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Developing an Evidence-Based Interprofessional Algorithm to Apply Noninvasive Ventilation in Acute Exacerbation of COPD
No full textBackground: When administered as first-line intervention to patients admitted with acute hypercapnic respiratory failure secondary to COPD exacerbation in conjunction with guideline-recommended therapies, noninvasive ventilation (NIV) has been shown to reduce mortality and endotracheal intubation. Opportunities to increase uptake of NIV continue to exist despite inclusion of this therapy in clinical guidelines. Prior studies suggest that efforts to increase NIV use in acute exacerbation of COPD (AECOPD) need to account for the complex and interprofessional nature of NIV delivery and the need for interprofessional team coordination.
Research question: We sought to develop an evidence-based interprofessional algorithm to apply NIV in AECOPD to improve the appropriate utilization of NIV in AECOPD.
Study design and methods: In this prospective qualitative descriptive study, subject matter expert physicians, nurses, and respiratory therapists practicing in a variety of clinical settings caring for patients with AECOPD were recruited for semistructured interviews. The Consolidated Criteria for Reporting Qualitative Research checklist was followed for interview development. Interview themes applicable to interprofessional collaborative practice were identified using deductive thematic analysis. An NIV algorithm based on recent society guidelines was constructed. Interprofessional team tasks appropriate for each phase of the NIV process were integrated into the algorithm.
Results: We present an interprofessional team-based algorithm for delivery of NIV in AECOPD inclusive of patient selection and initiation, titration, monitoring, and weaning of NIV. The goal is to increase appropriate uptake of NIV in the AECOPD population.
Interpretation: The identified roles and responsibilities of an interprofessional team could be integrated into an interprofessional education program pertaining to use and management of NIV for patients with AECOPD emphasizing collaborative best practice, interprofessional team communication, and support of professional autonomy when appropriate.
Keywords: COPD; acute exacerbation of COPD; interprofessional team; noninvasive ventilation
Emerging Educational and Networking Platforms in Interventional Cardiology: Expanding Beyond Traditional Social Media
No full textWith ubiquitous use of smartphones and other Internet-enabled devices, clinicians have access to a plethora of multimedia platforms that enable them to network, share educational content, and learn. Several platforms also enable resources that support clinical decision making. Traditional social media has been used extensively by cardiologists for several years and now extends to the entire care team including trainees, advanced practitioners, nurses and technologists. Numerous challenges include concerns about patient privacy and security, lack of peer-review and organization, and chances of propagating misinformation. More recently, newer networking platforms have emerged within cardiology to overcome several of the limitations of traditional social media. Additionally, mobile applications have emerged as an educational tool that provides clinicians with easy access to the latest information including guidelines, consensus documents, risk estimators and treatment algorithms. These point-of-care learning and decision-making tools are especially relevant and impactful in a procedural field like interventional cardiology. While professional societies are major drivers of these emerging platforms, there are also other stakeholders including educational institutions and the medical device industry. In this review article, we examine the role of traditional social media and describe newer networking platforms as well as mobile applications applicable to interventional cardiology with a discussion about their relative advantages and disadvantages.
Keywords: Interventional cardiology; online; smartphone; social media
Restrictive versus Liberal Transfusion in Myocardial Infarction - A Patient-Level Meta-Analysis
No full textBackground: Clinical guidelines have concluded that there are insufficient data to provide recommendations for the hemoglobin threshold for the use of red cell transfusion in patients with acute myocardial infarction (MI) and anemia. After the recent publication of the Myocardial Infarction and Transfusion (MINT) trial, we performed an individual patient-level data meta-analysis to evaluate the effect of restrictive versus liberal blood transfusion strategies.
Methods: We conducted searches in major databases. Eligible trials randomly assigned patients with MI and anemia to either a restrictive (i.e., transfusion threshold of 7-8 g/dl) or liberal (i.e., transfusion threshold of 10 g/dl) red cell transfusion strategy. We used individual patient data from each trial. The primary outcome was a composite of 30-day mortality or MI.
Results: We included 4311 patients from four trials. The primary outcome occurred in 334 patients (15.4%) in the restrictive strategy and 296 patients (13.8%) in the liberal strategy (relative risk [RR] 1.13, 95% confidence interval [CI], 0.97 to 1.30). Death at 30 days occurred in 9.3% of patients in the restrictive strategy and in 8.1% of patients in the liberal strategy (RR 1.15, 95% CI, 0.95 to 1.39). Cardiac death at 30 days occurred in 5.5% of patients in the restrictive strategy and in 3.7% of patients in the liberal strategy (RR 1.47, 95% CI, 1.11 to 1.94). Heart failure (RR 0.89, 95% CI, 0.70 to 1.13) was similar in the transfusion strategies. All-cause mortality at 6 months occurred in 20.5% of patients in the restrictive strategy compared with 19.1% of patients in the liberal strategy (hazard ratio 1.08, 95% CI, 1.05 to 1.11).
Conclusions: Pooling individual patient data from four trials did not find a definitive difference in our primary composite outcome of MI or death at 30 days. At 6 months, a restrictive transfusion strategy was associated with increased all-cause mortality. (Partially funded by a grant from the U.S. National Heart, Lung, and Blood Institute [R01HL171977].)
Perioperative direct oral anticoagulant management during cardiac implantable electronic device surgery: an updated systematic review and meta-analysis
No full textBackground: Patients undergoing cardiovascular implantable electronic device (CIED) implantation are often on direct oral anticoagulation (DOAC). However, the evidence on whether to continue or temporarily discontinue DOAC therapy during the perioperative period in these patients is unclear.
