Examining the Usefulness of Patient Documentation Forms as a Tool for Community Health Navigators: Findings from the ENCOMPASS Pilot Study

Introduction | Effective documentation of patient encounters may influence Community Health Navigators’ (CHNs) success in providing support to patients as well as provide a data source to examine CHN practices. The ENhancing COMmunity health through Patient navigation, Advocacy, and Social Support (ENCOMPASS) study, based in partnership between the University of Calgary and the Mosaic Primary Care Network (MPCN) is evaluating a CHN program to determine whether CHNs improve outcomes for patients with multiple chronic conditions. CHNs support their patients by helping them navigate the health system, connect to community resources, and access culturally appropriate support. The purpose of this study was to examine the quality and usefulness of CHN-patient documentation forms used in the ENCOMPASS pilot study (i.e., Initial Action Planning Form, Follow-up Action Planning Form, Patient Encounter Form, all implemented on the REDCap platform) and revise the documentation process using co-design with the end user. Methods | An iterative co-design quality improvement process was employed across three phases. First, content analyses were conducted on the Patient Encounter Form notes to examine how CHNs were using the forms and how they were documenting their activities. Second, a survey was distributed to CHNs to gather their perspectives about their experiences with the REDCap platform and the three forms. Third, a working group, consisting of four CHNs, met twice with research team members to discuss barriers to use and opportunities for improvement. Results | The REDCap platform and the three CHN-patient encounter forms did not adequately meet the needs of the CHNs. Content analysis revealed significant variation in how the Patient Encounter Form was utilized and various form sections were not completed as intended. In the survey, CHNs reported that the documentation experience was not satisfactory and the training that they had received to date was insufficient. The CHN working group suggested changes to the interface with the REDCap platform and form structure. Revisions were made based on these suggestions, and approved by the working group. Conclusions | The approved changes to REDCap and the three forms will be implemented and introduced to the CHN team. The research team will develop a patient encounter documentation guidelines document and will provide all members of the CHN team with the opportunity to receive re-training. These changes will be reviewed with the CHNs to continue the iterative quality improvement process. Prior to final implementation, consultation with the Clinical Research Unit administrators on the feasibility of the revisions made to the forms and interface with the REDCap platform will be held. The results of this study have the potential to provide a better overall experience for CHNs in the ENCOMPASS program and enhance their work with patients

Is current preoperative frailty assessment adequate?

Preoperative frailty predicts adverse postoperative outcomes. Recommendations for preoperative assessment of elderly patients include performing a frailty assessment. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical health care professionals’ perception and use of frailty assessment for perioperative care. We surveyed local health care employees to assess their attitudes toward and practices for frail patients. Nurses and allied health professionals were more likely than surgeons to agree frailty should play a role in planning a patient’s care. Lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians understanding that frailty affects their patients’ outcomes. Results of this survey suggest further training in frailty issues and the use of frailty assessment instruments is necessary and could improve the uptake of such tools for perioperative care planning

Is current preoperative frailty assessment adequate?

Preoperative frailty predicts adverse postoperative outcomes. Recommendations for preoperative assessment of elderly patients include performing a frailty assessment. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical health care professionals’ perception and use of frailty assessment for perioperative care. We surveyed local health care employees to assess their attitudes toward and practices for frail patients. Nurses and allied health professionals were more likely than surgeons to agree frailty should play a role in planning a patient’s care. Lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians understanding that frailty affects their patients’ outcomes. Results of this survey suggest further training in frailty issues and the use of frailty assessment instruments is necessary and could improve the uptake of such tools for perioperative care planning

Axon degeneration induces glial responses through Draper-TRAF4-JNK signalling

Draper/Ced-1/MEGF-10 is an engulfment receptor that promotes clearance of cellular debris in C. elegans, Drosophila and mammals. Draper signals through an evolutionarily conserved Src family kinase cascade to drive cytoskeletal rearrangements and target engulfment through Rac1. Glia also alter gene expression patterns in response to axonal injury but pathways mediating these responses are poorly defined. We show Draper is cell autonomously required for glial activation of transcriptional reporters after axonal injury. We identify TNF receptor associated factor 4 (TRAF4) as a novel Draper binding partner that is required for reporter activation and phagocytosis of axonal debris. TRAF4 and misshapen (MSN) act downstream of Draper to activate c-Jun N-terminal kinase (JNK) signalling in glia, resulting in changes in transcriptional reporters that are dependent on Drosophila AP-1 (dAP-1) and STAT92E. Our data argue injury signals received by Draper at the membrane are important regulators of downstream transcriptional responses in reactive glia

