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Total Joint Implant Alloy Oxide Layer Cell-Induced Damage
Get PDFCobalt-Chromium alloy is commonly used in total joint arthroplasty (TJA). Several studies have investigated evidence of inflammatory-cell-induced-corrosion (ICIC) causing pitting in TJA retrieved implants. Others have determined that placing orthopedic alloys into lower pH solutions will increase the rate of corrosion. We have determined that electrochemical potential and corrosion rates of human knee synovial fluid show a variation greater than an order of magnitude. This means there is going to be a significant variation between a patient’s local environment of the TJA implant and may affect how macrophages interact with alloy oxide layers. Knee disability can be quantified by using the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOSJR). In order to determine predictive measures of patient outcomes, we plan to measure the electrochemical properties of patient implants and associate them with these KOOSJR scores. In addition, we plan to further investigate the effects and extent of macrophage-mediated damage to alloys when under inflammatory conditions. The current results are inconclusive, but suggest that there is a relationship between these parameters and patient outcomes and encourage further investigation of the mechanisms at play
Efficacy of Various Interventions for Achieving Target HbA1C Levels for Patients with Type II Diabetes Mellitus and on Exogenous Insulin
Get PDFObjective: To learn the rates at which patients at UT Family Medicine–St. Francis (UTFM–SF) with type II diabetes mellitus are being prescribed recommended medications—namely metformin, sodium-glucose cotransporter 2 (SGLT2) inhibitors, and glucagon-like peptide 1 receptor agonists (GLP1RAs)—whether these rates correspond to the severity of hyperglycemia (as indicated by HbA1C level). A secondary goal of the study was to investigate if HbA1C levels are being checked at recommended intervals.
Methods: A retrospective chart review was conducted using records of patients seen at the clinic in the previous four years between the ages of 18 and 65 who had visits with ICD 10 codes for type II diabetes mellitus (E11) and long term insulin use (Z79.4). Patients with an HbA1C result from January 1, 2018 or later and a chart history of an insulin prescription were selected for further analysis.
Results: 234 patients met the search criteria and were divided into three groups based on an average of the three most recent HbA1C labs: Below the American Diabetes Association (ADA) recommended HbA1C of 7% (n=40), between 7% and the insurance quality metric goal of 9% (n=66), and above 9% (n=128). A chi-square test revealed there was no significant association between HbA1C group and the rate of prescription of metformin (2-sided, p=.631), SGLT2 inhibitors (P=.221), or GLP1RAs (P=.223); a chi-square test also showed there was no association between group and the number of medications prescribed (P=.236). A one-way ANOVA revealed no statistically significant differences between group with regards to frequency of HbA1C checks (P=.295).
Conclusion: Patients at UTFM–SF with lower levels of glycemic control are not receiving significantly different treatment from patients who demonstrate better glycemic control—they are not being prescribed recommended medication classes at a different rate, they are not having medications combined at a different rate, and their HbA1Cs are not being monitored differently. Increased utilization of metformin, SGLT2 inhibitors, and GLP1Ras, as well as quarterly HbA1C checks, are necessary to bring diabetic care at UTFM–SF more in line with ADA recommendations
Inflammatory Response Following Hemorrhagic Stroke: The Role of Cytokines
Get PDFHemorrhagic stroke is a dangerous form of stroke resulting from the rupturing of weakened blood vessels, releasing blood that increases intracranial pressure and causes the death of surrounding tissue. Treatment options are improving but remain limited, as evidenced by this condition being characterized by high rates of mortality as well as long-term morbidity. Unregulated inflammatory responses that occur following injury may be partially to blame for these poor outcomes. In response to any injury, the immune system releases cytokines to recruit immune cell activation and promote inflammation. But after hemorrhagic stroke, whether aneurysmal subarachnoid hemorrhage (aSAH) or intracerebral hemorrhage (ICH), the rapid increase in inflammation and an imbalance of inflammatory cytokines can lead to the development of secondary ischemic injury. Several animal models have been developed to investigate these forms of stroke, and despite their shortcomings, these models have been crudely applied for the study of neuroinflammation post-stroke. There is an imperative need to establish a clear and robust animal model that accurately represents the condition taking place in human patients. This dissertation work began with a systematic review of the literature to more clearly understand the work that has been done in this area. Next, the endovascular puncture model of aSAH was utilized in rats. Tissue samples were collected and compared to human blood and cerebrospinal fluid samples to assess for cytokine changes. Lastly, collagenase mouse models for ICH were utilized to understand the changes that take place in the TXNIP-NLRP3 inflammasome following stroke and the therapeutic effects of verapamil on inflammatory, functional, and behavioral outcomes. This dissertation work adds to the body of literature on the relationship between inflammation, cytokine release, and outcomes, which will ultimately allow for the development of improved treatment protocols
