A Quality Improvement Initiative to Provide Comprehensive Diabetic Management in a Rural Midwestern Clinic

An estimated 25.8 million people in the United States (US) have diabetes (Center for Disease Control and Prevention [CDC], 2014). The 2010 Patient Protection and Affordable Care Act led to an increased focus on Quality Improvement (QI) programs to reduce healthcare associated expenditures (Patient Protection and Affordable Care Act, 2010). The purpose of this Doctor of Nursing Practice (DNP) project was to address the following clinical question: Can the comprehensive diabetic bundle of quality metrics for type 2 diabetes mellitus (T2DM) patients in a rural Midwestern clinic be improved through (1) the creation of a QI protocol, (2) increased provider and staff education regarding quality metrics, and (3) the optimal use of QI dashboard software? The DNP project utilized the Donabedian model as the conceptual model to explore the phenomenon of interest, improving the quality of diabetes management. The Promoting Action on Research Implementation in Health Services (PARiHS) framework served as the implementation model to guide the design and development of the implementation strategies to support the evidence-based interventions. The interventions designed to answer this clinical question were: (1) the utilization of the Symphony Performance Health (SPH) QI dashboard software to obtain a T2DM QI metrics baseline, (2) development of a diabetic QI protocol regarding electronic health record (EHR) documentation on diabetes management and optimal SPH QI dashboard software utilization, (3) implementation and evaluation of an educational session intervention on T2DM QI metrics, and (4) the utilization of SPH QI dashboard software to obtain the overall changes in T2DM QI metrics. As a result of these interventions, 5 of 12 (41.6%) diabetic quality metrics were improved with significance (p= 0.05). After the implementation of this DNP project, 4 out of 12 diabetic quality metrics have met the National Committee for Quality Assurance (NCQA) QI metric benchmark percentiles. Prior to this DNP project, only one of the T2DM QI metrics met the NCQA diabetic QI metric benchmark percentiles. This improvement in quality indicator metrics demonstrated the effectiveness of a continuous multicomponent QI initiative to impact care in a rural primary care practice

The ‘truth’ about idiocy: Revisiting files of children in the Dutch ‘School for Idiots’ in the nineteenth century

In 1855 the Revd C. E. Van Koetsveld established his ‘School for Idiots’ in The Hague. Within two years, he had also opened a boarding facility that accommodated many of his pupils. Legal regulations demanded authorisation for a child to be placed in this asylum. This procedure included a questionnaire on the condition of the child. The paper discusses the analysis of data included in the files of 187 children admitted to Van Koetsveld’s institution between 1857 and 1873. In an earlier examination of these data, the author was intrigued about what could be inferred from these data. In this paper the same question is addressed from a new angle by applying the theoretical and methodological perspective of ‘praxeography’. This approach reveals the logic behind the process of inscribing characteristics on vulnerable children. Moreover, the analysis shows how children’s inner worlds were opened up for further examination and social intervention.Development Psychopathology in context: clinical setting

Genetic diversity, aggressiveness and metalaxyl sensitivity of Pythium aphanidermatum populations infecting cucumber in Oman

Seventy three isolates of Pythium aphanidermatum obtained from cucumber from four different regions of Oman and 16 isolates of muskmelon from the Batinah region in Oman were characterized for aggressiveness, sensitivity to metalaxyl and genetic diversity using AFLP fingerprinting. Twenty isolates of P. aphanidermatum from diverse hosts from different countries were also included in the study. Most isolates from Oman were found to be aggressive on cucumber seedlings and all were highly sensitive to metalaxyl (EC50 0.05), which implies a lack of host specialization in P. aphanidermatum on these two hosts in Oman. AFLP analysis of all isolates using four primer-pair combinations resolved 152 bands, of which 61 (~40%) were polymorphic. Isolates of P. aphanidermatum from Oman and other countries exhibited high genetic similarity (mean = 94.1%) and produced 59 different AFLP profiles. Analysis of molecular variance indicated that most AFLP variation among populations of P. aphanidermatum in Oman was associated with geographical regions (FST = 0.118; P < 0.0001), not hosts (FST = -0.004; P = 0.4323). These data were supported by the high rate of recovery (24%) of identical phenotypes between cucumber and muskmelon fields in the same region as compared to the low recovery (10%) across regions in Oman, which suggests more frequent movement of Pythium inoculum among muskmelon and cucumber fields in the same region compared to movement across geographically separated regions. However, recovering clones among regions and different countries may imply circulation of Pythium inoculum via common sources in Oman and also intercontinental spread of isolates

Changes in the Racial Composition of Phytophthora sojae in Australia Between 1979 and 1996

Surveys of commercial soybean fields, disease nurseries, and trial plots of soybean were conducted throughout eastern Australia between 1979 and 1996, and 694 isolates of Phytophthora sojae were collected and classified into races. Fourteen races, 1, 2, 4, 10, 15, and 25, and eight new races, 46 to 53, were identified, but only races 1, 4, 15, 25, 46, and 53 were found in commercial fields. Races 1 and 15 were the only races found in commercial fields in the soybean-growing areas of Australia up until 1989, with race 1 being the dominant race. Race 4 was found in central New South Wales in 1989 on cultivars with the Rps1a gene, and it is now the dominant race in central and southern New South Wales. Races 46 and 53 have only been found once, in southern New South Wales, and race 25 was identified in the same region in 1994 on a cultivar with the Rps1k gene. Only races 1 and 15 have been found in the northern soybean-growing regions, with the latter dominating, which coincides with the widespread use of cultivars with the Rps2 gene. Changes in the race structure of the P. sojae population from commercial fields in Australia follow the deployment of specific resistance genes

