way across studies, precluding any possible meta‐analysis, even if the interventions were considered sufficiently similar to include in meta‐analysis. We chose the outcomes for which data might be important for decisions about the interventions as per guidance in the Cochrane Handbook for Systematic Reviews of Interventions. We found moderate certainty evidence that one of the educational interventions reduced seizure frequency. There was low certainty evidence that two other educational interventions reduced seizure severity, seizure control, and seizure cure rates. The evidence for all other outcomes (drug adherence, knowledge, self‐efficacy and self‐perception of epilepsy on quality of life) was mixed. AUTHORS' CONCLUSIONS: Whilst each of the programmes evaluated in this review showed some benefit to children with epilepsy, their impact was extremely variable. No programme showed benefits across the full range of outcomes, and all studies had methodological problems. There is currently insufficient evidence in favour of any single programme. Further evidence from randomised controlled trials using validated measures and considering clinical meaningfulness as well as statistical significance of results is required.

BackgroundWorkplace aggression constitutes a serious issue for healthcare workers and organizations. Aggression is tied to physical and mental health issues at an individual level, as well as to absenteeism, decreased productivity or quality of work, and high employee turnover rates at an organizational level. To counteract these negative impacts, organizations have used a variety of interventions, including education and training, to provide workers with the knowledge and skills needed to prevent aggression. OBJECTIVES: To assess the effectiveness of education and training interventions that aim to prevent and minimize workplace aggression directed toward healthcare workers by patients and patient advocates.Search methodsCENTRAL, MEDLINE, Embase, six other databases and five trial registers were searched from their inception to June 2020 together with reference checking, citation searching and contact with study authors to identify additional studies.Selection criteriaRandomized controlled trials (RCTs), cluster-randomized controlled trials (CRCTs), and controlled before and after studies (CBAs) that investigated the effectiveness of education and training interventions targeting aggression prevention for healthcare workers.Data collection and analysisFour review authors evaluated and selected the studies resulting from the search. We used standard methodological procedures expected by Cochrane. We assessed the certainty of evidence using the GRADE approach.Main resultsWe included nine studies-four CRCTs, three RCTs, and two CBAs-with a total of 1688 participants. Five studies reported episodes of aggression, and six studies reported secondary outcomes. Seven studies were conducted among nurses or nurse aides, and two studies among healthcare workers in general. Three studies took place in long-term care, two in the psychiatric ward, and four in hospitals or health centers. Studies were reported from the United States, Switzerland, the United Kingdom, Taiwan, and Sweden. All included studies reported on education combined with training interventions. Four studies evaluated online programs, and five evaluated face-to-face programs. Five studies were of long duration (up to 52 weeks), and four studies were of short duration. Eight studies had short-term follow-up (< 3 months), and one study long-term follow-up (> 1 year). Seven studies were rated as being at "high" risk of bias in multiple domains, and all had "unclear" risk of bias in a single domain or in multiple domains. Effects on aggression Short-term follow-up The evidence is very uncertain about effects of education and training on aggression at short-term follow-up compared to no intervention (standardized mean difference [SMD] -0.33, 95% confidence interval [CI] -1.27 to 0.61, 2 CRCTs; risk ratio [RR] 2.30, 95% CI 0.97 to 5.42, 1 CBA; SMD -1.24, 95% CI -2.16 to -0.33, 1 CBA; very low-certainty evidence). Long-term follow-up Education may not reduce aggression compared to no intervention in the long term (RR 1.14, 95% CI 0.95 to 1.37, 1 CRCT; low-certainty evidence). Effects on knowledge, attitudes, skills, and adverse outcomes Education may increase personal knowledge about workplace aggression at short-term follow-up (SMD 0.86, 95% CI 0.34 to 1.38, 1 RCT; low-certainty evidence). The evidence is very uncertain about effects of education on personal knowledge in the long term (RR 1.26, 95% CI 0.90 to 1.75, 1 RCT; very low-certainty evidence). Education may improve attitudes among healthcare workers at short-term follow-up, but the evidence is very uncertain (SMD 0.59, 95% CI 0.24 to 0.94, 2 CRCTs and 3 RCTs; very low-certainty evidence). The type and duration of interventions resulted in different sizes of effects. Education may not have an effect on skills related to workplace aggression (SMD 0.21, 95% CI -0.07 to 0.49, 1 RCT and 1 CRCT; very low-certainty evidence) nor on adverse personal outcomes, but the evidence is very uncertain (SMD -0.31, 95% CI -1.02 to 0.40, 1 RCT; very low-certainty evidence). Measurements of these concepts showed high heterogeneity.Authors' conclusionsEducation combined with training may not have an effect on workplace aggression directed toward healthcare workers, even though education and training may increase personal knowledge and positive attitudes. Better quality studies that focus on specific settings of healthcare work where exposure to patient aggression is high are needed. Moreover, as most studies have assessed episodes of aggression toward nurses, future studies should include other types of healthcare workers who are also victims of aggression in the same settings, such as orderlies (healthcare assistants). Studies should especially use reports of aggression at an institutional level and should rely on multi-source data while relying on validated measures. Studies should also include days lost to sick leave and employee turnover and should measure outcomes at one-year follow-up. Studies should specify the duration and type of delivery of education and should use an active comparison to prevent raising awareness and reporting in the intervention group only.