The Uncertainty and Psychological Health of Family Caregivers of Patients with Delirium in Intensive Care Units
Get PDFEach year, more than 5 million patients are admitted to an intensive care unit (ICU) in the United States, and up to 80 % of these patients develop delirium. Delirium is a common indicator of acute brain dysfunction in the ICU and a predictor of mortality, longer ICU/hospital stay, and long-term cognitive impairment. Family caregivers are a valuable resource in preventing, detecting, and managing delirium in the ICU. However, witnessing delirium episodes can generate adverse psychological symptoms in family caregivers that may compromise their health and well-being. Research in this area has demonstrated a gap in the literature regarding how ICU delirium impacts family caregivers’ psychological health. The development of these adverse psychological symptoms among family caregivers has contributed to the uncertainty of illness among patients with delirium. Therefore, this dissertation research aimed to understand the psychological impact on family caregivers of patients experiencing delirium in the ICU by exploring the concept of uncertainty and examining the relationship between uncertainty associated with ICU delirium and the psychological health outcomes of family caregivers. Three projects were conducted: an integrative review, a concept analysis, and a descriptive correlational study. The integrative review project revealed the most common adverse psychological outcomes experienced by family caregivers of patients with ICU delirium, such as distress, anxiety, depression, uncertainty, and family caregivers’ need for support based upon a lack of information on delirium. These findings indicate that these unmet needs contributed to the negative psychological symptoms of family caregivers, consequently explaining their experience of uncertainty. The next project, a concept analysis of the uncertainty, was conducted to identify the attributes, antecedents, and consequences of the family caregivers’ uncertainty regarding the patient’s illness. These findings led to an understanding of how uncertainty could impact family caregivers’ psychological health. Collectively, findings from the two projects provided a general knowledge of ICU delirium, uncertainty, and psychological distress that led to the third project. The third project, a descriptive correlational study, was conducted to examine whether ICU delirium’s uncertainty is associated with psychological distress among family caregivers. Findings from this study revealed significant associations between family caregivers’ uncertainty of ICU delirium and psychological distress. Understating the adverse impact of ICU delirium on family caregivers’ psychological health could further inform the development of nursing interventions to mitigate these adverse outcomes. Family caregivers are the backbone of continuous, in-home care. Thus, caring for the family caregivers’ health translates to caring for society as a whole
Reducing Stress, Anxiety, and Depression for NICU Parents
Get PDFThis project aims to appraise evidence of the effectiveness of various practices on reducing stress, anxiety, and depression among parents of infants in the neonatal intensive care unit (NICU). The project contains six research articles from both national and international journals. Study designs include one meta-analysis, one randomized controlled trial, one small scale randomized controlled trial, one prospective phase lag cohort study, on pretest-posttest study, and one mixed-methods pretest-posttest study. Recommendations for effective interventions were based on best evidence discovered through quality appraisal and study outcomes. All interventions, except for educational programs and Kangaroo Care, resulted in a statistically significant reduction of either stress, anxiety, and/ or depression. Family centered care and mindfulness-based intervention reduced all barriers of interest. There is strong and high-quality evidence for the effect of Cognitive Behavioral Therapy on depression, moderate evidence for the effect of activity-based group therapy on anxiety, and promising evidence for the effect of HUG Your Baby on stress
Effectiveness of EHR-Depression Screening Among Adult Diabetics in an Urban Primary Care Clinic
Get PDFBackground Diabetes mellitus (DM) and depression are important comorbid conditions that can lead to more serious health outcomes. The American Diabetes Association (ADA) supports routine screening for depression as part of standard diabetes management. The PHQ2 and PHQ9 questionnaires are good diagnostic screening tools used for major depressive disorders in Type 2 diabetes mellitus (DM2). This quality improvement study aims to compare the rate of depression screening, treatment, and referral to behavioral health in adult patients with DM2 pre and post-integration of depression screening tools into the electronic health record (EHR).
Methods We conducted a retrospective chart review on patients aged 18 years and above with a diagnosis of DM2 and no initial diagnosis of depression or other mental illnesses. Chart reviews included those from 2018 or prior for before integration data and 2020 to present for after integration. Sixty subjects were randomly selected from a pool of 33,695 patients in the clinic with DM2 from the year 2013-2021. Thirty of the patients were prior to the integration of depression screening tools PHQ2 and PHQ9 into the EHR, while the other half were post-integration. The study population ranged from 18-83 years old.
