Metabolic Syndrome Screening in Seriously Mentally Ill Patients: A Quality Improvement Project

A Project Submitted in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCE in Nursing ScienceSeriously mentally ill patients who are taking second-generation antipsychotics have a high risk of metabolic complications, including obesity, diabetes mellitus type II, hypertension, and hyperlipidemia. Guidelines to screen for metabolic syndrome were established by the American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, and North American Association for the Study of Obesity (Clark, 2004). Compliance with implementing the guidelines to screen and monitor for metabolic syndrome vary from regular monitoring to little or none. This quality improvement project provided an educational intervention on screening and monitoring for metabolic syndrome in patients who were seriously mentally ill. The educational interventions were attended by 21 psychiatric-mental health nurse practitioners. After the educational intervention was completed, there was significant improvement in provider knowledge as well as motivation to screen and monitor patients taking second-generation antipsychotic medications for metabolic syndrome. Education may motivate mental health providers to increase the use of metabolic screening guidelines for patients taking second-generation antipsychotic medications potentially improving long term outcomes for this patient population.Title Page / Abstract / Table of Contents / List of Appendices / Metabolic Syndrome in Seriously Mentally Ill Patients: A Quality Improvement Project / Background Significance / Literature Review / Purpose / Educational Intervention using an Evidence Based Practice Model / Methods / Dissemination / Significance to Nursing / Limitations / Summary and Conclusions / References / Appendice

Development and Evaluation of AI-based Parkinson's Disease Related Motor Symptom Detection Algorithms

Parkinson's Disease (PD) is a chronic, progressive, neurodegenerative disorder that is typically characterized by a loss of (motor) function, increased slowness and rigidity. Due to a lack of feasible biomarkers, progression cannot easily be quantified with objective measures. For the same reason, neurologists have to revert to monitoring of (motor) symptoms (i.e. by means of subjective and often inaccurate patient diaries) in order to evaluate a medication's effectiveness. Replacing or supplementing these diaries with an automatic and objective assessment of symptoms and side effects could drastically reduce manual efforts and potentially help in personalizing and improving medication regime. In turn, appearance of symptoms could be reduced and the patient's quality of life increased. The objective of this thesis is two-fold: (1) development and improvement of algorithms for detecting PD related motor symptoms and (2) to develop a software framework for time series analysis

Proceeding: 3rd Java International Nursing Conference 2015 “Harmony of Caring and Healing Inquiry for Holistic Nursing Practice; Enhancing Quality of Care”, Semarang, 20-21 August 2015

This is the proceeding of the 3rd Java International Nursing Conference 2015 organized by School of Nursing, Faculty of Medicine, Diponegoro University, in collaboration with STIKES Kendal. The conference was held on 20-21 August 2015 in Semarang, Indonesia. The conference aims to enable educators, students, practitioners and researchers from nursing, medicine, midwifery and other health sciences to disseminate and discuss evidence of nursing education, research, and practices to improve the quality of care. This conference also provides participants opportunities to develop their professional networks, learn from other colleagues and meet leading personalities in nursing and health sciences. The 3rd JINC 2015 was comprised of keynote lectures and concurrent submitted oral presentations and poster sessions. The following themes have been chosen to be the focus of the conference: (a) Multicenter Science: Physiology, Biology, Chemistry, etc. in Holistic Nursing Practice, (b) Complementary Therapy in Nursing and Complementary, Alternative Medicine: Alternative Medicine (Herbal Medicine), Complementary Therapy (Cupping, Acupuncture, Yoga, Aromatherapy, Music Therapy, etc.), (c) Application of Inter-professional Collaboration and Education: Education Development in Holistic Nursing, Competencies of Holistic Nursing, Learning Methods and Assessments, and (d) Application of Holistic Nursing: Leadership & Management, Entrepreneurship in Holistic Nursing, Application of Holistic Nursing in Clinical and Community Settings

A stochastic multi-scale model of HIV-1 transmission for decision-making: application to a MSM population.