BackgroundThe demand for residential aged care is increasing due to the ageing population. Optimising the design or adapting the physical environment of residential aged care facilities has the potential to influence quality of life, mood and function.ObjectivesTo assess the effects of changes to the physical environment, which include alternative models of residential aged care such as a 'home-like' model of care (where residents live in small living units) on quality of life, behaviour, mood and depression and function in older people living in residential aged care.Search methodsCENTRAL, MEDLINE, Embase, six other databases and two trial registries were searched on 11 February 2021. Reference lists and grey literature sources were also searched.Selection criteriaNon-randomised trials, repeated measures or interrupted time series studies and controlled before-after studies with a comparison group were included. Interventions which had modified the physical design of a care home or built a care home with an alternative model of residential aged care (including design alterations) in order to enhance the environment to promote independence and well-being were included. Studies which examined quality of life or outcomes related to quality of life were included. Two reviewers independently assessed the abstracts identified in the search and the full texts of all retrieved studies.Data collection and analysisTwo reviewers independently extracted data, assessed the risk of bias in each included study and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled.Main resultsTwenty studies were included with 77,265 participants, although one large study included the majority of participants (n = 74,449). The main comparison was home-like models of care incorporating changes to the scale of the building which limit the capacity of the living units to smaller numbers of residents and encourage the participation of residents with domestic activities and a person-centred care approach, compared to traditional designs which may include larger-scale buildings with a larger number of residents, hospital-like features such as nurses' stations, traditional hierarchical organisational structures and design which prioritises safety. Six controlled before-after studies compared the home-like model and the traditional environment (75,074 participants), but one controlled before-after study included 74,449 of the participants (estimated on weighting). It is uncertain whether home-like models improve health-related quality of life, behaviour, mood and depression, function or serious adverse effects compared to traditional designs because the certainty of the evidence is very low. The certainty of the evidence was downgraded from low-certainty to very low-certainty for all outcomes due to very serious concerns due to risk of bias, and also serious concerns due to imprecision for outcomes with more than 400 participants. One controlled before-after study examined the effect of home-like models on quality of life. The author stated "No statistically significant differences were observed between the intervention and control groups." Three studies reported on global behaviour (N = 257). One study found little or no difference in global behaviour change at six months using the Neuropsychiatric Inventory where lower scores indicate fewer behavioural symptoms (mean difference (MD) -0.04 (95% confidence interval (CI) -0.13 to 0.04, n = 164)), and two additional studies (N = 93) examined global behaviour, but these were unsuitable for determining a summary effect estimate. Two controlled before-after studies examined the effect of home-like models of care compared to traditional design on depression. After 18 months, one study (n = 242) reported an increase in the rate of depressive symptoms (rate ratio 1.15 (95% CI 1.02 to 1.29)), but the effect of home-like models of care on the probability of no depressive symptoms was uncertain (odds ratio 0.36 (95% CI 0.12 to 1.07)). One study (n = 164) reported little or no difference in depressive symptoms at six months using the Revised Memory and Behaviour Problems Checklist where lower scores indicate fewer depressive symptoms (MD 0.01 (95% CI -0.12 to 0.14)). Four controlled before-after studies examined function. One study (n = 242) reported little or no difference in function over 18 months using the Activities of Daily Living long-form scale where lower scores indicate better function (MD -0.09 (95% CI -0.46 to 0.28)), and one study (n = 164) reported better function scores at six months using the Interview for the Deterioration of Daily Living activities in Dementia where lower scores indicate better function (MD -4.37 (95% CI -7.06 to -1.69)). Two additional studies measured function but could not be included in the quantitative analysis. One study examined serious adverse effects (physical restraints), and reported a slight reduction in the important outcome of physical restraint use in a home-like model of care compared to a traditional design (MD between the home-like model of care and traditional design -0.3% (95% CI -0.5% to -0.1%), estimate weighted n = 74,449 participants at enrolment). The remaining studies examined smaller design interventions including refurbishment without changes to the scale of the building, special care units for people with dementia, group living corridors compared to a non-corridor design, lighting interventions, dining area redesign and a garden vignette.Authors' conclusionsThere is currently insufficient evidence on which to draw conclusions about the impact of physical environment design changes for older people living in residential aged care. Outcomes directly associated with the design of the built environment in a supported setting are difficult to isolate from other influences such as health changes of the residents, changes to care practices over time or different staff providing care across shifts. Cluster-randomised trials may be feasible for studies of refurbishment or specific design components within residential aged care. Studies which use a non-randomised design or cluster-randomised trials should consider approaches to reduce risk of bias to improve the certainty of evidence.

Cyclocryotherapy and transscleral cyclophotocoagulation are commonly used procedures for the treatment of refractory glaucoma, but still with many complications. Ultrasound cyclo plasty (UCP) is a novel technique that determines a selective and more precise coagulation necrosis of the ciliary body to reduce intraocular pressure (IOP), but its efficacy and safety have been less investigated in Chinese population. This study aimed to evaluate the clinical efficacy and safety of UCP in Chinese patients with refractory glaucoma. We designed a prospective, before–after study involving 36 eyes of 36 patients with refractory glaucoma that underwent uneventful UCP. Mean IOP, mean IOP reduction and subjective pain scale scores before and after UCP were compared to evaluate the efficacy of UCP in these patients. Procedural success defined as no abnormality of the treatment sites, and complications were recorded, along with confirmation of the safety of UCP. The 36 UCP patients had a mean IOP of 53.61 ± 12.4 mmHg and a mean VAS score of 5.69 ± 3.02 preoperatively. Successful operation was achieved in 28 patients, with a success rate of 77.8%. In the follow-up observation at day 1, day 7, and month 1, 2, 3 and 6 postoperatively, both mean IOP and mean VAS score were significantly lower than those before operation (both P

Study objective Sickle cell disease (SCD) is an inherited hematologic disorder that affects approximately 100,000 US individuals and results in greater than 200,000 emergency department (ED) visits annually in the United States, with pain being the most common complaint. The objective of this retrospective study is to determine the effect of implementing individualized pain plans in the treatment of patients with SCD in the ED on time to first opioid, length of stay, and disposition. Methods At The Ohio State University Wexner Medical Center, a multidisciplinary group including hematologists and ED physicians was formed and enacted a protocol for using individualized pain plans, with the goal of decreasing time to treatment for patients with SCD who presented to the ED with chief complaint of pain. In this retrospective study, data from the year before through the year of implementation were gathered. Generalized linear models were fit to compare time to first opioid, length of stay, and disposition before and after protocol implementation. Results Data showed a 48% decrease in time to first opioid and a 22% decrease in length of ED stay after protocol implementation. No significant change was found in disposition or length of inpatient admission before and after protocol initiation. Conclusion The use of individualized pain plans in the treatment of patients with SCD in the ED is a useful method of not only ensuring rapid and adequate treatment but also decreasing use of health care resources.

Study objective This was a prospective, pre-post, 13-year observational study documenting the multiyear implementation of an observation unit sickle cell pathway for patients with uncomplicated vaso-occlusive events. Methods The sickle cell pathway begins with rapid triage to identify patients with uncomplicated vaso-occlusive events for immediate transfer to the observation unit and initiation of patient-controlled analgesia followed by repeated evaluations of pain and identification of other complications. Data were abstracted from the electronic medical record or observation unit database. The sickle cell pathway was initiated in April 2006. Major revisions of it were carried out in June 2009 (physician evaluation occurs in sickle cell pathway and only patient-controlled analgesia administration of medications) and October 2010 (multidisciplinary management and individual dosing). Results Annual ED visits ranged between 287 and 528. The preimplementation hospital admission rate was 33% (123/368), 3-day return rate 16% (60/368), and 30-day return rate 67% (248/368). Refinements to the sickle cell pathway have resulted in a decrease in admission rate to 20% (258/1276); 3-day return rate, to 3.6% (46/1,276); and 30-day return rate, to 41% (525/1,276) for the past 3 years. Conclusion The use of a sickle cell pathway for the treatment of uncomplicated vaso-occlusive events has been effective in providing rapid treatment and reducing hospital admissions. However, it was not only the intervention and its refinement that made the sickle cell pathway successful. With the Consolidated Framework for Implementation Research, it was discerned that outer setting factors of organizational commitment to the care of patients with SCD, inner setting factors of learning climate and leadership engagement, individuals, and process contributed to the success of the sickle cell pathway.

Background Studies have shown significant improvement in hepatocellular carcinoma (HCC) recurrence rates after liver transplantation since the united network of organ sharing (UNOS) implementation of a 6-month wait period prior to accrued exception model for end-stage liver disease (MELD) points enacted on October 8, 2015. However, few have examined the impact on HCC dropout rates for patients awaiting liver transplant. Our objective is to evaluate the outcomes of HCC dropout rates before and after the mandatory 6-month wait policy enacted. Methods We conducted a retrospective cohort study on adult patients added to the liver transplant wait list between January 1, 2012, and March 8, 2019 (n = 767). Information was obtained through electronic medical records and organ procurement and transplant network (OPTN) publicly available national data reports. Results In response to the 2015 UNOS-mandated 6-month wait time, dropout rates in the HCC patient population at our center increased from 12% pre-mandate to 20.8% post-mandate This increase was similarly reflected in the national dropout rate, which also increased from 26.3% pre-mandate to 29.0% post-mandate. Discussion From these changes, it is evident that the UNOS mandate achieved its goal of increasing equity of liver organ allocation, but HCC patients are nonetheless dropping off of the wait list at an increased rate and are therefore disadvantaged.

