Resuscitation clinical care plans (resuscitation plans) are gradually replacing 'Not for Cardiopulmonary Resuscitation' orders in the hospital setting. The 7-Step Pathway Resuscitation Plan and Alert ...form (7-Step form) is one example of a resuscitation plan. Treatment recommendations in resuscitation plans currently lack standardised language, creating potential for misinterpretation and patient harm.
To explore how terminology used in resuscitation plans is interpreted and applied by clinicians.
A mixed methods study surveyed 50 general medical doctors, who were required to interpret and apply a 7-Step form in three case vignettes and define seven key terms. Statistical analysis on multiple choice and thematic analysis on free-text responses was performed.
Terminology was inconsistently interpreted and inconsistently applied, resulting in clinically significant differences in treatment choices. Three key themes influenced the application of a resuscitation plan: in-depth discussion, precise documentation and personal experience of the bedside deciding doctor.
This study highlights persistent communication deficiencies in resuscitation plan documentation and how this may adversely affect patient care; findings unlikely to be unique to Australia or South Australia.
Removing ambiguity by standardising and defining the terminology in resuscitation plans will improve bedside decision-making, while also supporting the rights of the patient to receive appropriate and desired care.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Few well-controlled studies have comprehensively examined the effects of very-low-carbohydrate diets on type 2 diabetes (T2D).
We compared the effects of a very-low-carbohydrate, high-unsaturated ...fat, low-saturated fat (LC) diet with a high-carbohydrate, low-fat (HC) diet on glycemic control and cardiovascular disease risk factors in T2D after 52 wk.
In this randomized controlled trial that was conducted in an outpatient research clinic, 115 obese adults with T2D mean ± SD age: 58 ± 7 y; body mass index (in kg/m(2)): 34.6 ± 4.3; glycated hemoglobin (HbA1c): 7.3 ± 1.1%; duration of diabetes: 8 ± 6 y were randomly assigned to consume either a hypocaloric LC diet 14% of energy as carbohydrate (carbohydrate <50 g/d), 28% of energy as protein, and 58% of energy as fat (<10% saturated fat) or an energy-matched HC diet 53% of energy as carbohydrate, 17% of energy as protein, and 30% of energy as fat (<10% saturated fat) combined with supervised aerobic and resistance exercise (60 min; 3 d/wk). Outcomes were glycemic control assessed with use of measurements of HbA1c, fasting blood glucose, glycemic variability assessed with use of 48-h continuous glucose monitoring, diabetes medication, weight, blood pressure, and lipids assessed at baseline, 24, and 52 wk.
Both groups achieved similar completion rates (LC diet: 71%; HC diet: 65%) and mean (95% CI) reductions in weight LC diet: -9.8 kg (-11.7, -7.9 kg); HC diet: -10.1 kg (-12.0, -8.2 kg), blood pressure LC diet: -7.1 (-10.6, -3.7)/-6.2 (-8.2, -4.1) mm Hg; HC diet: -5.8 (-9.4, -2.2)/-6.4 (-8.4, -4.3) mm Hg, HbA1c LC diet: -1.0% (-1.2%, -0.7%); HC diet: -1.0% (-1.3%, -0.8%), fasting glucose LC diet: -0.7 mmol/L (-1.3, -0.1 mmol/L); HC diet: -1.5 mmol/L (-2.1, -0.8 mmol/L), and LDL cholesterol LC diet: -0.1 mmol/L (-0.3, 0.1 mmol/L); HC diet: -0.2 mmol/L (-0.4, 0.03 mmol/L) (P-diet effect ≥ 0.10). Compared with the HC-diet group, the LC-diet group achieved greater mean (95% CI) reductions in the diabetes medication score LC diet: -0.5 arbitrary units (-0.7, -0.4 arbitrary units); HC diet: -0.2 arbitrary units (-0.4, -0.06 arbitrary units); P = 0.02, glycemic variability assessed by measuring the continuous overall net glycemic action-1 LC diet: -0.5 mmol/L (-0.6, -0.3 mmol/L); HC diet: -0.05 mmol/L (-0.2, -0.1 mmol/L); P = 0.003, and triglycerides LC diet: -0.4 mmol/L (-0.5, -0.2 mmol/L); HC diet: -0.01 mmol/L (-0.2, 0.2 mmol/L); P = 0.001 and greater mean (95% CI) increases in HDL cholesterol LC diet: 0.1 mmol/L (0.1, 0.2 mmol/L); HC diet: 0.06 mmol/L (-0.01, 0.1 mmol/L); P = 0.002.