BackgroundIn the absence of an effective vaccine against HIV-1, the scientific community is presented with the challenge of developing alternative methods to curb its spread. Due to the complexity of the disease, however, our ability to predict the impact of various prevention and treatment strategies is limited. While ART has been widely accepted as the gold standard of modern care, its timing is debated.ObjectivesTo evaluate the impact of medical interventions at the level of individuals on the spread of infection across the whole population. Specifically, we investigate the impact of ART initiation timing on HIV-1 spread in an MSM (Men who have Sex with Men) population.Design and methodsA stochastic multi-scale model of HIV-1 transmission that integrates within a single framework the in-host cellular dynamics and their outcomes, patient health states, and sexual contact networks. The model captures disease state and progression within individuals, and allows for simulation of therapeutic strategies.ResultsEarly ART initiation may substantially affect disease spread through a population.ConclusionsOur model provides a multi-scale, systems-based approach to evaluate the broader implications of therapeutic strategies

Focused Deterrence and the Prevention of Violent Gun Injuries: Practice, Theoretical Principles, and Scientific Evidence

Focused deterrence strategies are a relatively new addition to a growing portfolio of evidence-based violent gun injury prevention practices available to policy makers and practitioners. These strategies seek to change offender behavior by understanding the underlying violence-producing dynamics and conditions that sustain recurring violent gun injury problems and by implementing a blended strategy of law enforcement, community mobilization, and social service actions. Consistent with documented public health practice, the focused deterrence approach identifies underlying risk factors and causes of recurring violent gun injury problems, develops tailored responses to these underlying conditions, and measures the impact of implemented interventions. This article reviews the practice, theoretical principles, and evaluation evidence on focused deterrence strategies. Although more rigorous randomized studies are needed, the available empirical evidence suggests that these strategies generate noteworthy gun violence reduction impacts and should be part of a broader portfolio of violence prevention strategies available to policy makers and practitioners

Promoting physical activity among university students: a systematic review of controlled trials

Objective: University study is often accompanied by a decline in physical activity (PA) levels but can offer the opportunity to promote a lifelong active lifestyle. This review aims to summarize controlled trials of interventions promoting PA among uni- versity students, describing the quality of the evidence, effective strategies, and deficiencies in the interventions employed, to provide directions for future research and for practical implementations. Data Source: PubMed, PsychINFO, Cochrane Library, Education Source, and SPORTDiscus. Study Inclusion Criteria: Randomized or nonrandomized controlled trial, describing an intervention to promote PA in uni- versity students, where PA was one of the outcomes and results were published in English. Data Extraction: Country, study design, participants\u2019 inclusion criteria, participation rate and characteristics, randomization, blinding, theoretical framework, intervention characteristics, participant retention rate and withdrawal reasons, measures employed, data analysis, PA results, and findings regarding PA correlates. Data Synthesis: Data were synthetized considering study characteristics, strategies used, and outcomes. Results: Two thousand five hundred eighty-five articles were identified. Twenty-seven studies met the inclusion criteria. Sixteen studies reported an increase in PA levels. Conclusion: Physical Activity promotion interventions should address a range of behavioral determinants. Personalized approaches and PA sessions should be considered in future studies. The high risk of bias of many studies (mainly due to attrition and poor reporting) and missing information about intervention components limit the strength of conclusions about the most effective strategies and the evidence of effectiveness, highlighting the need for further high-quality studies

Eye Examination:Satisfying a Quality Care Measure in Diabetes

Abstract Purpose: Diabetic retinopathy (DR), a microvascular complication occurs in patients with poorly controlled diabetes mellitus (DM). A known risk of increased visual impairment associated with DM occurs in patients when the glycosylated hemoglobin level (HbA1c) increases over 7.0%. Therefore, an annual retinal assessment as a quality care measure in diabetes management is necessary. The conducted study aimed to evaluate the documentation of an annual eye exam in all patients with DM in a private family practice clinic and to investigate any possible association between HbA1c level. Method: This quality improvement study included a retrospective medical record review in a cohort of patients with DM in a private Midwestern family practice clinic from June 1, 2017, through March 31, 2018. All adult patients, aged 18-90 years, meeting criteria for DM were included. The HbA1c for each patient with the presence or absence of a documented eye examination were recorded. Results: All patients seen with DM had a documentation of HbA1c (n=129, 100%), average HbA1c results was 7.41%, SD = 1.78. Only 30% (n=39) had documented eye exam results. Implications: An opportunity exists for lowering the HbA1c and documenting completed eye examinations in this family practice clinic. Consideration for a template for tracking HbA1c and eye exam results may fulfill the quality care measure requirements for DM. Lowering HbA1c reduces the risk for DR, and obtaining an annual eye exam allows early recognition and treatment for DR in patients with DM

