Early fluid bolus in adults with sepsis in the emergency department: a systematic review, meta-analysis and narrative synthesis

Background Early intravenous fluids for patients with sepsis presenting with hypoperfusion or shock in the emergency department remains one of the key recommendations of the Surviving Sepsis Campaign guidelines to reduce mortality. However, compliance with the recommendation remains poor. While several interventions have been implemented to improve early fluid administration as part of sepsis protocols, the extent to which they have improved compliance with fluid resuscitation is unknown. The factors associated with the lack of compliance are also poorly understood. Methods We conducted a systematic review, meta-analysis and narrative review to investigate the effectiveness of interventions in emergency departments in improving compliance with early fluid administration and examine the non-interventional facilitators and barriers that may influence appropriate fluid administration in adults with sepsis. We searched MEDLINE Ovid/PubMed, Ovid EMBASE, CINAHL, and SCOPUS databases for studies of any design to April 2021. We synthesised results from the studies reporting effectiveness of interventions in a meta-analysis and conducted a narrative synthesis of studies reporting non-interventional factors. Results We included 31 studies out of the 825 unique articles identified in the systematic review of which 21 were included in the meta-analysis and 11 in the narrative synthesis. In meta-analysis, interventions were associated with a 47% improvement in the rate of compliance [(Random Effects (RE) Relative Risk (RR) = 1.47, 95% Confidence Interval (CI), 1.25–1.74, p-value < 0.01)]; an average 24 min reduction in the time to fluids [RE mean difference = − 24.11(95% CI − 14.09 to − 34.14 min, p value < 0.01)], and patients receiving an additional 575 mL fluids [RE mean difference = 575.40 (95% CI 202.28–1353.08, p value < 0.01)]. The compliance rate of early fluid administration reported in the studies included in the narrative synthesis is 48% [RR = 0.48 (95% CI 0.24–0.72)]. Conclusion Performance improvement interventions improve compliance and time and volume of fluids administered to patients with sepsis in the emergency department. While patient-related factors such as advanced age, co-morbidities, cryptic shock were associated with poor compliance, important organisational factors such as inexperience of clinicians, overcrowding and inter-hospital transfers were also identified. A comprehensive understanding of the facilitators and barriers to early fluid administration is essential to design quality improvement projects. PROSPERO Registration ID CRD42021225417.

Influence of Psychological Supervision on Athletes’ Compliance, Mental Elasticity Characteristics and Acute Stress Disorder in Traumatic Fracture Rehabilitation Training

Background: We aimed to explore the effect of psychological supervision on rehabilitation training compliance, mental elasticity characteristics, and acute stress disorder. Methods: From March 2018 to March 2020, 128 athletes with traumatic fractures in Zhoukou Sports Club in China were divided into two groups using the random number table method, The intervention group (64 athletes) received psychological supervision during the rehabilitation training, while the control group (64 athletes) without psychological supervision. The rehabilitation training compliance in the two groups was observed, and the mental elasticity characteristics and acute stress disorder changes were compared between the two groups before and post-intervention. Results: The compliance rate during postoperative rehabilitation training in the intervention group is 92.19%, which was significantly higher than 73.44% in the control group (P<0.05). Compared with the scores before intervention, the CD-RISC score and SASRD score of the two groups were significantly lower than the scores post-intervention. The SMFA function and vexation indexes of the intervention group in three months after operation were significantly lower than those of the control group (P<0.05). The QOL scores of the intervention group in social, environmental, psychological, and physiological fields were significantly higher than those of the control group in three months after operation (P<0.05). Conclusion: The implementation of psychological supervision for athletes with traumatic fractures could improve rehabilitation training compliance, increase the level of mental elasticity, and relieve acute stress disorder.

