Cardiac surgery is associated with hyperglycemia, which in turn is associated with adverse postsurgical outcomes such as wound infections, acute renal failure, and mortality. This pilot study seeks ...to determine if Dexcom G6Pro continuous glucose monitor (Dexcom G6Pro CGM) is accurate during the postoperative cardiac surgery period when fluid shifts, systemic inflammatory response syndrome, and vasoactive medications are frequently encountered, compared to standard glucose monitoring techniques.
This study received institutional review board approval. In this prospective study, correlation between clinical and Dexcom glucose readings was evaluated. Clinical glucose (blood gas, metabolic panel, and point of care) data set included 1428 readings from 29 patients, while the Dexcom G6Pro CGM data included 45 645 data points following placement to upper arm. Additionally, average clinical measurements of day and overnight temperatures and hemodynamics were evaluated.
Clinical and Dexcom data were restricted to being at least 1 hour after prior clinical reading Matching Dexcom G6Pro CGM data were required within 5 minutes of clinical measure. Data included only if taken at least 2 hours after Dexcom G6Pro CGM insertion (warm-up time) and analyzed only following intensive care unit (ICU) admission. Finally, a data set excluding the first 24 hours after ICU admission was created to explore stability of the device. Patients remained on Dexcom G6Pro CGM until discharge or 10 days postoperatively.
The population was 71% male, 14% with known diabetes; 66% required intravenous insulin infusion. The Clarke error grid plot of all measures post-ICU admission showed 53.5% in zone A, 45.9% in zone B, and 0.6% (n = 5) in zones D or E. The restricted dataset that excluded the first 24 hours post-ICU admission showed 55.9% in zone A, 43.9% in zone B, and 0.2% in zone D. Mean absolute relative difference between clinical and Dexcom G6Pro CGM measures was 20.6% and 21.6% in the entire post-ICU admission data set, and the data set excluding the first 24 hours after ICU admission, respectively. In the subanalysis of the 12 patients who did not have more than a 5-minute tap in the operating room, a consensus error grid, demonstrated that after ICU admission, percentage in zone A was 53.9%, zone B 45.4%, and zone C 0.7%. Similar percentages were obtained removing the first 24 hours post-ICU admission. These numbers are very similar to the entire cohort.
A consensus error grid created post-ICU admission demonstrated: (zone A) 54%, (zone B) 45%, (zone C) 0.9%, and the following for the dataset created excluding the first 24 hours: (zone A) 56%, (zone B) 44%, (zone C) 0.4%, which demonstrated very close agreement with the original Clarke error grid. No adverse events were reported.
Almost 100% of Dexcom G6Pro CGM and clinical data matching points fell within areas considered as giving clinically correct decisions (zone A) and clinically uncritical decisions (zone B). However, the relatively high mean absolute relative difference precludes its use for both monitoring and treatment in the clinical context. As technology evolves, interstitial glucose monitoring may become an important tool to limit iatrogenic anemia and mitigate glycemic fluctuations.
Hyperglycemia is associated with adverse post-surgical outcomes. We evaluated Dexcom G6 accuracy following cardiac surgery. A clinical glucose dataset included 1428 readings of 29 patients, Dexcom ...data included 45,645 measures. Clinical and Dexcom measures were restricted at least 1 hour after prior measure. Matching clinical and Dexcom measures were required within 5 min. Data were included at least 2 hr after Dexcom insertion and ICU admit. A dataset only measuring ≥24 hrs post ICU admit was created to explore device stability. Patients remained on Dexcom until discharge or 10 days postop. The population was 71% male 14% with known diabetes, 66% who went on intravenous insulin infusion. Figure 1a is Clarke error grid plot of all measures post-ICU admission: 53.5% were Zone A, 45.9% Zone B, and 0.6% (n=5) Zones D or E. Figure 1b uses restricted dataset beginning 24 hours post-ICU admission: 55.9% in Zone A, 43.9% in Zone B, and 0.2% in Zone D. MARD between clinical and Dexcom measures was 20.6% and 21.6% in post-ICU admission dataset and dataset excluding first 24 hours after ICU admission. Almost 100% of Dexcom G6 and clinical data matching points fell within areas considered as giving clinically correct decisions (Zone A) and clinically uncritical decisions (Zone B). If CGM readings are used for clinical decision-making, glucose targets or insulin dosing algorithms may need adjustment. As technology evolves, this device may limit glycemic fluctuations.