Introduction: There is concern about the initiation of opiates in healthcare settings due to the risk of future misuse. Although opiate medications have historically been at the core of prehospital pain management, several states are introducing non-opiate alternatives to prehospital care. Prior studies suggest that non-opiate analgesics are non-inferior to opiates for many acute complaints, yet there is little literature describing practice patterns of pain management in prehospital care. Our goal was to describe the practice patterns and attitudes of paramedics toward pain management after the introduction of non-opiates to a statewide protocol. Methods: This study was two-armed. The first arm employed a pre/post retrospective chart review model examining medication administrations reported to the Massachusetts Ambulance Trip Information System between January 1, 2017–December 31, 2018. We abstracted instances of opiate and non-opiate utilizations along with patients’ clinical course. The second arm consisted of a survey administered to paramedics one year after implementation of non-opiates in the state protocol, which used binary questions and Likert scales to describe beliefs pertaining to prehospital analgesia. Results: Pain medications were administered in 1.6% of emergency medical services incidents in 2017 and 1.7% of incidents in 2018. The rate of opiate analgesic use was reduced by 9.4% in 2018 compared to 2017 (90.6% vs 100.0%). The absolute reduction in opiate use in 2018 was 3.6%. Women were less likely (odds ratio [OR] = 0.78, 95% confidence interval [CI], 0.69–0.89) and trauma patients were more likely to receive opiates (OR = 2.36, CI, 1.96–2.84). Mean transport times were longer in opiate administration incidents (36.97 vs 29.35 minutes, t = 17.34, p

OBJECTIVES Postcardiac arrest care bundles following adult cardiac arrest are associated with improved survival to discharge. We aimed to evaluate whether a clinical pathway and computerized order entry were associated with improved pediatric postcardiac arrest care and discharge outcomes. DESIGN Single-center retrospective before-after study. SETTING Academic PICU. PATIENTS Patients who suffered an in- or out-of-hospital cardiac arrest from January 2008 to December 2015 cared for in the PICU within 12 hours of sustained return of circulation. INTERVENTION Deployment of a postcardiac arrest clinical pathway and computerized order entry system. MEASUREMENTS AND MAIN RESULTS There were 380 patients included-163 in the pre-pathway period and 217 in the post-pathway period. Primary outcome was percent adherence to pathway clinical goals at 0-6 and 6-24 hours post-return of circulation and to diagnostics (continuous electroencephalogram monitoring, head CT for out-of-hospital cardiac arrests, echocardiogram). Secondary outcomes included survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). The pre-pathway and post-pathway groups differed in their baseline Pediatric Cerebral Performance Category scores and the following causes of arrest: airway obstruction, arrhythmias, and electrolyte abnormalities. Pathway adherence was not significantly different between the pre-pathway and post-pathway groups, with the exception of higher rates of continuous electroencephalogram monitoring (45% vs 64%; p < 0.001). There was no difference in survival to hospital discharge between the two groups (56% vs 67%; adjusted odds ratio, 1.68; 95% CI, 0.95-2.84; p = 0.05). Survival to discharge was higher in the post-pathway group for the in-hospital cardiac arrest cohort (55% vs 76%; adjusted odds ratio, 3.06; 95% CI, 1.44-6.51; p < 0.01). There was no difference in favorable neurologic outcome between all patients (adjusted odds ratio, 1.21; 95% CI, 0.72-2.04) or among survivors (adjusted odds ratio, 0.72; 95% CI, 0.27-1.43). CONCLUSIONS After controlling for known potential confounders, the creation and deployment of a postcardiac arrest care pathway and computerized order entry set were not associated with improvement in pathway adherence or overall outcomes, but was associated with increased survival to hospital discharge for children with in-hospital cardiac arrests.

Idiopathic pulmonary fibrosis (IPF) is a fatal progressive disease with a median survival of 2–5 years. Nintedanib is a small tyrosine kinase inhibitor that reduces IPF progression, significantly slowing the annual decline in Forced Vital Capacity (FVC). Very little data is available on the molecular mechanisms of this treatment in IPF, despite a growing interest in the definition of IPF pathogenesis and target therapy. A functional proteomic approach was applied to the analysis of serum samples from IPF patients in order to highlight differential proteins potentially indicative of drug-induced molecular pathways modifications and response to therapy. Twelve serum samples were collected from six IPF patients in care at Siena Regional Referral Center for Interstitial Lung Diseases (ILDs) and treated with nintedanib for one year. Serum samples were analyzed at baseline (T0 before starting therapy) and after one year of treatment (T1) and underwent differential proteomic and bioinformatic analysis. Proteomic analysis revealed 13 protein species that were significantly increased after one year of treatment. When the targets of nintedanib (VEGFR, FGFR and PDGFR) were added, enrichment analysis extracted molecular pathways and process networks involved in cell differentiation (haptoglobin and albumin), coagulation (antithrombin III), epithelial mesenchymal transition, cell proliferation and transmigration. PI3K and MAPK induced up-regulation of apolipoprotein C3. Proteomic study found 13 protein species up-regulated in IPF patients after one year of nintedanib treatment. Haptoglobin, a central hub of our analysis was validated by 2D-WB and ELISA as theranostic marker in a more numerous populations of patients.

Objective: The aim of this study was to evaluate the feasibility and preliminary effects of a multicomponent intervention to decrease sedentary time during and shortly after hospitalization. Design: This is a quasi-experimental pilot study comparing outcomes in patients admitted before and after the implementation of the intervention. Setting: The study was conducted in a university hospital. Subjects: Participants were adult patients undergoing elective organ transplantation or vascular surgery. Interventions: In the control phase, patients received usual care, whereas in the intervention phase, patients also received a multicomponent intervention to decrease sedentary time. The intervention comprised eight elements: paper and digital information, an exercise movie, an activity planner, a pedometer and Fitbit Flex™, a personal activity coach and an individualized digital training program. Measures: Measures of feasiblity were the self-reported use of the intervention components (yes/no) and satisfaction (low–high = 0–10). Main outcome measure was the median % of sedentary time measured by an accelerometer worn during hospitalization and 7–14 days thereafter. Results: A total of 42 controls (mean age = 59 years, 62% male) and 52 intervention patients (58 years, 52%) were included. The exercise movie, paper information and Fitbit Flex were the three most frequently used components, with highest satisfaction scores for the fitbit, paper information, exercise movie and digital training. Median sedentary time decreased from 99.6% to 95.7% and 99.3% to 91.0% between Days 1 and 6 in patients admitted in the control and intervention phases, respectively. The difference at Day 6 reached statistical significance (difference = 41 min/day, P = 0.01). No differences were seen after discharge. Conclusion: Implementing a multicomponent intervention to reduce sedentary time appeared feasible and may be effective during but not directly after hospitalization.