Field evaluation of tolerance to Tobacco streak virus in sunflower germplasm, and observations of seasonal disease spread

Strong statistical evidence was found for differences in tolerance to natural infections of Tobacco streak virus (TSV) in sunflower hybrids. Data from 470 plots involving 23 different sunflower hybrids tested in multiple trials over 5 years in Australia were analysed. Using a Bayesian Hierarchical Logistic Regression model for analysis provided: (i) a rigorous method for investigating the relative effects of hybrid, seasonal rainfall and proximity to inoculum source on the incidence of severe TSV disease; (ii) a natural method for estimating the probability distributions of disease incidence in different hybrids under historical rainfall conditions; and (iii) a method for undertaking all pairwise comparisons of disease incidence between hybrids whilst controlling the familywise error rate without any drastic reduction in statistical power. The tolerance identified in field trials was effective against the main TSV strain associated with disease outbreaks, TSV-parthenium. Glasshouse tests indicate this tolerance to also be effective against the other TSV strain found in central Queensland, TSV-crownbeard. The use of tolerant germplasm is critical to minimise the risk of TSV epidemics in sunflower in this region. We found strong statistical evidence that rainfall during the early growing months of March and April had a negative effect on the incidence of severe infection with greatly reduced disease incidence in years that had high rainfall during this period

Nummular keratopathy in a patient with Hyper-IgD Syndrome

<p>Abstract</p> <p>Purpose</p> <p>To report a case of recurrent nummular keratitis in a pediatric patient with Hyperimmunoglobulinemia D syndrome.</p> <p>Methods</p> <p>A retrospective chart review.</p> <p>Results</p> <p>A 14-year-old boy with Hyperimmunoglobulinemia D syndrome (HIDS) presented with photophobia and ocular irritation concomitant with disease exacerbation. He was found on exam to have significant nummular keratitis, which responded to a short course of topical steroids. Despite acute response to local immunosuppression, the patient had several recurrent attacks and eventually developed a large corneal scar and decreased vision. After initiation of infliximab therapy his ocular sequelae improved dramatically and his vision returned to 20/20.</p> <p>Conclusion</p> <p>One possible form of end-organ damage associated with HIDS is vision threatening nummular keratopathy.</p

Dry flower disease of Macadamia in Australia caused by Neopestalotiopsis macadamiae sp. nov. and Pestalotiopsis macadamiae sp. nov

Incidence of dry flower disease of macadamia (Macadamia integrifolia), expressed as blight of the flowers, necrosis and dieback of the rachis, is increasing in Australia. In the 2012/13 production season, incidence of dry flower disease resulted in 10% to 30% yield loss in the affected orchards. Etiology of the disease has not been established. This study was established to characterise the disease and identify the causal pathogen. A survey of the major macadamia producing regions in Australia revealed dry flower disease symptoms, regardless of cultivar or location at all stages of raceme development. Based on colony and conidial morphology, the majority (41%) of fungal isolates obtained from tissue samples were identified as Pestalotiopsis and Neopestalotiopsis spp. The phylogeny of the combined partial sequence of the internal transcribed spacer, beta-tubulin and translation elongation factor 1-alpha gene loci, segregated the isolates into two well supported clades, independent of location or part of the inflorescence affected. Further morphological examination supported the establishment of two new species, which are formally described as Neopestalotiopsis macadamiae sp. nov. and Pestalotiopsis macadamiae sp. nov. Using spore suspensions of isolates of both species, Koch?s postulates were fulfilled on three macadamia cultivars at all stages of raceme development. To our knowledge, this is the first report of species of Neopestalotiopsis and Pestalotiopsis as causal agents of inflorescence disease in macadamia

Abuse in the caregiving relationship between older people with memory disorders and family caregivers: A systematic review

Aim To synthesize what is known about elder abuse and relationship factors associated with abuse between caregivers and older people with memory disorders at home. Background Concerns about abuse in the caring relationship between older people with memory disorders and family caregivers have increased. Abuse is associated with negative outcomes on older people's health, quality of life, and zest for life. Abuse in the caring relationship manifests in financial exploitation, neglect, mistreatment, and physical issues. Design Systematic review. Data Sources Databases including Scopus, PubMed/Medline, SveMed+, Cinalh, SonINDEX, and ProQuest were searched using keywords about abuse in the caring relationship between older people with memory disorders and family caregivers at home. Articles published between 2005–2019 were retrieved and underwent data analysis and knowledge synthesis. Review Methods The review was presented under the categories of the dyadic approach of elder abuse in connection with the role of caregiver (risk) and care recipient (vulnerability) by Fulmer et al. (2005). Results The search process led to 12 quantitative studies, including an intervention, a prospective, nine surveys, and a cross‐sectional structural interview. Findings were synthesized and presented under ‘personal’, ‘physical and psychological’, and ‘social’ domains indicating the bilateral roles of caregiver and care recipient leading to abuse. Conclusion This review depicted factors influencing abuse in the caring relationship between older people with memory disorders and their family caregivers at home. They included family caregivers’ psychological issues, knowledge of memory disorders and modifications, previous caring relationship, social support, number of care recipients, and care recipients’ functional level. Impact This review identifies what influences elder abuse by family caregivers using the dyadic approach and explains how abuse can be prevented through suggested strategies. The review findings are relevant to multidisciplinary healthcare providers and can guide the provision of support, screening and assessment, educational programs, and legislative initiatives