Performance Evaluation of Watershed Environment Governance—A Case Study of Taihu Basin

The rapid development of urbanization and industrialization brings a series of problems of environment governance, and several basins are facing huge pressure. This paper selects the Taihu basin in the Yangtze River Delta of China as the study area, establishes the DPSIR model to measure the water environment governance performance of the region (), analyzes the causes of changes in the five subsystems (the governance performance of the subsystems is recorded as ), and uses the diagnostic model to identify the barrier factors that restrict the improvement of in the last 5 years. The results show that during the study period， of the driving force subsystem generally tends to increase and maintains a steady growth, which is closely linked to economic growth in the basin; of the pressure subsystem increases with a small fluctuation, and the pollution generation still needs attention; in the state subsystem, shows a large fluctuation, and varies significantly in a cyclical manner, corresponding to the short maintenance time and repeated treatment of pollution in the watershed; of the impact subsystem shows an overall upward but a slightly slower trend, and it is related to the fact that the industrial structure of the basin still needs to be improved; and of the response subsystem shows an overall upward trend and a slightly larger increase, and the multi-actor collaborative management has helped a lot. The main barrier factors include key cross-sections’ water quality compliance rate, the water quality compliance rate of key water function areas, water consumption per 10,000 yuan of industrial added value, and the lake trophic status index. Based on the results of the study, the article gives recommendations for watershed governance, such as controlling pollution generation, optimising industrial structure, using technological tools to help governance, sharing the cost of governance among multiple parties and strengthening supervision The findings help to make scientific environmental protection planning and policies of the study region. The research can also provide experience for other countries and regions in watershed governance.

Abbreviated Perioperative Fasting Management for Elective Fresh Fracture Surgery: Guideline Adherence Analysis

BackgroundLong-term fasting for elective surgery has been proven unnecessary based on established guidelines. Instead, preoperative carbohydrate loading 2 hours before surgery and recommencing oral nutrition intake as soon as possible after surgery is recommended. This study was performed to analyze the compliance with and effect of abbreviated perioperative fasting management in patients undergoing surgical repair of fresh fractures based on current guidelines.MethodsPatients with fresh fractures were consecutively enrolled from May 2019 to July 2019 at our hospital. A carbohydrate-enriched beverage was recommended up to 2 hours before surgery for all surgical patients except those with contraindications. Postoperatively, oral clear liquids were allowed once the patients had regained full consciousness, and solid food was allowed 1 to 2 hours later according to the patients’ willingness. The perioperative fasting time was recorded and the patients’ subjective comfort with respect to thirst and hunger was assessed using an interview-assisted questionnaire.ResultsIn total, 306 patients were enrolled in this study. The compliance rate of preoperative carbohydrate loading was 71.6%, and 93.5% of patients began ingestion of oral liquids within 2 hours after surgery. The median (interquartile range) preoperative fasting time for liquids and solids was 8 (5.2–12.9) and 19 (15.7–22) hours, respectively. The median postoperative fasting time for liquids and solids was 1 (0.5–1.9) and 2.8 (2.2–3.5) hours, respectively. A total of 70.3% and 74.2% of patients reported no thirst or hunger during the perioperative period. Logistic regression analysis showed that the preoperative fasting time for liquids was an independent risk factor for perioperative hunger. No adverse events such as aspiration pneumonia or gastroesophageal reflux were observed.ConclusionsIn this study of a real clinical practice setting, abbreviated perioperative fasting management was carried out with high compliance in patients with fresh fractures. The preoperative fasting time should be further shortened to further improve patients’ subjective comfort.