Linking public health agencies and hospitals for improved emergency preparedness: North Carolina's public health epidemiologist program

<p>Abstract</p> <p>Background</p> <p>In 2003, 11 public health epidemiologists were placed in North Carolina's largest hospitals to enhance communication between public health agencies and healthcare systems for improved emergency preparedness. We describe the specific services public health epidemiologists provide to local health departments, the North Carolina Division of Public Health, and the hospitals in which they are based, and assess the value of these services to stakeholders.</p> <p>Methods</p> <p>We surveyed and/or interviewed public health epidemiologists, communicable disease nurses based at local health departments, North Carolina Division of Public Health staff, and public health epidemiologists' hospital supervisors to 1) elicit the services provided by public health epidemiologists in daily practice and during emergencies and 2) examine the value of these services. Interviews were transcribed and imported into ATLAS.ti for coding and analysis. Descriptive analyses were performed on quantitative survey data.</p> <p>Results</p> <p>Public health epidemiologists conduct syndromic surveillance of community-acquired infections and potential bioterrorism events, assist local health departments and the North Carolina Division of Public Health with public health investigations, educate clinicians on diseases of public health importance, and enhance communication between hospitals and public health agencies. Stakeholders place on a high value on the unique services provided by public health epidemiologists.</p> <p>Conclusions</p> <p>Public health epidemiologists effectively link public health agencies and hospitals to enhance syndromic surveillance, communicable disease management, and public health emergency preparedness and response. This comprehensive description of the program and its value to stakeholders, both in routine daily practice and in responding to a major public health emergency, can inform other states that may wish to establish a similar program as part of their larger public health emergency preparedness and response system.</p

Factors associated with parents’ experiences using a knowledge translation tool for vaccination pain management: a qualitative study

Background: Vaccination is a common painful procedure for children. Parents’ concern regarding vaccination pain is a significant driver of vaccine hesitancy. Despite the wealth of evidence-based practices available for managing vaccination pain, parents lack knowledge of, and access to, these strategies. Knowledge translation (KT) tools can communicate evidence-based information to parents, however little is known about what factors influence parents’ use of these tools. A two-page, electronic KT tool on psychological, physical, and pharmacological vaccination pain management strategies for children, was shared with parents as part of a larger mixed methods study, using explanatory sequential design, exploring factors related to uptake of this KT tool. The aim of this qualitative study was to understand what influenced parents’ perceptions of the relevance of the KT tool, as well as their decision as to whether to use the tool. Methods: A qualitative descriptive design was used. A total of 20 parents of children aged 0–17 years (n = 19 mothers) reviewed the KT tool ahead of their child’s upcoming vaccination and participated in a semi-structured interview at follow-up. Interviews were recorded, transcribed verbatim, and analyzed with reflexive thematic analysis using an inductive approach. Results: The analysis generated three interrelated themes which described factors related to parents’ use of the KT tool: (1) Relevance to parents’ needs and circumstances surrounding their child’s vaccination; (2) Alignment with parents’ personal values around, and experiences with, vaccination pain management (e.g., the importance of managing pain); and (3) Support from the clinical environment for implementing evidence-based strategies (e.g., physical clinical environment and quality of interactions with the health care provider). Conclusions: Several factors were identified as central to parents’ use of the KT tool, including the information itself and the clinical environment. When the tool was perceived as relevant, aligned with parents’ values, and was supported by health care providers, parents were more inclined to use the KT tool to manage their children’s vaccination pain. Future research could explore other factors related to promoting engagement and uptake when creating parent-directed KT tools for a range of health-related contexts

A Combination of Two Human Monoclonal Antibodies Limits Fetal Damage by Zika Virus in Macaques

Human infection by Zika virus (ZIKV) during pregnancy can lead to vertical transmission and fetal aberrations, including microcephaly. Prophylactic administration of antibodies can diminish or prevent ZIKV infection in animal models, but whether passive immunization can protect nonhuman primates and their fetuses during pregnancy has not been determined. Z004 and Z021 are neutralizing monoclonal antibodies to domain III of the envelope (EDIII) of ZIKV. Together the two antibodies protect nonpregnant macaques against infection even after Fc modifications to prevent antibody-dependent enhancement in vitro (ADE) and extend their half-lives. Here we report on prophylactic co-administration of the Fc-modified antibodies to pregnant rhesus macaques challenged 3 times with ZIKV during first and second trimester. The two antibodies did not entirely eliminate maternal viremia but limited vertical transmission protecting the fetus from neurologic damage. Thus, maternal passive immunization with two antibodies to EDIII can shield primate fetuses from the harmful effects of ZIKV

Oxidized phospholipids are proinflammatory and proatherogenic in hypercholesterolaemic mice.