AIM Insulin is the preferred treatment for the control of diabetes in hospital, but it raises the risk of hypoglycaemia, often because oral intake of carbohydrates in hospitalized persons is lower than planned. Our aim was to assess the effect on the incidence of hypoglycaemia of giving prandial insulin immediately after a meal depending on the amount of carbohydrate ingested. METHODS A prospective pre-post intervention study in hospitalized persons with diabetes eating meals with stable doses of carbohydrates present in a few fixed foods. Foods were easily identifiable on the tray and contained fixed doses of carbohydrates that were easily quantifiable by nurses as multiples of 10 g (a 'brick'). Prandial insulin was given immediately after meals in proportion to the amount of carbohydrates eaten. RESULTS In 83 of the first 100 people treated with the 'brick diet', the oral carbohydrate intake was lower than planned on at least one occasion (median: 3 times; Q1-Q3: 2-6 times) over a median of 5 days. Compared with the last 100 people treated with standard procedures, postprandial insulin given on the basis of ingested carbohydrate significantly reduced the incidence of hypoglycaemic events per day, from 0.11 ± 0.03 to 0.04 ± 0.02 (P

Introduction: Ventilator-associated pneumonia (VAP) is a nosocomial infection that develops 48 h after the initiation of mechanical ventilatory support. Current evidence-based guidelines demonstrate that VAP prevention is feasible through the implementation of certain VAP prevention bundle of interventions simultaneously. We aimed in this study to investigate the effect of VAP prevention pre- and post- implementation. Methods: This is a single-center, cohort study that took place at the Pediatric Intensive Care Unit (PICU) of King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia from January 2015 to March 2018 and assessed the rate of VAP before and after implementation of the bundle. Results: The study included 141 children, 95 were included from the pre-bundle group and 36 from the bundle group. VAP developed in 35% of the pre-bundle group compared to 31% of the bundle group (p = 0.651) with incidence rates equaled to 18 and 12 per 1000 ventilator days, respectively. Conclusion: This study found that VAP bundle did not significantly reduce VAP rate in the PICU. Further large prospective multi-center studies with longer intervention duration are indicated to investigate the benefits of using VAP prevention bundle. Keywords: Ventilator-associated pneumonia, VAP, VAP Bundle, PICU

Background: Physician-led smoking cessation services are suboptimal in Nigeria. Objectives: This study evaluated a text messaging intervention designed to increase the knowledge and practices of physicians in Nigeria to help smokers quit. Methods: Using a pre-post study design, all physicians ( N = 946) in 3 tertiary care hospitals located in 3 geopolitical zones in Nigeria were sent 2–3 text messages weekly over a 13-week period to create awareness and improve cessation practices using the “Ask, Advise and Refer” (AAR) model. The primary outcomes were the awareness of AAR and the proportion of physicians who offered each of the components of the brief intervention (AAR) to at least half of eligible patients. Secondary outcomes included the attitudes and self-reported effects of the messages on motivation to offer AAR to patients who smoke. Results: Of the 946 eligible respondents, only 165 responded to both the before and after intervention surveys (17.4% participation rate). Participants were more likely to indicate awareness of the AAR approach after the intervention (60%) than before (21.2%). Overall, physicians’ practice of each component of the AAR changed significantly after the intervention ( P Conclusions: A brief and low-cost text messaging intervention to physicians increased the awareness and practice of AAR in those who participated in the study. However, the relatively low participation rate highlights the importance of new research to improve and expand text messaging as an intervention among physicians to help them foster tobacco treatment among their patients.

Purpose The aim of this study was to explore the effects of an enteral nutrition (EN) feeding protocol in critically ill patients. Methods This was a prospective multi-center before-after study. We compared energy related and prognostic indicators between the control group (pre-implementation stage) and intervention group (post-implementation stage). The primary endpoint was the percentage of patients receiving EN within 7 days after ICU admission. Results 209 patients in the control group and 230 patients in the intervention group were enrolled. The implementation of the EN protocol increased the percentage of target energy reached from day 3 to day 7, and the difference between two groups reached statistical significance in day 6 (P = .01) and day 7 (P = .002). But it had no effects on proportion of patient receiving EN (P = .65) and start time of EN (P = .90). The protocol application might be associated with better hospital survival (89.1% vs 82.8%, P = .055) and reduce the incidence of EN related adverse (P = .004). There was no difference in ICU length of stay, duration of mechanical ventilation and ICU cost. Conclusion The implementation of the enteral feeding protocol is associated with improved energy intake and a decreased incidence of enteral nutrition related adverse events for critically ill patients, but it had no statistically beneficial effects on reducing the hospital mortality rate. Trial registration ClinicalTrials.gov , NCT02976155 . Registered November 29, 2016- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02976155 .

Objective To compare a multidimensional care package for pre‐eclampsia/eclampsia in Central American health facilities, before and after implementation of the Salud Mesoamérica Initiative. Methods An evaluation study was conducted at 67 basic‐ and comprehensive‐level health facilities serving the poorest areas in Honduras, Nicaragua, and Belize. Cases of severe pre‐eclampsia or eclampsia were randomly sampled and relevant quality of care data extracted from medical records at baseline (n=111) from January 1, 2011, to March 31, 2013, and at second‐phase follow‐up (n=249) from June 1, 2015, to September 30, 2017. The primary outcome was evidence of the delivery of multidimensional care for the management of pre‐eclampsia/eclampsia. Results The care of 360 women with severe pre‐eclampsia or eclampsia was analyzed. Odds of multidimensional care for pre‐eclampsia management (P=0.271) increased (although not significantly) in the second‐phase follow‐up compared to baseline. Multidimensional care was significantly associated with training (P, Multidimensional care for pre‐eclampsia management increased across all facility types, participating countries, and severity of disease under the Salud Mesoamérica Initiative model in Central America.