Naltrexone Implant for Opioid Use Disorder

The continued rise in the availability of illicit opioids and opioid-related deaths in the United States has left physicians, researchers, and lawmakers desperate for solutions to this ongoing epidemic. The research into therapeutic options for the treatment of opioid use disorder (OUD) began with the introduction of methadone in the 1960s. The approval of oral naltrexone initially showed much promise, as the drug was observed to be highly potent in antagonizing the effects of opioids while producing no opioid agonist effects of its own and having a favorable side effect profile. Patients that routinely take their naltrexone reported fewer days of heroin use and had more negative drug tests than those without treatment. Poor outcomes in OUD patients treated with naltrexone have been directly tied to short treatment time. Studies have shown that naltrexone given orally vs. as an implant at the 6-month interval showed a higher non-compliance rate among those who used oral medications at the 6-month mark and a slower return to use rate. There were concerns that naltrexone could possibly worsen negative symptoms seen in opiate use disorder related to blockade of endogenous opioids that are important for pleasurable stimuli. Studies have shown that naltrexone demonstrated no increase in levels of anxiety, depression and anhedonia in participants and another study found that those treated with naltrexone had a significant reduction in mental health-related hospitalizations. The latter study also concluded that there was no increased risk for mental health-related incidents in patients taking naltrexone via a long-acting implant. Although not yet FDA approved in the United States, naltrexone implant has shown promising results in Europe and Australia and may provide a novel treatment option for opioid addiction.

Comparative analysis of an innovative app versus conventional techniques to improve patient compliance after minor oral surgical procedures (Preprint)

BACKGROUND Certain factors such as compliance, comprehension, retention of instructions, and other unaccounted elements impact the objectives of post-operative care. It is imperative that patients follow the instructions and prescribed regimen diligently for a smooth and placid healing. Keeping the same principles in view, ExoDont was designed by our team, an android-based mHealth app which ensures a smooth post-operative period for the patients after a dental extraction. Besides providing post-operative instructions at defined intervals, the app also sends out drug reminders as an added advantage over other available conventional modes. OBJECTIVE To compare the compliance rate of individuals with respect to the prescribed regimen, postoperative instructions, and additionally, assess any significant changes in post-operative complications rate under the three categories namely Verbal, Verbal plus Written, and ExoDont group. METHODS The patients after tooth extraction were randomly assigned to the aforementioned groups and a one week follow-up through a phone call was planned to obtain the responses from study participants. The result obtained from the three groups was then statistically analyzed. RESULTS The compliance rate in patients for post-operative instructions and prescribed drug adherence was statistically significant in the group using ExoDont app than in Verbal or Verbal plus Written group. However, the difference in the incidence of postoperative complication rate was not significant among the three groups. CONCLUSIONS As evident from the result, it is anticipated that the ExoDont app will be revolutionary in not only circumventing the unaccounted possibilities of missing the prescribed dose and post-operative instructions but also ensure a smooth post-operative phase and easy recovery for the patients.

Study on the Effect of MRI in the Diagnosis of Benign and Malignant Thoracic Tumors

In order to investigate the effectiveness and accuracy of magnetic resonance imaging (MRI) in the diagnosis of benign and malignant thoracic tumors, the research retrospectively selected 80 patients with thoracic tumors admitted from May 2019 to May 2020 as the study subject and all patients were underwent MRI detection. Using pathological diagnostic results as the gold standard, the research analyzed the detection of benign and malignant thoracic tumors by MRI, as well as the diagnostic sensitivity and specificity. After pathological diagnosis, there were 35 malignant tumors and 45 benign tumors. 41 cases of malignant tumors and 39 cases of benign tumors were diagnosed by MRI, with a diagnostic sensitivity of 80.00%, a diagnostic specificity of 71.11%, and a diagnostic compliance rate of 75.00%. In the MRI diagnosis of tumors in different parts of the chest, the diagnostic sensitivity for lung tumors, mediastinal tumors, chest wall tumors, and esophageal tumors was 83.33%, 71.43%, 83.33%, 75.00%, and 87.50%, respectively, and the specificity was 66.67%, 77.78%, 57.14%, 50.00%, and 91.67% according to and breast tumors, respectively. And the accuracy was 73.33%, 75.00%, 69.23, 62.50%, and 90.00%, respectively, with the highest diagnostic sensitivity, specificity, and accuracy for breast tumors. MRI has a good effect on the diagnosis of benign and malignant thoracic tumors and has a high diagnostic value, which is helpful to identify the location, nature, source, and lesion scope of the tumor. It is safe and worthy of promotion.