Disclosure
S.R.Insler: None. B.J.Wakefield: None. J.F.Bena: None. A.Debs: None. K.Brake: None. I.Nwosu: None. M.Lansang: Research Support; Dexcom, Inc., Abbott, Alertgy Inc.
Measuring the impact of epilepsy on families Dawes, Alex; Attipoe, Selasi; Mittlesteadt, Jackson ...
Epilepsy & behavior,
October 2020, 2020-10-00, 20201001, Letnik:
111
Journal Article
Recenzirano
Caring for a child with illness or a child with disability impacts family in various ways. The ability to assess the impact of this care on families is one way to proactively provide the necessary ...support and resources for impacted families. Accordingly, the goal of the current study was to assess the impact of pediatric epilepsy on individual families in a comprehensive epilepsy clinic using a slightly modified version of the Impact on Families Scale (IFS).
Families of patients with epilepsy completed the IFS up to three times. The IFS score and the six categories (i.e., total impact, financial impact, general impact, family/social impact, coping, and sibling impact) were assessed using Student's two sample t-test to determine the differences between binary groups and Pearson's correlation to assess the associations with continuous variables. Linear regression modeling was used to develop a model to predict IFS score.
Three hundred and forty-one patients completed the scale at one time point, 314 at two time points, and 61 at three time points. The overall impact of epilepsy on families was 109 (95% confidence interval (CI): 106–112) at time point 1, 111 (95% CI: 108–114) at time point 2, and 112 (95% CI: 105–119) at time point 3. There was no statistical difference in IFS score among the three time points. There were no associations with age or gender. Multivariable modeling using stepwise regression indicated that treatment resistance and seizure-free status were associated with IFS score. No interaction effects were identified.
Findings from the current study suggest that the impact of epilepsy is highest for families that have children with active seizures at the time of their clinical visit and for those with children having treatment-resistant epilepsy. Although intuitive, this is the first study, to our knowledge, that has empirically verified these findings.
•Seizures are the main symptom of epilepsy and the major target of its treatment.•Gaps in seizure frequency documentation exist.•Quality improvement methodology may assist in closing the gap.
Objective
A multidisciplinary quality improvement (QI) team was established to conduct analysis of data for prescribed seizure rescue medication doses from January 2013 to December 2015 to identify ...and improve inappropriately low dose prescriptions. The QI team identified areas of focus for improvement opportunities and developed the project objective based on the 2017 American Academy of Neurology (AAN) and Child Neurology Society (CNS) quality measure.
Methods
Within a freestanding children's hospital, the QI team developed key drivers and implemented interventions, such as the midazolam prefilled syringe program with use of standardized dosing, electronic chart tools, monthly pharmacy review of all underdosed prescriptions, and provider and nursing education. The team created an automated monthly report to monitor prescribed seizure rescue medication dosing compliance. The year 2015 was used as the preliminary data baseline period with an average noncompliance rate of 3.5%.
Results
From January 2016 to December 2019, the team has decreased and sustained the noncompliance rate to an average of 0.38%. The data for the project included 12,975 seizure rescue medication prescribed by a neurology provider from January 2015 to December 2019. Compliance with properly dosed diazepam orders continues to be the largest area of opportunity. The data demonstrated a centerline shift in January 2019, moving the baseline average of 7.2% noncompliance to the current average rate of 0.22%. In comparison, underdosed midazolam orders occurred at an average rate of 0.037% in the same timeframe.
Significance
Using quality improvement methodologies, the team successfully and substantially decreased provider prescribed and signed underdosed rescue medication orders by an average of 89%. This QI project demonstrates successful implementation and improvement addressing the AAN/CNS quality measure of proper rescue seizure treatment dosing.
We evaluated the performance of the iLet bionic pancreas (BP) in non-Hispanic White individuals (here referred to as "Whites") and in Black, Hispanic, and other individuals (here collectively ...referred to as "Minorities").