Results All subjects (100%) were screened using PHQ2 before integration and after integration. Twenty percent of patients screened had a positive PHQ2 among subjects before integration, while 10% had a positive PHQ2 after integration. Twenty percent of patients were screened with a PHQ9 pre-integration which accounted for 100% of those subjects with a positive PHQ2. However, of the 10% of patients with a positive PHQ2 post-integration, only 6.7 % of subjects were screened, which means not all patients with a positive PHQ2 were adequately screened post-integration. Interestingly, 10% of patients were treated with antidepressants before integration, while none were treated with medications in the post-integration group. There were no referrals made to the behavior team in either group.
Conclusion There is no difference between the prevalence of depression screening before or after integration of depression screening tools in the EHR. The study noted that there is a decrease in the treatment using antidepressants after integration. However, other undetermined conditions could have influenced this. Furthermore, not all patients with positive PHQ2 in the after-integration group were screened with PHQ9. The authors are unsure if the integration of the depression screens influenced this change. In both groups, there is no difference between referrals to the behavior team. Implications to Nursing Practice This quality improvement study shows that providers are good at screening their DM2 patients for depression whether the screening tools were incorporated in the EHR or not. However, future studies regarding providers, support staff, and patient convenience relating to accessibility and availability of the tool should be made. Additional issues to consider are documentation reliability, hours of work to scan documents in the chart, risk of documentation getting lost, and the use of paper that requires shredding to comply with privacy
Efficacy of Integrating CBT for Mental Health Care into Substance Abuse Treatment in Patients with Comorbid Disorders of Substance Abuse and Mental Illness
Get PDFAbstract: Multiple studies have found that psychiatric disorders, like mood disorders and substance use disorders, are highly comorbid among adults with either disorder. Integrated treatment refers to the treatment of two or more conditions and the use of multiple therapies such as the combination of psychotherapy and pharmacotherapy. Integrated therapy for comorbidity per numerous studies has consistently been superior to the treatment of individual disorders separately. The purpose of this QI project was to identify the effectiveness of Cognitive Behavioral Therapy (CBT) instead of current treatment as usual for treating Substance Use Disorder (SUD) or mental health diagnosis independently. It is a retrospective chart review. The review examines CBT\u27s efficacy for engaging individuals with co-occurring mood and substance use disorders in treatment by enhancing adherence and preventing disengagement and relapse.
Methods: Forty adults aged 26-55 with a DSM-IV diagnosis of a mood disorder of Major Depressive Disorder and/or anxiety and concurrent substance use disorder (at least weekly use in the past month). Participants received 12 sessions of individual integrated CBT treatment delivered with case management over a 12-week period.
Results: The intervention was associated with significant improvements in mood disorder, substance use, and coping skills at 4, 8, and 12 weeks post-treatment.
Conclusions: These results provide some evidence for the effectiveness of the integrated CBT intervention in individuals with co-occurring disorders. Of note, all psychotherapies are efficacious; however, it would be more advantageous to develop a standardized CBT that identifies variables that facilitate treatment outcomes specifically to comorbid disorders of substance use and mood disorders. It is concluded that there is potentially more to be gained from further studies using randomized controlled designs to determine its efficacy
Postoperative Nausea and Vomiting Implications in Neostigmine versus Sugammadex
Get PDFPurpose/Background: Postoperative nausea and vomiting (PONV) is a frequent complaint in the postoperative period, which can delay discharge, result in readmission, and increase cost for patients and facilities. Inducing paralysis is common in anesthesia, as is utilizing the drugs neostigmine and sugammadex as reversal agents for non-depolarizing neuromuscular blockers. Many studies are available that compare these two drugs to determine if neostigmine increases the risk of PONV over sugammadex. Sugammadex has a more favorable pharmacologic profile and may improve patient outcomes by reducing PONV.
Methods: This review included screening a total of 39 studies and peer-reviewed articles that looked at patients undergoing general anesthesia who received non-depolarizing neuromuscular blockers requiring either neostigmine or sugammadex for reversal, along with their respective PONV rates. 8 articles were included, while 31 articles were removed based on our exclusion criteria. These were published between 2014 and 2020 exclusively. The key words used were “neostigmine”, “sugammadex”, “PONV”, along with combinations “paralytic reversal agents and PONV”. This search was performed on the scholarly database MEDLINE. The data items were PONV rates in neostigmine group, PONV rates in sugammadex group, incidence of postoperative analgesic consumption in neostigmine group, and incidence of postoperative analgesic consumption in sugammadex group.