Both diets achieved substantial weight loss and reduced HbA1c and fasting glucose. The LC diet, which was high in unsaturated fat and low in saturated fat, achieved greater improvements in the lipid profile, blood glucose stability, and reductions in diabetes medication requirements, suggesting an effective strategy for the optimization of T2D management. This trial was registered at www.anzctr.org.au as ACTRN12612000369820.
Type 1 diabetes (T1D) is a chronic disease resulting from the destruction of pancreatic beta cells, due to a poorly understood combination of genetic, environmental, and immune factors. The JDRF ...Network for Pancreatic Organ donors with Diabetes (nPOD) program recovers transplantation quality pancreas from organ donors throughout the USA. In addition to recovery of donors with T1D, non‐diabetic donors include those with islet autoantibodies. Donors with type 2 diabetes and other conditions are also recovered to aid investigations directed at the full spectrum of pathophysiological mechanisms affecting beta cells. One central processing laboratory conducts standardized procedures for sample processing, storage, and distribution, intended for current and future cutting edge investigations. Baseline histology characterizations are performed on the pancreatic samples, with images of the staining results provided though whole‐slide digital scans. Uniquely, these high‐grade biospecimens are provided without expense to investigators, working worldwide, seeking methods for disease prevention and reversal strategies. Collaborative working groups are highly encouraged, bringing together multiple investigators with different expertise to foster collaborations in several areas of critical need. This mini‐review will provide some key histopathological findings emanating from the nPOD collection, including the heterogeneity of beta cell loss and islet inflammation (insulitis), beta cell mass, insulin‐producing beta cells in chronic T1D, and pancreas weight reductions at disease onset. Analysis of variations in histopathology observed from these organ donors could provide for mechanistic differences related to etiological agents and serve an important function in terms of identifying the heterogeneity of T1D.
Controversy exists regarding the potential regenerative influences of incretin therapy on pancreatic β-cells versus possible adverse pancreatic proliferative effects. Examination of pancreata from ...age-matched organ donors with type 2 diabetes mellitus (DM) treated by incretin therapy (n = 8) or other therapy (n = 12) and nondiabetic control subjects (n = 14) reveals an ∼40% increased pancreatic mass in DM treated with incretin therapy, with both increased exocrine cell proliferation (P < 0.0001) and dysplasia (increased pancreatic intraepithelial neoplasia, P < 0.01). Pancreata in DM treated with incretin therapy were notable for α-cell hyperplasia and glucagon-expressing microadenomas (3 of 8) and a neuroendocrine tumor. β-Cell mass was reduced by ∼60% in those with DM, yet a sixfold increase was observed in incretin-treated subjects, although DM persisted. Endocrine cells costaining for insulin and glucagon were increased in DM compared with non-DM control subjects (P < 0.05) and markedly further increased by incretin therapy (P < 0.05). In conclusion, incretin therapy in humans resulted in a marked expansion of the exocrine and endocrine pancreatic compartments, the former being accompanied by increased proliferation and dysplasia and the latter by α-cell hyperplasia with the potential for evolution into neuroendocrine tumors.
Nanoscale or single-cell technologies are critical for biomedical applications. However, current mass spectrometry (MS)-based proteomic approaches require samples comprising a minimum of thousands of ...cells to provide in-depth profiling. Here, we report the development of a nanoPOTS (nanodroplet processing in one pot for trace samples) platform for small cell population proteomics analysis. NanoPOTS enhances the efficiency and recovery of sample processing by downscaling processing volumes to <200 nL to minimize surface losses. When combined with ultrasensitive liquid chromatography-MS, nanoPOTS allows identification of ~1500 to ~3000 proteins from ~10 to ~140 cells, respectively. By incorporating the Match Between Runs algorithm of MaxQuant, >3000 proteins are consistently identified from as few as 10 cells. Furthermore, we demonstrate quantification of ~2400 proteins from single human pancreatic islet thin sections from type 1 diabetic and control donors, illustrating the application of nanoPOTS for spatially resolved proteome measurements from clinical tissues.
Consumer escalation systems allow patients and families to escalate concerns about acute clinical deterioration. Hospital staff can impact upon the success of this process. As part of evaluation ...processes within a Local Health Network, where a consumer escalation system was introduced in accordance with National requirements, we sought to explore clinicians' understanding and perceptions of consumer escalation.
Voluntary and anonymous staff surveys pre, and post, system introduction. Quantitative data was analysed using descriptive statistics, chi-square independence, and non-parametric independent samples median tests. Qualitative data was evaluated using content analysis and cross-referenced with quantitative responses.