Oxidized phospholipids (OxPL) are ubiquitous, are formed in many inflammatory tissues, including atherosclerotic lesions, and frequently mediate proinflammatory changes 1 . Because OxPL are mostly the products of non-enzymatic lipid peroxidation, mechanisms to specifically neutralize them are unavailable and their roles in vivo are largely unknown. We previously cloned the IgM natural antibody E06, which binds to the phosphocholine headgroup of OxPL, and blocks the uptake of oxidized low-density lipoprotein (OxLDL) by macrophages and inhibits the proinflammatory properties of OxPL2-4. Here, to determine the role of OxPL in vivo in the context of atherogenesis, we generated transgenic mice in the Ldlr-/- background that expressed a single-chain variable fragment of E06 (E06-scFv) using the Apoe promoter. E06-scFv was secreted into the plasma from the liver and macrophages, and achieved sufficient plasma levels to inhibit in vivo macrophage uptake of OxLDL and to prevent OxPL-induced inflammatory signalling. Compared to Ldlr-/- mice, Ldlr -/- E06-scFv mice had 57-28% less atherosclerosis after 4, 7 and even 12 months of 1% high-cholesterol diet. Echocardiographic and histologic evaluation of the aortic valves demonstrated that E06-scFv ameliorated the development of aortic valve gradients and decreased aortic valve calcification. Both cholesterol accumulation and in vivo uptake of OxLDL were decreased in peritoneal macrophages, and both peritoneal and aortic macrophages had a decreased inflammatory phenotype. Serum amyloid A was decreased by 32%, indicating decreased systemic inflammation, and hepatic steatosis and inflammation were also decreased. Finally, the E06-scFv prolonged life as measured over 15 months. Because the E06-scFv lacks the functional effects of an intact antibody other than the ability to bind OxPL and inhibit OxLDL uptake in macrophages, these data support a major proatherogenic role of OxLDL and demonstrate that OxPL are proinflammatory and proatherogenic, which E06 counteracts in vivo. These studies suggest that therapies inactivating OxPL may be beneficial for reducing generalized inflammation, including the progression of atherosclerosis, aortic stenosis and hepatic steatosis

Loss of mTORC1 signaling alters pancreatic α cell mass and impairs glucagon secretion

Glucagon plays a major role in the regulation of glucose homeostasis during fed and fasting states. However, the mechanisms responsible for the regulation of pancreatic α cell mass and function are not completely understood. In the current study, we identified mTOR complex 1 (mTORC1) as a major regulator of α cell mass and glucagon secretion. Using mice with tissue-specific deletion of the mTORC1 regulator Raptor in α cells (αRaptorKO), we showed that mTORC1 signaling is dispensable for α cell development, but essential for α cell maturation during the transition from a milk-based diet to a chow-based diet after weaning. Moreover, inhibition of mTORC1 signaling in αRaptorKO mice and in WT animals exposed to chronic rapamycin administration decreased glucagon content and glucagon secretion. In αRaptorKO mice, impaired glucagon secretion occurred in response to different secretagogues and was mediated by alterations in KATP channel subunit expression and activity. Additionally, our data identify the mTORC1/FoxA2 axis as a link between mTORC1 and transcriptional regulation of key genes responsible for α cell function. Thus, our results reveal a potential function of mTORC1 in nutrient-dependent regulation of glucagon secretion and identify a role for mTORC1 in controlling α cell-mass maintenance

Factors associated with risk of evacuation failure from Hurricane Isabel in North Carolina, 2003

Important differences in evacuation exist across households. This study describes associations between social factors and evacuation from Hurricane Isabel by residents of North Carolina in 2003. Census blocks in three affected counties were stratified by flood zone and 30 census blocks were selected probability proportionate to population size from each flood zone. Within selected blocks, 7 random interview locations were chosen using a geographic information systems-based site selection tool. Risk differences and 95% confidence intervals for evacuation were calculated. High levels of neighborhood social cohesion, markers of territoriality (e.g., no trespassing signs), membership in church or civic organization, volunteerism, neighbors’ evacuation, and longer length of residence were associated with reduced hurricane evacuation. Differential levels of social capital, social cohesion, and related social factors contributed to differential rates of evacuation from Hurricane Isabel. Those who reported closer relationships with neighbors and were active volunteers in the community may be more susceptible to evacuation failure and should receive targeted messages regarding evacuation from officials