Exploring health systems integration in urban South Africa : from integrating prevention of mother-to-child transmission of HIV to prevention of type 2 diabetes after gestational diabetes

L'intégration du traitement et de la prévention des maladies chroniques non transmissibles (MNT) au sein des soins de santé primaires représente le principal défi à venir pour la santé publique et les systèmes de santé dans les pays à faible et moyen revenu comme l’Afrique du Sud. Il constitue le principal objectif de cette thèse. L’expérience de l'intégration de la prévention de la transmission du VIH de la mère à l'enfant (PTME) dans les soins de santé primaires (SSP) peut apporter des leçons importantes pour l'intégration de la prévention du diabète chez les femmes souffrant de diabète gestationnel récent (DSG) dans les SSP. Il a été estimé que le DSG touche plus de 9,1 % des grossesses en 2018 en Afrique du Sud. Le DSG augmente le risque de développer ultérieurement du diabète de type 2 (DT2). Le DSG multiplie par plus de 7 le risque de développer un DT2 ainsi que les risques de troubles métaboliques pour les bébés des femmes qui en sont atteintes. Cette thèse explore comment appliquer les leçons tirées de l’intégration de la PTME pour intégrer le dépistage du DSG et les initiatives de prévention du DT2 dans les soins de santé primaires de routine en Afrique du Sud. Le cadre conceptuel adapté pour cette thèse permet ainsi de comprendre les aspects de l’intégration au niveau du patient et du système de santé, englobant les contextes, les mécanismes et la mise en œuvre de l’intégration d’interventions préventives dans les services existants. L'étude s'inscrit dans le cadre du projet IINDIAGO, « Intervention intégrée du système de santé visant à réduire les risques de diabète de type 2 chez les femmes défavorisées après un diabète gestationnel en Afrique du Sud ». La thèse présente d’abord une revue narrative de l’impact de la PTME sur les services et les systèmes de soins de santé en Afrique subsaharienne (Article 1). Les résultats de cette revue montrent que la PTME a eu l’impact positif et négatif sur d’autres services de soins de santé et que son intégration dans les systèmes de santé est de plus en plus privilégiée. L’article 2 est une étude qualitative analysant l’histoire et l’expérience locales de l’intégration de la PTME dans les SSP de routine en Afrique du Sud de différents points de vue. Bien qu’elle ait constaté un fort soutien en faveur de l’intégration parmi tous les répondants, cette étude a fait état de multiples obstacles à la pleine intégration de la PTME dans les SSP, le post-partum en particulier. Les articles 3 et 4 ont utilisé les méthodes mixtes et révélé que l’intégration des services dans les SSP de routine, à base communautaire, pour dépister universellement le DSG et pour prévenir ou retarder le DT2 après le DSG, était perçue comme faisable, acceptable et nécessaire de toute urgence en Afrique du Sud. L’article 6 (dont le protocole est l’article 5) présentait une revue systématique et une méta-analyse sur la prise en charge intégrée du DSG et du DT2 dans le contexte de la multimorbidité en Afrique. Les 13 études incluses dans cette étude ont montré que la gestion intégrée du DSG et du DT2 dans le cadre de la multimorbidité était mise en œuvre avec succès, mais qu’elle nécessitait une formation et une supervision adéquates des infirmières, et la fourniture d’équipements et de médicaments additionnels au sein des systèmes de santé nationaux en Afrique. Les conclusions de cette thèse suggèrent que, bien qu’elle n’ait pas toujours été retenue, en raison de défis structurels et opérationnels, l’intégration complète plutôt que partielle des services de santé est considérée comme souhaitable et réalisable par les femmes, les travailleurs de la santé, les gestionnaires et les experts. L’intégration complète