Respondent's (pre: 215; post: 89) area of work varied significantly between survey periods. Most agreed that patients/families have a sound knowledge of a patient's typical health status (pre: 192/215 (89.3%); post 82/88 (93.2%)) and that patients/families should be encouraged to escalate concerns of deterioration to ward staff (pre: 209/212 (98.6%); post: 85/89 (95.5%)). Respondent perceptions of patient/family ability to recognise clinical deterioration varied. Staff agreement towards local response expectations decreased as the degree of clinical requirement increased. Staff concerns of increased workloads (pre: 90/214 (42.1%); post 12/72 (16.7%), p<0.001) and conflict generation (pre: 71/213 (33.3%); post: 7/71 (9.9%), p = 0.001) decreased significantly following system introduction. However, clinician perceptions of positive system effects also decreased (patient-staff rapport pre: 163/213 (76.5%); post: 38/72 (52.8%), p = 0.001; patient centred care pre: 188/214 (87.9%); post: 53/72 (73.6%), p = 0.012; patient safety pre: 173/214 (80.8%); post: 49/72 (68.1%), p = 0.077). Only 53% of respondents (pre: 112/213 (52.6%); post: 48/88 (54.5%)) perceived that patient/family have sufficient confidence to escalate concerns.
Consumer escalation systems require staff support. Staff perceptions may indicate, and act as, barriers to the operation of consumer escalation processes. Further exploration in identifying and managing staff barriers is crucial to the success of consumer escalation.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Aims/hypothesis
Previous studies of pancreases obtained at autopsy or by radiography note reduced pancreas weight (PW) and size, respectively, in type 1 diabetes; this finding is widely considered to ...be the result of chronic insulinopenia. This literature is, however, limited with respect to the influence of age, sex, anthropometric factors and disease duration on these observations. Moreover, data are sparse for young children, a group of particular interest for type 1 diabetes. We hypothesised that the pancreas-to-body weight ratio would normalise confounding inter-subject factors, thereby permitting better characterisation of PW in type 1 diabetes.
Methods
Transplant-grade pancreases were recovered from 216 organ donors with type 1 diabetes (
n
= 90), type 2 diabetes (
n
= 40) and no diabetes (
n
= 86). Whole-organ and head, body and tail weights were determined. The relative PW (RPW; PW g / body weight kg) was calculated and tested for normalisation of potential differences due to age, sex and BMI.
Results
PW significantly correlated with body weight in control donors (
R
2
= 0.76,
p
< 0.001) while RPW (1.03 ± 0.36, mean ± SD) did not significantly differ across ages (0–58 years). Donors with type 1 diabetes (0.57 ± 0.18,
p
< 0.001), but not those with type 2 diabetes (0.93 ± 0.30), had significantly lower RPW. The relative weights of each pancreatic region from donors with type 1 diabetes were significantly smaller than those of regions from control donors and donors with type 2 diabetes (
p
< 0.001). Perhaps most interestingly, the RPW was not significantly associated with duration of type 1 diabetes or type 2 diabetes.
Conclusions/interpretation
RPW allows for comparisons across a wide range of donor ages by eliminating confounding variables. These data validate an interesting feature of the type 1 diabetes pancreas and underscore the need for additional studies to identify the mechanistic basis for this finding, including those beyond the chronic loss of endogenous insulin secretion.
We sought the role of the hospital inpatient observation and response chart (ORC) in reducing adverse outcomes. We sourced articles written in English and published in PubMed. Track, trigger and ...response systems can be tiered and use single parameter or aggregate scoring systems; the latter being more prone to error. The documentation and detection of abnormal vital signs can be affected by choice of trigger and response and by ORC design. There is considerable variation in the design of ORC and of rapid response systems (RRS) in general, and this impairs assessment of their efficacy. A high rate of modification of pre‐determined triggers and poor sensitivity of measured outcomes further compromise systematic review. The best‐designed ORC and RRS should optimise the frequency of response team activation to minimise adverse patient outcomes without excess resource utilisation. The role and the risks of electronic data recording are under‐explored. Detecting and responding to deteriorating patients relies upon accurate and clear documentation of vital signs. ORC design and staff education on ORC implementation and usage are integral to minimising ALF and optimising patient outcomes. Standardisation of the design of both the ORC and the hospital RRS are overdue.
Type 1 diabetes (T1D) is considered a pancreatic beta cell-specific disease that results in absolute insulin deficiency. Nevertheless, clinical studies from 1940 onwards showed that patients with T1D ...had an abnormal exocrine pancreas due to the presence of subclinical exocrine insufficiency and acinar atrophy. Exocrine abnormalities are an important, and mostly neglected, characteristic associated with T1D. It is however still unclear whether the exocrine dysfunction in T1D is a primary damage caused by the same pathogenic event that led to beta cell destruction or secondary to beta cell loss. In this review, we collect evidence supporting the hypothesis that T1D is a combined endocrine-exocrine disease in which the loss of functional beta cell mass is most clinically apparent.
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