Objectives: This work sought to identify and describe the theoretical foundations, components, duration, delivery mode, and results of the nursing interventions aimed at persons with venous ulcers as available in the literature. Materials and method: Integrative review between 2000 and 2018 in the Pubmed, Ovidnursing, and EBSCOhost electronic databases. Results: This review includes 16 articles. Most of the interventions were of educational nature; three were developed in the community (through the Leg Club model) and the other ones were delivered by a nursing professional, face to face. The minimum time of duration for these was eight weeks, with telephone follow up. The most-common result variables were venous ulcer healing and reduction of the wound area. Conclusions: Diversity existed in relation with the components of the interventions and the results expected. Report of the interventions must be reinforced, along with the use of nursing theories that support their design. RESUMEN Objetivos: identificar y describir los fundamentos teóricos, los componentes, la duración, el modo de entrega y los resultados de las intervenciones de enfermería dirigidas a personas con úlceras venosas disponibles en la literatura. Materiales y método: revisión integrativa entre los años 2000 y 2018 en las bases de datos electrónicas Pubmed, Ovidnursing y EBSCOhost. Resultados: esta revisión incluye dieciséis artículos. En su mayoría, las intervenciones fueron de carácter educativo, tres se desarrollaron en la comunidad (bajo el modelo Leg Club) y el resto de intervenciones fueron entregadas personalmente, cara a cara, por una enfermera profesional. El tiempo mínimo de duración de aquellas fue de ocho semanas, con seguimientos telefónicos. Las variables de resultados más comunes fueron la cicatrización de la úlcera venosa y la reducción del área de la herida. Conclusiones: hubo diversidad en relación con los componentes de las intervenciones y los resultados esperados. Se debe reforzar el reporte de las intervenciones y el uso de teorías de enfermería que respalden su diseño. RESUMO Objetivos: identificar e descrever os fundamentos teóricos, os componentes, a duração, o modo de entrega e os resultados das intervenções de Enfermagem dirigidas a pessoas com úlceras varicosas disponíveis na literatura. Materiais e método: revisão integrativa entre 2000 e 2018 nas bases de dados eletrônicas PubMed, Ovidnursing e EBSCOhost. Resultados: esta revisão inclui 16 artigos. Em sua maioria, as intervenções foram de caráter educativo; três foram desenvolvidas na comunidade (com o modelo Leg Club) e o restante foi entregue pessoalmente por uma enfermeira profissional. O tempo mínimo de duração foi de oito semanas, com seguimento telefônico. As variáveis de resultados mais comuns foram a cicatrização da úlcera varicosa e a redução da área da ferida. Conclusões: houve diversidade quanto aos componentes das intervenções e dos resultados esperados. Deve-se salientar o relato das intervenções e o uso de teorias de Enfermagem que apoiem seu desenho.

PURPOSE Online programs may help to engage patients in advance care planning in outpatient settings. We sought to implement an online advance care planning program, PREPARE (Prepare for Your Care; http://www.prepareforyourcare.org), at home and evaluate the changes in advance care planning engagement among patients attending outpatient clinics. METHODS We undertook a prospective before-and-after study in 15 primary care clinics and 2 outpatient cancer centers in Canada. Patients were aged 50 years or older (primary care) or 18 years or older (cancer care) and free of cognitive impairment. They used the PREPARE website over 6 weeks, with reminders sent at 2 or 4 weeks. We used the 55-item Advance Care Planning Engagement Survey, which measures behavior change processes (knowledge, contemplation, self-efficacy, readiness) on 5-point scales and actions relating to substitute decision makers, quality of life, flexibility for the decision maker, and asking doctors questions on an overall scale from 0 to 21; higher scores indicate greater engagement. RESULTS In total, 315 patients were screened and 172 enrolled, of whom 75% completed the study (mean age = 65.6 years, 51% female, 35% had cancer). The mean behavior change process score was 2.9 (SD 0.8) at baseline and 3.5 (SD 0.8) at follow-up (mean change = 0.6; 95% CI, 0.49-0.73); the mean action measure score was 4.0 (SD 4.9) at baseline and 5.2 (SD 5.4) at follow-up (mean change = 1.2; 95% CI, 0.54-1.77). The effect size was moderate (0.75) for the former and small (0.23) for the latter. Findings were similar in both primary care and cancer care populations. CONCLUSIONS Implementation of the online PREPARE program in primary care and cancer care clinics increased advance care planning engagement among patients.

Background Sepsis is a medical emergency; timely management has been shown to reduce mortality. We aimed to improve the care of inpatients who developed sepsis after hospital admission by integrating a sepsis bundle with an existing medical emergency team (MET). Methods We performed a before-and-after study at an Australian institution. A multimodal intervention was implemented including formation of a working group, development of a guideline, standard documentation, education, audit and feedback. The primary outcome was the proportion of MET calls where there was compliance with the sepsis resuscitation bundle within one hour of MET call. Results There was an improvement in completion of the entire resuscitation bundle (OR 2.33, 95%, CI: 1.23 – 4.41) and lactate measurement (OR 2.72, CI: 1.53, 4.84) within one hour of MET call. There was a non-significant reduction in the median time to antibiotic administration in patients where antibiotics were initiated or changed at the MET call (60 mins vs. 44 mins, p=0.8). In hospital mortality was observed to fall from 22.1% to 11.4%, but after adjusting for age and baseline illness severity this differences was not statistically significant (OR 0.52, CI: 0.23, 1.19, p=0.12). Conclusion The implementation of a multimodal sepsis bundle and the utilisation of an existing MET call system demonstrated an increase in the overall uptake of a sepsis bundle. This was associated with an observed reduction in all-cause in-hospital mortality, although this difference was not statistically significant after adjustment for confounders. Further interventions with a focus on nursing education and engagement may improve timely antibiotic administration.

This study evaluates the effectiveness of traditional Chinese opera on older adults with dementia; those who met the inclusion criteria were categorized into intervention (n = 21) and control (n = 22) groups. Traditional Chinese opera was organized for the intervention group for 12 weeks. The Mini-Mental State Examination (MMSE), the Chinese version of the neuropsychiatric inventory (CNPI), and Quality of Life in Alzheimer's disease (QOL-AD) assessed the effectiveness at the pre-test stage and after 6 and 12 weeks of the intervention, and generalized estimated equation was used for statistical analysis. Statistically significant (P 0.05) differences were observed between the intervention and control groups in terms of MMSE, CNPI, and QOL-AD. Traditional Chinese opera can potentially be an effective therapy for improving the cognitive function of older adults with dementia, reducing their behavioral and psychiatric symptoms and enhancing their quality of life.

WHAT IS KNOWN AND OBJECTIVE The incorrect or insufficient prophylaxis of postoperative nausea and vomiting (PONV) is common in practice. A clinical pharmacist-led guidance team (CPGT) was established and included in general surgery teams. OBJECTIVE This study aimed to evaluate the effects of the CPGT on the improvement of PONV and prophylaxis administration. METHODS A prospective before-after study was conducted on 156 female patients undergoing abdominal surgery at a Chinese tertiary teaching hospital from December 2016 to December 2017. A total of 82 patients were enrolled in the preintervention period, and 74 patients were included in the post-intervention period. The CPGT established the evidence-based criteria for prophylactic anti-emetic administration and conducted interventions, including a review of medical records, provision of feedback, educational outreach, and dedicated support. Primary outcomes included the incidence of PONV within 24 hours of surgery, administered number of prophylactic anti-emetics, and accuracy of the timing for prophylactic anti-emetics. Outcomes were analysed by logistic regression or multivariable linear regression. RESULTS AND DISCUSSION After intervention, patients reported significantly less PONV (33.78% vs 56.10%; odds ratio [OR]: 0.29; numbers needed to treat [NNT]: 3.47), vomiting (29.73% vs 45.12%; OR: 0.42; NNT: 5.16) and nausea (31.08% vs 56.10%; OR: 0.24; NNT: 3.19) within 24 hours of surgery. The accuracy of the timing for prophylactic anti-emetics significantly increased (OR: 3.66; P: .003). Anaesthesiologists administered increased numbers of prophylactic anti-emetics (OR: 5.82; P

Background: The U.S. Centers for Disease Control and Prevention recommend bathing prior to surgery, surgical skin antisepsis, peri-operative antibiotic administration, normothermia throughout the p...