Results: Despite numerical differences being noted in the incidence of PONV with sugammadex over reversal with neostigmine, there did not appear to be any statistically significant data in the multiple peer-reviewed trials included in our review, for not one of the 8 studies concluded that there was a higher incidence of PONV in one drug or the other of an y clinical relevance. Although the side-effect profile tended to be better in the sugammadex group than neostigmine in areas other than PONV, there was not sufficient evidence to conclude that one drug was superior to the other in causing a direct reduction of PONV. Implications for Nursing Practice: There were variable but slight differences noted between both drug groups in PONV rates, but it remained that none of the studies determined it was statically significant or clinically conclusive. This review did, however, note other advantages to sugammadex over neostigmine, including its pharmacologic profile of more efficiently reversing non-depolarizing neuromuscular blocking drugs and its more favorable pharmacokinetics. This lack of statistically significant evidence found within these studies consequentially does not support pharmacologic decision-making of one drug in favor of the other for reducing PONV; therefore, PONV alone is not a sufficient rationale for a provider to justify using one reversal over another at the current time until further research proves otherwise
Taste Learning in Insular Cortex: Plasticity Is Influenced by Experience Type
Get PDFThe gustatory cortex (GC) has long been studied as the main cortical area encoding taste stimuli and likely integrates sensory, visceral, and emotional information to guide taste-related behaviors. However, our understanding of cortical taste coding on a single-cell level has only become clear in recent years. The anatomical location of GC on the lateral and ventral surface of the brain makes it difficult to target with traditional imaging methods. Thus, much of what we know about cortical taste coding and cortical taste plasticity has been derived either from multiunit electrode recordings or anesthetized imaging experiments, techniques which lack the ability to reliably track neurons over time.
To address this limitation, we use miniaturized microendoscope (miniscope) imaging of the calcium indicator GCaMP6s to investigate how cortical taste coding changes with different types of experience. In a basic taste experience paradigm, in which animals consume taste stimuli based on innate taste preferences, we address the question of how novelty and familiarity of taste stimuli effect cortical coding. Using multiday cell tracking, we find two populations of neurons: a stable population encoding taste quality information, and a transient cell population whose activity correlates with the animal\u27s behavioral state.
We use the associative learning paradigm conditioned taste aversion (CTA) to show changes in the transient cell population depend upon experience type. With basic experience, the number of transient cells decreases as animals become familiar with taste stimuli and the behavioral task. After increasing situational salience using CTA, the number of transient cells increases to levels seen during novel taste exposure. This research demonstrates a clear role for novelty and familiarity in population responses to taste stimuli in GC, and suggests an overall implication for these effects in cortical coding of sensory stimuli
Medicated-Assisted Treatment and 12-Step Programs: Evaluating the Referral Process
Get PDFPurpose/Background Overdose deaths in the U.S. from opioids have dramatically increased since the COVID-19 pandemic. Although medicated-assisted treatment (MAT) programs are widely available for sufferers of opiate addiction, many drop out of treatment prematurely. Twelve-step programs are considered a valuable part of treatment, but few studies have examined the effect of combining these approaches. We aimed to compare abstinence rates among patients receiving MAT who were referred to 12-step programs to those only receiving MAT.
Methods In this prospective study, a cohort of participants from a MAT clinic agreeing to attend a 12-step program was compared to 15 controls selected from a database before project implementation. Eligible participants were diagnosed with OUD, receiving buprenorphine (opiate agonist), and at least 18. Participants were provided with temporary sponsors to attend Narcotics Anonymous, Alcoholics Anonymous, and Medication-Assisted Recovery meetings together. The primary endpoint was the change in positive opiate urine drug screens over 6 months between participants and controls.
Results Between March 29, 2021, and April 16, 2021, 166 patients were scheduled at the clinic. Of those scheduled, 146 were established patients, and 123 were scheduled for face-to-face visits. Of these, 64 appeared for the appointment, 6 were screened, and 3 were enrolled. None of the participants attended a 12-step meeting. Enrollment barriers included excluding new patients and those attending virtual visits, the high percentage of patients who missed appointments, and lack of staff referrals. The low incidence of referrals was due to time constraints by both staff and patients.
Implications for Nursing Practice Low enrollment limited our ability to determine whether combining medication management with a 12-step program improves abstinence. Failure to keep appointments is common among patients with OUD, and virtual meetings are becoming more prevalent post-COVID. Although these factors are unlikely to be controllable, developing strategies to expedite the enrollment process for staff and patients could hasten recruitment