A multicenter, randomized controlled trial evaluated glycemic management with the BP versus standard of care (SC) in 161 adult and 165 pediatric participants with type 1 diabetes over 13 weeks.
In Whites (n = 240), the mean baseline-adjusted difference in 13-week HbA1c between the BP and SC groups was -0.45% (95% CI -0.61 to -0.29 -4.9 mmol/mol; -6.6 to -3.1; P < 0.001), while this difference among Minorities (n = 84) was -0.53% (-0.83 to -0.24 -6.0 mmol/mol; -9.2 to -2.8; P < 0.001). In Whites, the mean baseline-adjusted difference in time in range between the BP and SC groups was 10% (95% CI 7-12; P < 0.001) and in Minorities was 14% (10-18; P < 0.001).
The BP improves glycemic control in both Whites and Minorities and offers promise in decreasing health care disparities.
Currently, the tracking of seizures is highly subjective, dependent on qualitative information provided by the patient and family instead of quantifiable seizure data. Usage of a seizure detection ...device to potentially detect seizure events in a population of epilepsy patients has been previously done. Therefore, we chose the Fitbit Charge 2 smart watch to determine if it could detect seizure events in patients when compared to continuous electroencephalographic (EEG) monitoring for those admitted to an epilepsy monitoring unit. A total of 40 patients were enrolled in the study that met the criteria between 2015 and 2016. All seizure types were recorded. Twelve patients had a total of 53 epileptic seizures. The patient-aggregated receiver operating characteristic curve had an area under the curve of 0.58 0.56, 0.60, indicating that the neural network models were generally able to detect seizure events at an above-chance level. However, the overall low specificity implied a false alarm rate that would likely make the model unsuitable in practice. Overall, the use of the Fitbit Charge 2 activity tracker does not appear well suited in its current form to detect epileptic seizures in patients with seizure activity when compared to data recorded from the continuous EEG.
Infantile spasms (IS) are early childhood seizures with potentially devastating consequences. Standard therapies (adrenocorticotropic hormone ACTH, high-dose prednisolone, and vigabatrin) are ...strongly recommended as the first treatment for IS. Although this recommendation comes without preference for one standard therapy over another, early remission rates are higher with hormone therapy (ACTH and high-dose prednisolone) when compared with vigabatrin. Using quality improvement (QI) methodology that included hormone therapy as the first treatment, we sought to increase the percentage of children with new-onset nontuberous sclerosis complex (TSC)-associated IS achieving 3-month electroclinical remission from a mean of 53.8% to ≥70%.
This was an observational consecutive sample cohort study at a single academic tertiary care hospital that compared a prospective intervention cohort (May 2019-January 2022, N = 57) with a retrospective baseline cohort (November 2015-April 2019, N = 67). Our initiative addressed key drivers such as the routine use of vigabatrin over hormone therapy as first treatment and the common initiation of a second treatment after 14 days for initial nonresponders. We included consecutive children without TSC presenting with new-onset IS diagnosed and treated between ages 2 and 24 months. We displayed our primary outcome and process measures as control charts in which the centerline is the quarterly (previous 3 months) mean based on statistical process control methodology.
QI interventions that included the standardization of hormone therapy as the first treatment resulted in higher rates of 3-month remission, rising from 53.8% (baseline cohort) to 75.9% (intervention cohort). Process measure results included an increased rate of children receiving hormone therapy as first treatment (mean, 44.6%-100%) and a decreased number of days to both clinical follow-up after first treatment (mean, of 16.3-12.6 days) and starting a second treatment within 14 days for initial nonresponders (mean, 36.3-17.2 days).
For children with IS, improved rates of 3-month electroclinical remission can be achieved with QI methodology. Implementation of similar QI initiatives at other centers may likewise improve local remission rates.
OBJECTIVETo identify factors associated with low benzodiazepine (BZD) dosing in patients with refractory status epilepticus (RSE) and to assess the impact of BZD treatment variability on seizure ...cessation.