Aim: Direct medical control using video conferencing capabilities of smartphones has never been conducted in out-of-hospital cardiac arrest patients. This study was conducted to investigate the feasibility and treatment effectiveness of real-time smartphone video conferencing calls for the management of out-of-hospital cardiac arrest. Methods: This study was a pre–post-intervention prospective cohort study conducted from January 2013 to July 2015. The intervention was pre-hospital advanced life support under a physician’s direction using a smartphone video call. Results: In total, 942 cardiac arrests occurred over the 2-year period; 308 patients were excluded, and 314 (49.5%) and 320 (50.5%) cardiac arrest patients were enrolled during the pre- and post-intervention study periods, respectively. There were 248/320 (77.5%) cases of smartphone video-assisted advanced life support during the post-intervention period. For patients in the pre- and post-intervention groups, the pre-hospital return of spontaneous circulation was 6.7 and 20%, respectively (adjusted odds ratio 3.3, 95% confidence interval 1.6–6.8, P < 0.01), and favourable neurological outcomes were ascertained in 1.9 and 6.9%, respectively (adjusted odds ratio 23.6, 95% confidence interval 3.4–164.0, P < 0.01). The smartphone voice and video quality were rated 8.5 and 8.2 out of 10, respectively, in physician evaluation, while the overall utility was rated 9.1. Conclusion: We concluded that a multidisciplinary approach including the re-education of basic life support, simulation training for advanced life support, real-time medical direction via video call, and dispatching two teams rather than one team improved the outcome of out-of-hospital cardiac arrest.

OBJECTIVES Rotavirus vaccination has 87% to 100% effectiveness against severe rotavirus acute gastroenteritis (AGE) in healthy infants in high-income countries. Little is known whether infants with medical risk conditions (MRCs) are equally protected and if the vaccine is equally well tolerated. We conducted a quasi-experimental prospective multicenter before-after cohort study to assess the vaccine effectiveness (VE) and safety profile of the human rotavirus vaccine (HRV) among MRC infants that required prolonged or frequent postnatal care. METHODS The Netherlands has no national rotavirus immunization program, but HRV was implemented in routine care for MRC infants in 13 Dutch hospitals. Participants in the before and after cohort, HRV unvaccinated and vaccinated, respectively, were followed for occurrence of (rotavirus) AGE. VE of at least 1 dose was estimated by using time-to-event analysis for severe rotavirus AGE. Vaccine-related serious adverse event (AEs) after HRV were retrieved systematically from medical charts. Solicited AEs after vaccinations were prospectively collected and compared between vaccination time points with or without HRV. RESULTS In total, 1482 high-risk infants with MRC were enrolled, including 631 in the before and 851 in the after cohorts; 1302 infants were premature (88.3%), 447 were small for gestational age (30.2%), and 251 had at least 1 congenital disorder (17.0%). VE against severe rotavirus AGE was 30% (95% confidence interval [CI]: −36% to 65%). Overall, the observed number of rotavirus hospitalizations was low and not significantly different between the cohorts (2 and 2, respectively). The rate of vaccine-related serious AE was 0.24 per 100 vaccine doses. The adjusted risk ratio for any AE after HRV vaccination compared with other routine vaccinations was 1.09 (95% CI: 1.05 to 1.12) for concomitant administration and 0.91 (95% CI: 0.81 to 0.99) for single HRV administration. Gastrointestinal AEs were 10% more frequent after HRV. CONCLUSIONS In contrast to previous findings among healthy term infants, in routine use, HRV offered limited protection to vulnerable medical risk infants. HRV is generally well tolerated in this group in single administration, but when coadministered with routine vaccines, it is associated with higher risk of (mostly gastrointestinal) AE. Our study highlights the importance of studying vaccine performance in subgroups of medically vulnerable infants.

Australia has one of the highest prevalences of obesity in the developed world with recognised gaps in patient access to obesity services. This non-randomised before and after study investigated the health benefits and patient acceptability of integrating the Get Healthy Service, a state-funded telephone-delivered coaching service in Australia, as an adjunct to multidisciplinary care for adults attending a public obesity service. Forty-one participants received multidisciplinary care alone while 39 participants were subsequently allocated to receive adjunctive treatment with the Get Healthy Service. Weight, body mass index, glycosylated haemoglobin, measurement of hepatic steatosis and liver enzymes were collected at baseline and 6 months. Participant evaluation was obtained post intervention. Statistically significant reductions from baseline were achieved for both control and intervention with respect to weight (−6.7 ± 2.2 kg, p = 0.01, −12.6 ± 3.2, p = 0.002), body mass index (−2.3 ± 0.8, p = 0.01, −4.8 ± 1.2 kg/m2, p = 0.002) and glycosylated haemoglobin (−0.2 ± 0.2%, p = 0.2 (NS), −0.7 ± 0.2%, p = 0.02), respectively. There were no significant differences in steatosis or liver enzymes or in outcomes between control and intervention cohorts. A high level of patient acceptability was reported. Integrating telephone-delivered coaching provided non-inferior care and high levels of patient satisfaction. Telephone coaching aligned with the principles of an obesity service should be trialled to improve patient access to obesity interventions.

Non-Pharmaceutical Public Health Interventions (NPHIs) have been used by different countries to control the spread of the COVID-19. Despite available evidence regarding the effectiveness of NPHSs, there is still no consensus about how policymakers can trust these results. Studies on the effectiveness of NPHSs are single studies conducted in specific communities. Therefore, they cannot individually prove if these interventions have been effective in reducing the spread of the infection and its adverse health outcomes. In this systematic review, we aimed to examine the effects of NPHIs on the COVID-19 case growth rate, death growth rate, Intensive Care Unit (ICU) admission, and reproduction number in countries, where NPHIs have been implemented. We searched relevant electronic databases, including Medline (via PubMed), Scopus, CINAHL, Web of Science, etc. from late December 2019 to February 1, 2021. The key terms were primarily drawn from Medical Subject Heading (MeSh and Emtree), literature review, and opinions of experts. Peer-reviewed quasi-experimental studies were included in the review. The PROSPERO registration number is CRD42020186855. Interventions were NPHIs categorized as lockdown, stay-at-home orders, social distancing, and other interventions (mask-wearing, contact tracing, and school closure). We used PRISMA 2020 guidance for abstracting the data and used Cochrane Effective Practice and Organization of Practice (EPOC) Risk of Bias Tool for quality appraisal of the studies. Hartung-Knapp-Sidik-Jonkman random-effects model was performed. Main outcomes included COVID-19 case growth rate (percentage daily changes), COVID-19 mortality growth rate (percentage daily changes), COVID-19 ICU admission (percentage daily changes), and COVID-19 reproduction number changes. Our search strategies in major databases yielded 12,523 results, which decreased to 7,540 articles after eliminating duplicates. Finally, 35 articles qualified to be included in the systematic review among which 23 studies were included in the meta-analysis. Although studies were from both low-income and high-income countries, the majority of them were from the United States (13 studies) and China (five studies). Results of the meta-analysis showed that adoption of NPHIs has resulted in a 4.68% (95% CI, -6.94 to -2.78) decrease in daily case growth rates, 4.8% (95 CI, -8.34 to -1.40) decrease in daily death growth rates, 1.90 (95% CI, -2.23 to -1.58) decrease in the COVID-19 reproduction number, and 16.5% (95% CI, -19.68 to -13.32) decrease in COVID-19 daily ICU admission. A few studies showed that, early enforcement of lockdown, when the incidence rate is not high, contributed to a shorter duration of lockdown and a lower increase of the case growth rate in the post-lockdown era. The majority of NPHIs had positive effects on restraining the COVID-19 spread. With the problems that remain regarding universal access to vaccines and their effectiveness and considering the drastic impact of the nationwide lockdown and other harsh restrictions on the economy and people’s life, such interventions should be mitigated by adopting other NPHIs such as mass mask-wearing, patient/suspected case isolation strategies, and contact tracing. Studies need to address the impact of NPHIs on the population’s other health problems than COVID-19.