pourrait être idéale pour dépister, diagnostiquer et soigner les maladies chroniques, y compris le DSG et le DT2, au sein des SSP de routine et selon l’approche de la PTME dont les leçons d’intégration n’ont pas été adaptées à ce prochain défi de santé publique.Integrating chronic, non-communicable diseases (NCDs) and their prevention into primary health care is the next major challenge for public health and health systems in low and middle-income countries like South Africa and is the primary focus of this thesis. The experience of integration of Prevention of Mother-to-Child Transmission (PMTCT) of HIV into primary health care (PHC) may have important lessons for integrating prevention of diabetes among women with recent gestational diabetes (GDM) into PHC. GDM was estimated to affect more than 9.1% of pregnancies in 2018 in South Africa. GDM increases the risk of developing subsequent type 2 diabetes (T2DM) more than 7-fold as well as increasing the risks of metabolic disorders for the babies of women who had GDM. This thesis conducted a systematised narrative synthesis, a systematic review and a convergent mixed methods study using primarily qualitative methods in South Africa (focus on Cape Town, Western Cape) to explore how to apply lessons from PMTCT integration in order to integrate GDM screening and T2DM prevention initiatives into routine PHC in South Africa. The adapted conceptual framework for this thesis enables to understand both patient-level and health system-level aspects of integration and encompassing the contexts, mechanisms and implementation for integrating preventive interventions in the existing services. The study was nested in the IINDIAGO project, “Integrated health system intervention aimed at reducing type 2 diabetes risks in disadvantaged women after gestational diabetes in South Africa”. The thesis first presents a narrative review of the impact of PMTCT on health care services and systems in sub-Saharan Africa (Paper 1). This review findings show that PMTCT has had positive and negative impacts on other health care services and that its integration into health systems is increasingly favored. Paper 2 qualitatively documented the local history and experience of PMTCT integration into routine PHC in South Africa from different perspectives. Though it found strong support for integration among all respondents (N=20), this study reported multiple barriers for the full integration of PMTCT into PHC, especially in postpartum. Papers 3 and 4 used mixed methods and highlighted that integrating services within routine, community-based PHC to universally screen GDM and to prevent or delay of T2DM after GDM, was perceived as feasible, acceptable and urgently needed in South Africa – but that it is not currently occurring at a satisfactory level, despite international and national guidelines. The fifth article is a published protocol for Paper 6, a systematic review and meta-analysis on the integrated management of GDM and T2DM in the context of multimorbidity in Africa. This was a study in which all 13 included studies showed that integrated management of GDM and T2DM within multimorbidity was successfully implemented but it required adequate training and supervision of nurses, provision of additional equipment and drugs to the existing resources within national health systems in Africa. This thesis concludes that although not always opted for, due to structural and operational challenges, the full instead of partial integration of health services to screen, diagnose and care for chronic diseases including GDM and T2DM into routine PHC, following the PMTCT approach, was seen as both desirable and feasible by women, health workers, managers, and experts. However, the lessons learned through the history of PMTCT and its integration have not been adapted to this next public health challenge