An Evidence-based General Anesthesia and Prone Position Nursing Checklist: Development and Testing

Background and Aim: Prone positioning during general anesthesia is one of the most difficult practices for the perioperative nurse. Patients in this position are vulnerable to many preventable complications. However, no studies have developed an evidenced-based tool to improve nursing practice during general anesthesia and prone positioning. This study aimed to develop and test a general anesthesia and prone position nursing checklist for use by the circulating nurse. Methods: The WHO checklist development model and evidence-based methods guided the checklist development process. A prospective pre-post study was performed between November 2020 and March 2021. We prospectively observed circulating nurses that attended to prone general anesthesia during posterior lumbar spine surgery for three months before and after the introduction of the general anesthesia and prone position nursing risk checklist. The main outcomes were successful delivery of essential prone positional nursing practices during each surgery and the nurse's opinion of the checklist’s efficacy and utility. Results: A general anesthesia and prone position nursing checklist comprised of 4 pause points and 22 necessary nursing practices was developed. Seventy-two nurses participated in this study. Use of the checklist significantly increased the average performance of essential practices during each surgery from 72.72% to 95.45%. Three measures had a compliance rate of 100%. The delivery rate of 14 measures was significantly improved, 91.7% of nurses considered the checklist easy to use, and 94.4% nurses would want the checklist to be used if they underwent a prone position and general anesthesia operation. Conclusions: A general anesthesia and prone position nursing checklist was developed. The instrument was found to be an effective and positively received tool for facilitating key measures of prone positioning during nursing care, translating evidence into practice, and standardizing the nursing process.

A 5 Years Audit Report on Diabetic Ketoacidosis Patients from a Tertiary Care Hospital in Saudi Arabia

Objective: To evaluate the causes of high admission rate of diabetic ketoacidosis (DKA) in adults with diabetes mellitus presenting to a tertiary care hospital in Saudi Arabia with specific emphasis on the clinical and biochemical phenotype and identify components of intervention and improve clinical outcomes in these patients. Study Design: Observational study. Place and Duration of the Study: Department of Diabetes & Endocrinology, Armed Forces Hospital Al-Hada, Taif, Kingdom of Saudi Arabia from 1st August 2015 to 31st January 2020. Methodology: One hundred and fifteen patients with diabetes mellitus presenting with diabetic ketoacidosis during the last 5 years were enrolled. Approximately 50 different variables pertaining to the patients at the time of presentation were thoroughly scrutinized. Results: There were 31 (28%) males and 81 (72 %) were females with type 1 DM 92%, type 2 DM 7% and 1% unclassified DM with a mean age of 20.90±7.4 years. 18% were diagnosed to have DM for the first time and others had a mean duration of DM of 8.0±3.6 years with an average daily insulin requirement being 64.0±20.2 units. Moreover 84% of patients were on basal bolus regimen and only 5% were on mixed insulin. 73% of the DKA episodes occurred in 15-25 years of age group. The commonest precipitating factors were non-compliance with insulin (44%) and respiratory tract infections (17%). Most common presenting symptoms were vomiting and abdominal pain present in 81% and 53% of patients. The mean blood sugar on presentation was 463±157.3 mg/dl whereas the mean HbA1c was 14±2.9. The mean pH and bicarbonate levels on presentation were 7.16±0.128 and 7±4.83 meq/L respectively. 80% of the patients were admitted to the general wards however 19% required ICU care. 69% of patients had a history of readmission with DKA and 29% were transferred from another periphery hospital. The mean duration of stay in the hospital was 2±3.8 days and the mortality was 0.9%. Conclusion: A very low mortality rate is witness to excellent acute management of these very sick patients. However a very high non-compliance rate of 44%, combined with a readmission rate of 69% and a mean HbA1c of 14% are very alarming as far as long term prognosis is concerned. Keywords: Diabetes mellitus, Ketoacidosis, Characteristics, DKA, Tertiary level care