METHODSThis was a retrospective study with prospectively collected data of children with convulsive RSE admitted between June 2011 and January 2019. We analyzed the initial and total BZD dose within 10 minutes of treatment initiation. We used logistic regression modeling to evaluate predictors of low BZD dosing and multivariate Cox regression analysis to assess the impact of low BZD dosing on time to seizure cessation.
RESULTSWe included 289 patients (55.7% male) with a median age of 4.3 (1.3–9.5) years. BZDs were the initial medication in 278 (96.2%). Of those, 161 patients (57.9%) received a low initial dose. Low initial BZD doses occurred in both out-of-hospital (57 of 106; 53.8%) and in-hospital (104 of 172; 60.5%) settings. One hundred three patients (37.1%) received low total BZD dose. Male sex (odds ratio OR 2, 95% confidence interval CI 1.18–3.49; p = 0.012), older age (OR 1.1, 95% CI 1.05–1.17; p < 0.001), no prior diagnosis of epilepsy (OR 2.1, 95% CI 1.23–3.69; p = 0.008), and delayed BZD treatment (OR 2.2, 95% CI 1.24–3.94; p = 0.007) were associated with low total BZD dose. Patients who received low total BZD dosing were less likely to achieve seizure cessation (hazard ratio 0.7, 95% CI 0.57–0.95).
CONCLUSIONBZD doses were lower than recommended in both out-of-hospital and in-hospital settings. Factors associated with low total BZD dose included male sex, older age, no prior epilepsy diagnosis, and delayed BZD treatment. Low total BZD dosing was associated with decreased likelihood of Seizure cessation.
CLASSIFICATION OF EVIDENCEThis study provides Class III evidence that patients with RSE who present with male sex, older age, no prior diagnosis of epilepsy, and delayed BZD treatment are more likely to receive low total BZD doses. This study provides Class III evidence that in pediatric RSE low total BZD dose decreases the likelihood of seizure cessation.
•The ORBIT model was used to develop a social norms adherence intervention for teens.•Focus group/interviews identified key features for an adherence intervention.•Usability testing found minor ...problems and preferences, which were easily addressed.•The mobile social norms adherence intervention was deemed usable.•The mobile social norms adherence intervention will be tested in a Phase 2 trial.
Adherence is suboptimal in adolescents with epilepsy. Social norms comparison (i.e., feedback about someone else’s behavior related to one’s own behavior) strategies may be beneficial in improving medication adherence. Using a novel model of behavioral intervention development, the aim of the current study was to create a social norms intervention for adolescents with epilepsy via focus groups and usability studies.
A focus group, individual interviews, short-term usability, and extended usage testing studies were conducted. Across all study phases, content and images of intervention components were displayed to participants as mock-ups in PowerPoint slide decks. After each phase, updated iterations were shown to participants to refine the intervention. Several questionnaires were completed by adolescents and caregivers to characterize the samples.
Twelve adolescents participated in the focus group/individual interviews and usability studies. The final Behavioral Economic Adherence for Teens (BEAT) intervention consists of a text messaging system and a graphical user interface. General feedback indicated the need for simplicity and ease of use regarding obtaining the graphical messages (e.g., no extra login and passwords); engaging visual images; and weekly comparisons of a target patient’s medication adherence to other adolescents’ performance. The average system usability system (SUS) rating was 88.3 + 3.8.
Our final intervention had high usability ratings and was perceived as engaging and easy to understand. An important next step is to test the BEAT intervention in a Phase 2 randomized trial.
Epilepsy and seizures represent a frequent cause of emergency department (ED) visits for patients. By implementing quality improvement (QI) methodology, we planned to decrease ED visits for children ...and adolescents with epilepsy.
In 2016, a multidisciplinary team was created to implement QI methodology to address ED visits for patients with epilepsy. Based on previous successes, further ED visit reduction was deemed possible. Our aim statement was to decrease the number of ED visits, per 1000 established patients with epilepsy, from 13.03 to 11.6, by December 2019 and sustain for 1 year.
We successfully decreased ED visits for seizure-related care in patients with epilepsy from 13.03% to 10.2% per 1,000 patients, which resulted in a centerline shift.
Using QI methodology, we improved the outcome measure of decreasing ED visits for children with epilepsy. Implementations of these interventions can be considered at other institutions that may lead to similar results.
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