American Geriatrics Society and National Institute on Aging Bench-to-Bedside conference: sensory impairment and cognitive decline in older adults

This article summarizes the presentations and recommendations of the tenth annual American Geriatrics Society and National Institute on Aging Bench‐to‐Bedside research conference, “Sensory Impairment and Cognitive Decline,” on October 2–3, 2017, in Bethesda, Maryland. The risk of impairment in hearing, vision, and other senses increases with age, and almost 15% of individuals aged 70 and older have dementia. As the number of older adults increases, sensory and cognitive impairments will affect a growing proportion of the population. To limit its scope, this conference focused on sensory impairments affecting vision and hearing. Comorbid vision, hearing, and cognitive impairments in older adults are more common than would be expected by chance alone, suggesting that some common mechanisms might affect these neurological systems. This workshop explored the mechanisms and consequences of comorbid vision, hearing, and cognitive impairment in older adults; effects of sensory loss on the aging brain; and bench‐to‐bedside innovations and research opportunities. Presenters and participants identified many research gaps and questions; the top priorities fell into 3 themes: mechanisms, measurement, and interventions. The workshop delineated specific research questions that provide opportunities to improve outcomes in this growing population.Funding was provided by National Institutes of Health (NIH) Grant U13 AG054139-01. Dr. Whitson's efforts and contributions were supported by R01AG043438, R24AG045050, UH2AG056925, and 5P30AG028716. Dr. Lin's effort and contributions were also supported by R01AG055426, R01HL096812, and R33DC015062. (U13 AG054139-01 - National Institutes of Health (NIH); R01AG043438; R24AG045050; UH2AG056925; 5P30AG028716; R01AG055426; R01HL096812; R33DC015062)Accepted manuscrip

AN INVESTIGATION OF CHANGES IN DIABETES TRENDS AFTER THE AFFORDABLE CARE ACT

INTRODUCTION: Diabetes Mellitus (DM) is one of the fastest growing and most costly chronic diseases in the United States. DM is severely underdiagnosed, resulting in increased complications, costs, and mortality. Primary goals of the Affordable Care Act (ACA) were to increase health insurance coverage and access to care, and to improve chronic disease outcomes. However, the effects of the legislation have not been widely studied, particularly the relationship between proper diabetes diagnosis and a variety of health related factors. AIM: Determine the relationship between DM prevalence and under-diagnosis, to healthcare utilization, usual source of care, insurance, type of insurance, and population characteristics have changed since the implementation of the ACA. METHODS: Data collected between 2005 and 2016 in the National Health and Nutrition Examination Survey were used for this work. The Andersen behavioral health model was used as a theoretical framework and selection of study variables. Descriptive statistics and advanced statistical modeling techniques were applied. Distinct multilevel models were used to model the logit of the probability of DM and the logit of the probability of a proper DM diagnosis each as a function of study variables with an indicator of pre- or post-ACA included as a fixed effect. Marginal models are multilevel models that apply population averaged estimates for parameters. Marginal models were specified to account for clustering by time, and generalized estimating equations used to estimate model parameters. The quasi-likelihood under the null (QIC) statistic was estimated for model comparisons. The SAS Software System was used for data analysis and the level of significance set at .05. RESULTS: The sample consisted of 31,225 participants, with half pre-ACA (n=15,612) and half post-ACA. Females comprised 51.64% of the study sample with 43.50% White, 25.82% Hispanic, and 20.65% Black and a mean (standard deviation) age of 49.3 (17.9) years. About 11.45% of those in the Pre ACA period had a diagnosis of DM, while 13.5% of those in the Post ACA period had a diagnosis of DM. The percentage of uninsured was 23.95% in the Pre ACA period and 20.69% in the Post ACA time period. The prevalence of undiagnosed DM patients was 26.7% before the ACA, and 21.3% after. A multilevel model with DM status as the dependent outcome showed that sex (females vs males: OR=0.83, 95%CI=0.78,0.89,p =.02), USC (yes vs no: OR=1.28, 95%CI=1.03,1.59, p=.03), health insurance (yes vs no: OR=1.21, 95%CI=1.17,1.26, p =.02), and education level(college graduate vs less than high school: OR=0.79, 95%CI=0.64,0.97, p=.05, high school graduate vs less than high school: OR=0.97, 95%CI=0.93,1.03, p=.05) were significantly associated with presence of DM. Participants were more likely to have their DM properly diagnosed after the ACA: in the final multivariable multilevel model, only ACA time period had a significant effect on correct DM diagnosis (OR=1.51, 95%CI=1.24,1.85, p=.04). CONCLUSIONS: Although prevalence of DM has increased in recent years, under-diagnosis is less of an issue after the ACA. In the multivariable model comparing DM status (having the disease) to selected covariates, sex, health insurance, education, and USC were related to DM status. The ACA time period had no significant relationship with DM status in the multivariable model. However, in the multivariable model for correctly diagnosed DM, ACA time period was the only independent variable that had a significant association with correct DM diagnosis