Objective: To evaluate the effect of training on intravenous medication administration in pediatric patients on nursing staff ’s learning and response. Method: This is a quasi-experimental study (pre- and post-test), with 38 nursing professionals who participated in training on administration of intravenous (IV) medication in pediatric patients with heart disease. For data collection, a questionnaire with 19 items was applied to evaluate participants’ learning before (pre-test) and after (post-test) training. Data were analyzed by descriptive and analytical statistics (binomial and Friedman tests). Results: Nurses predominated (52.6%), mean age 41.2 years and 9.8 years of professional experience in pediatrics. For learning evaluation, there was an increase in the rate of hits from the pre-test to the post-test in 13 items, with a significant difference (p < 0.05) in the items: removing adornments to sanitize hands; wearing gloves when administering medication; administering medication with gloves, mask and goggles; and checking patient name by asking their companion. Conclusion: Training had positive effects on nursing professionals’ learning and reaction. RESUMEN Objetivo: Evaluar el efecto del entrenamiento sobre la administración de fármacos intravenosos en pacientes pediátricos sobre el aprendizaje y la reacción del equipo de enfermería. Método: Estudio cuasiexperimental (pre-y post-test), con 38 profesionales de enfermería que participaron en la formación sobre la administración de medicación intravenosa (IV) en pacientes pediátricos con cardiopatías. Para la recolección de datos, se aplicó un cuestionario con 19 ítems para evaluar el aprendizaje de los participantes antes (pre-test) y después (post-test) del entrenamiento. Los datos fueron analizados mediante estadística descriptiva y analítica (pruebas binomial y Friedman). Resultados: Hubo predominio de enfermeras (52,6%), edad media 41,2 años y 9,8 años de experiencia profesional en pediatría. En la evaluación de aprendizajes, hubo un aumento en la tasa de aciertos del pre-test al post-test en 13 ítems, con una diferencia significativa (p < 0.05) en los ítems: quitar los adornos para desinfectar las manos; usar guantes al administrar medicamentos; administrar medicamentos con guantes, mascarilla y anteojos; y comprobar el nombre del paciente preguntándole a su acompañante. Conclusión: La formación tuvo efectos positivos en el aprendizaje y la reacción de los profesionales de enfermería. RESUMO Objetivo: Avaliar o efeito de um treinamento sobre administração de medicamento endovenoso em pacientes pediátricos na aprendizagem e reação da equipe de enfermagem. Método: Estudo quase experimental (pré-e pós-teste), com 38 profissionais da enfermagem que participaram de um treinamento sobre administração de medicamento endovenoso (EV) em pacientes pediátricos cardiopatas. Para coleta de dados, aplicou-se um questionário com 19 itens para avaliar a aprendizagem dos participantes antes (pré-teste) e após (pós-teste) o treinamento. Analisaram-se os dados por estatística descritiva e analítica (testes binomial e Friedman). Resultados: Predominaram enfermeiras (52,6%), média de 41,2 anos de idade e 9,8 anos de experiência profissional na pediatria. Na avaliação da aprendizagem, houve aumento no índice de acertos do pré-teste para o pós-teste em 13 itens, com diferença significativa (p < 0,05) nos quesitos: retirar adornos para higienizar as mãos; usar luva ao administrar medicamento; administrar medicamento com luva, máscara e óculos de proteção; e conferir nome do paciente perguntando a ele ou ao acompanhante. Conclusão: O treinamento apresentou efeitos positivos na aprendizagem e reação dos profissionais de enfermagem.

IntroductionAntimicrobial resistance (AMR) is increasing in low resource settings. It complicates the management of infectious diseases and is an increasing cause of death. This is due to, among other things, lack of health resources for appropriate diagnosis and unregulated access to antimicrobials in the public sphere. Developing context-specific interventions that enable judicious use of antimicrobials is important to curb this problem.MethodsWe will conduct a systematic review of antimicrobial stewardship (AMS) approaches in Development Assistance Committee in least developed and low-income countries. The inclusion criteria are antimicrobial stewardship interventions in hospitalised patients of all age groups and exclusion criteria are community-based trials and studies that solely focus on viral, fungal or parasite infections. Antimicrobial stewardship interventions will be classified as structural, enabling, persuasive, restrictive or combined. Outcomes of included studies will be classified as clinical, microbiological or behavioural outcomes. The studies to be included will be randomised controlled trials, controlled before–after studies, interrupted time series trials, cohort and qualitative studies. Data will be extracted using forms adapted from the Cochrane collaboration data collection form. This systematic review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and risk of bias will be done according to the Integrated quality Criteria for Review of Multiple Study Designs.Ethics and disseminationOur findings will be presented to clinicians and policymakers, to support developing AMS protocols for low resource settings. We will publish our results in peer-reviewed journals.Trial registration numberCRD42020210634.