Methods: We conducted a comprehensive literature review using PubMed, Embase, and Cochrane databases through July 2024. We included studies comparing uninterrupted versus interrupted perioperative DOAC therapy in patients undergoing CIED procedure- primary implants, pulse generator replacement, and device upgrades. Primary outcomes were clinically significant device-pocket hematoma and thromboembolic events. Secondary outcomes included any device-pocket hematoma, all-cause mortality, major bleeding, and any bleeding.
Results: A total of 1,607 patients from 8 studies were included. The mean age was 73.2 years, with atrial fibrillation as the indication for DOAC therapy in most patients. The mean CHA2DS2-VASc was 3.4. Among the included studies, 2 were randomized control trials (RCTs), while the others were observational cohort studies, including one that was propensity score matched. Our meta-analysis found both strategies to be similar in terms of clinically significant pocket hematoma (RR 1.70; 95%CI 0.84-3.45; p = 0.14; I2 = 0%), thromboembolic complications (RR 0.35; 95%CI 0.04-3.32; p = 0.36; I2 = 19%), any pocket hematoma, all-cause mortality and any bleeding with a higher risk of major bleeding with uninterrupted anticoagulation.
Conclusion: This meta-analysis shows that uninterrupted DOAC therapy is comparable to interrupted therapy for CIED procedures, with a potential increase in major bleeding risk but low overall complication rates. Further research is needed to confirm the best approach of periprocedural anticoagulation in these patients.
Keywords: Bleeding; DOAC; Defibrillator; Direct oral anticoagulants; Hematoma; Pacemaker
Short versus 1-Year Dual Antiplatelet Therapy after Percutaneous Coronary Intervention: An Updated Systematic Review and Meta-Analysis
No full textCurrent guidelines recommend dual antiplatelet therapy (DAPT) for 6 to 12 months post percutaneous coronary intervention (PCI), with recent trials assessing the safety and efficacy of shortening DAPT duration to ≤3 months. A systematic search of PubMed, Scopus, and Cochrane Central databases identified studies comparing short DAPT followed by P2Y12i monotherapy (78% ticagrelor) vs. standard 12-month DAPT in patients undergoing PCI with drug-eluting stent (DES). Nine randomized controlled trials, including 42,770 patients (short DAPT n=21,370, 49.96%) of whom 28,307 (66.18%) presented with acute coronary syndrome (ACS), were included. Short DAPT significantly reduced NACE (RR 0.78; 95%CI 0.67-0.91; p=0.001; I2=62%), major bleeding (RR 0.54; 95%CI 0.39-0.73; p\u3c0.001; I2=63%) as well as any bleeding (RR 0.55; 95%CI 0.43-0.72; p\u3c0.001; I2=77%) at 12 months compared with 1-year DAPT. No significant differences were observed in MACCE, myocardial infarction, stroke, stent thrombosis, mortality, or revascularization. Ticagrelor monotherapy after short DAPT further reduced MACCE (RR 0.85, 95% CI 0.73-0.99, p=0.040; I²=22%), NACE (RR 0.74, 95% CI 0.61-0.89, p=0.001; I²=68%), and major bleeding (RR 0.56, 95% CI 0.40-0.78, p\u3c0.001; I²=71%) compared with 1-year DAPT, however, the test for subgroup interaction (Pinteraction\u3e0.05) for clopidogrel subgroup was not significant. P2Y12i monotherapy reduced the risk of NACE (RR 0.77; 95%CI 0.66-0.90; p=0.001; I2=52%, Pinteraction=0.58) and major bleeding (RR 0.44; 95%CI 0.35-0.55; p\u3c0.001; I2=0%, Pinteraction\u3c0.01) in the ACS cohort, but not in the CCS cohort. In conclusion, short DAPT for ≤3 months followed by P2Y12i monotherapy (particularly ticagrelor) was associated with decreased NACE and bleeding without differences in other outcomes and should be considered a favorable option in patients with either ACS or CCS following PCI with DES.
Keywords: 1-year DAPT; Dual Antiplatelet Therapy; P2Y12i Monotherapy; Percutaneous Coronary Intervention; Short DAPT
Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study
No full textBackground: In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or \u27rural\u27 areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States.
Methods: We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes.
Results: Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to get things in order before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration.
Conclusion: Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America
Sarcopenia and aortic valve disease
No full textValvular heart disease, including calcific or degenerative aortic stenosis (AS), is increasingly prevalent among the older adult population. Over the last few decades, treatment of severe AS has been revolutionised following the development of transcatheter aortic valve replacement (TAVR). Despite improvements in outcomes, older adults with competing comorbidities and geriatric syndromes have suboptimal quality of life outcomes, highlighting the cumulative vulnerability that persists despite valve replacement. Sarcopenia, characterised by loss of muscle strength, mass and function, affects 21%-70% of older adults with AS. Sarcopenia is an independent predictor of short-term and long-term outcomes after TAVR and should be incorporated as a prognostic marker in preprocedural planning. Early diagnosis and treatment of sarcopenia may reduce morbidity and mortality and improve quality of life following TAVR. The adverse effects of sarcopenia can be mitigated through resistance training and optimisation of nutritional status. This is most efficacious when administered before sarcopenia has progressed to advanced stages. Management should be individualised based on the patient\u27s wishes/preferences, care goals and physical capability. Exercise during the preoperative waiting period may be safe and effective in most patients with severe AS. However, future studies are needed to establish the benefits of prehabilitation in improving quality of life outcomes after TAVR procedures.
Keywords: Heart Valve Diseases
Nursing News & Views - April 2024
Get PDFNursing News & Views Newsletter - April 2024https://scholarlycommons.libraryinfo.bhs.org/nursing_newsletters/1033/thumbnail.jp