Background Ministries of health, donors, and other decision‐makers are exploring how they can use mobile technologies to acquire accurate and timely statistics on births and deaths. These stakeholders have called for evidence‐based guidance on this topic. This review was carried out to support World Health Organization (WHO) recommendations on digital interventions for health system strengthening. Objectives Primary objective: To assess the effects of birth notification and death notification via a mobile device, compared to standard practice. Secondary objectives: To describe the range of strategies used to implement birth and death notification via mobile devices and identify factors influencing the implementation of birth and death notification via mobile devices. Search methods We searched CENTRAL, MEDLINE, Embase, the Global Health Library, and POPLINE (August 2, 2019). We searched two trial registries (August 2, 2019). We also searched Epistemonikos for related systematic reviews and potentially eligible primary studies (August 27, 2019). We conducted a grey literature search using mHealthevidence.org (August 15, 2017) and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies in Web of Science and Google Scholar (May 15, 2020). We searched for studies published after 2000 in any language. Selection criteria For the primary objective, we included individual and cluster‐randomised trials; cross‐over and stepped‐wedge study designs; controlled before‐after studies, provided they have at least two intervention sites and two control sites; and interrupted time series studies. For the secondary objectives, we included any study design, either quantitative, qualitative, or descriptive, that aimed to describe current strategies for birth and death notification via mobile devices; or to explore factors that influence the implementation of these strategies, including studies of acceptability or feasibility. For the primary objective, we included studies that compared birth and death notification via mobile devices with standard practice. For the secondary objectives, we included studies of birth and death notification via mobile device as long as we could extract data relevant to our secondary objectives. We included studies of all cadres of healthcare providers, including lay health workers; administrative, managerial, and supervisory staff; focal individuals at the village or community level; children whose births were being notified and their parents/caregivers; and individuals whose deaths were being notified and their relatives/caregivers. Data collection and analysis For the primary objective, two authors independently screened all records, extracted data from the included studies and assessed risk of bias. For the analyses of the primary objective, we reported means and proportions, where appropriate. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a 'Summary of Findings' table. For the secondary objectives, two authors screened all records, one author extracted data from the included studies and assessed methodological limitations using the WEIRD tool and a second author checked the data and assessments. We carried out a framework analysis using the Supporting the Use of Research Evidence (SURE) framework to identify themes in the data. We used the GRADE‐CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in the evidence and we prepared a 'Summary of Qualitative Findings' table. Main results For the primary objective, we included one study, which used a controlled before‐after study design. The study was conducted in Lao People’s Democratic Republic and assessed the effect of using mobile devices for birth notification on outcomes related to coverage and timeliness of Hepatitis B vaccination. However, we are uncertain of the effect of this approach on these outcomes because the certainty of this evidence was assessed as very low. The included study did not assess resource use or unintended consequences. For the primary objective, we did not identify any studies using mobile devices for death notification. For the secondary objective, we included 21 studies. All studies were conducted in low‐ or middle‐income settings. They focussed on identification of births and deaths in rural, remote, or marginalised populations who are typically under‐represented in civil registration processes or traditionally seen as having poor access to health services. The review identified several factors that could influence the implementation of birth‐death notification via mobile device. These factors were tied to the health system, the person responsible for notifying, the community and families; and include: ‐ Geographic barriers that could prevent people’s access to birth‐death notification and post‐notification services ‐ Access to health workers and other notifiers with enough training, supervision, support, and incentives ‐ Monitoring systems that ensure the quality and timeliness of the birth and death data ‐ Legal frameworks that allow births and deaths to be notified by mobile device and by different types of notifiers ‐ Community awareness of the need to register births and deaths ‐ Socio‐cultural norms around birth and death ‐ Government commitment ‐ Cost to the system, to health workers and to families ‐ Access to electricity and network connectivity, and compatibility with existing systems ‐ Systems that protect data confidentiality We have low to moderate confidence in these findings. This was mainly because of concerns about methodological limitations and data adequacy. Authors' conclusions We need more, well‐designed studies of the effect of birth and death notification via mobile devices and on factors that may influence its implementation., Plain language summary Birth and death notification via mobile devices: a mixed methods review What is the aim of this review? In this Cochrane Review, we aimed to assess the effect of using mobile devices to notify births and deaths. We also aimed to describe how these mobile solutions are being used in practice and the factors that influence their use. We collected and analysed all relevant studies to answer these questions. Key messages We know very little about the effects of using mobile devices to notify births and deaths. Factors that can influence the implementation of this approach include factors tied to the health system and the notification system, the person responsible for notifying, the community, and the families involved. What was studied in the review? By registering notified births and deaths, governments can track the health of their population, identify needs and problems, and design better services. In many countries, births and deaths are not properly registered. Sometimes this is because government systems are poorly designed to facilitate registration, government workers do not have proper training, people live far from government services, or are not aware of the need to register births or deaths. In many cases, registration is affected by delays in or lack of birth or death notification. Governments are starting to use mobile devices such as mobile phones to reduce problems with birth or death notification. In some settings, members of the public, healthcare workers and others use mobile phones to notify a birth or death to the health system or to a central registration system. The main aim of our review was to assess what happens when people use mobile devices to notify births and deaths, compared to other systems or no systems at all. For instance, do they register more birth and deaths, and do they do this at the right time? And does this lead more babies and children to use or receive health services, such as immunisation? We also wanted to find out how people are using these mobile systems in practice and what influences their use. What are the main results of the review? We found 21 relevant studies. All of the studies were from low‐ or middle‐income countries. Most of these studies focussed on the notification of births and deaths in rural, remote, or marginalised populations who are often under‐represented in birth or death registration processes or have poor access to health services. Only one of the studies assessed the effect of using mobile devices for notification systems. This study focussed on birth notification. We did not find any studies that assessed the effect of using mobile devices for death notification. We are uncertain of the effect of this approach on the number of births and deaths that are properly notified because the certainty of this evidence was assessed as very low. The other studies had information about how people use the mobile device‐based birth and death notification systems in practice. These studies pointed to several factors that could influence the implementation of birth‐death notification via mobile devices. These factors were tied to the health system and the notification system, the person responsible for notifying, the community, and the families involved. They include: ‐ Geographic barriers that could prevent people’s access to birth‐death notification and post‐notification services ‐ Access to health workers and other notifiers with enough training, supervision, support, and incentives ‐ Monitoring systems that ensure the quality and timeliness of the birth and death data ‐ Legal frameworks that allow births and deaths to be notified by mobile device and by different types of notifiers ‐ Community awareness of the need to register births and deaths ‐ Socio‐cultural norms around birth and death ‐ Government commitment ‐ Cost to the system, to health workers and to families ‐ Access to electricity and network connectivity, and compatibility with existing systems ‐ Systems that protect data confidentiality We have low to moderate confidence in these findings. This was mainly because of the ways in which the studies were designed and small amounts of data. How up‐to‐date is this review? We searched for studies that had been published up to August 2, 2019.

Objective: To evaluate the impact of cone-beam computed tomography (CBCT) in endodontic therapeutic decision-making of immature traumatized teeth with suspected pulp necrosis. Methods: Over two years, consecutive patients with a dental trauma in their front teeth (apex >0.5 mm) and with suspected pulp necrosis based on clinical and radiographic findings were referred to a specialist clinic in Sweden. Fifteen patients aged 6–13 (18 teeth) were included and clinically examined by an endodontist. Intraoral radiographs and CBCT examinations were obtained. Five practitioners, three endodontists and two residents in endodontics, used these examinations to determine the most appropriate treatment for the 18 cases (all central incisors) on two occasions scheduled 19 weeks apart. On the first occasion, the practitioners had access to clinical information and the intraoral radiographs (‘before’ CBCT); on the second occasion, the practitioners had also access to a radiologist report and the CBCT images (‘after’ CBCT). Their treatment plans – no treatment, watchful waiting, endodontic orthograde treatment, or extraction – were made anonymously and independently. Results were analysed using descriptive statistics and Wilcoxon signed-rank test. Results: ‘After’ CBCT, practitioners changed treatment plans in 30% of the 90 assessments, 74% of which were more aggressive (p = 0.028). In 49% of the assessments, practitioners who chose the watchful and waiting treatment plan ‘before’ CBCT changed to a more aggressive therapy such as endodontic orthograde treatment and extraction ‘after’ CBCT (p = 0.005). Conclusion: This study provides evidence that CBCT influences endodontic therapeutic decision-making regarding immature traumatised teeth with suspected pulp necrosis, chiefly when expectant management (i.e., watchful and waiting) was selected before access to CBCT.