Developing priorities to achieve health equity through diabetes translation research: A concept mapping study

Introduction: The goal of diabetes translation research is to advance research into practice and ensure equitable benefit from scientific evidence. This study uses concept mapping to inform and refine future directions of diabetes translation research with the goal of achieving health equity in diabetes prevention and control. Research design and methods: This study used concept mapping and input from a national network of diabetes researchers and public health practitioners. Concept mapping is a mixed-method, participant-based process. First, participants generated statements by responding to a focus prompt ( Results: Ten clusters were identified containing between 6 and 12 statements from 95 total generated statements. The ranges of average importance and feasibility ratings for clusters were fairly high and narrow (3.62-4.09; 3.10-3.93, respectively). Clusters with the most statements in the go-zone quadrant (above average importance/feasibility) were Conclusions: This study created a framework of 10 priority areas to guide current and future efforts in diabetes translation research to achieve health equity. Themes rated as highly important and feasible provide the basis to evaluate current research support. Future efforts should explore how to best support innovative-targets, those rated highly important but less feasible

Peripheral-Blood Stem Cells versus Bone Marrow from Unrelated Donors

BACKGROUND Randomized trials have shown that the transplantation of filgrastim-mobilized peripheral-blood stem cells from HLA-identical siblings accelerates engraftment but increases the risks of acute and chronic graft-versus-host disease (GVHD), as compared with the transplantation of bone marrow. Some studies have also shown that peripheral-blood stem cells are associated with a decreased rate of relapse and improved survival among recipients with high-risk leukemia. METHODS We conducted a phase 3, multicenter, randomized trial of transplantation of peripheral-blood stem cells versus bone marrow from unrelated donors to compare 2-year survival probabilities with the use of an intention-to-treat analysis. Between March 2004 and September 2009, we enrolled 551 patients at 48 centers. Patients were randomly assigned in a 1:1 ratio to peripheral-blood stem-cell or bone marrow transplantation, stratified according to transplantation center and disease risk. The median follow-up of surviving patients was 36 months (interquartile range, 30 to 37). RESULTS The overall survival rate at 2 years in the peripheral-blood group was 51% (95% confidence interval [CI], 45 to 57), as compared with 46% (95% CI, 40 to 52) in the bone marrow group (P=0.29), with an absolute difference of 5 percentage points (95% CI, −3 to 14). The overall incidence of graft failure in the peripheral-blood group was 3% (95% CI, 1 to 5), versus 9% (95% CI, 6 to 13) in the bone marrow group (P=0.002). The incidence of chronic GVHD at 2 years in the peripheral-blood group was 53% (95% CI, 45 to 61), as compared with 41% (95% CI, 34 to 48) in the bone marrow group (P=0.01). There were no significant between-group differences in the incidence of acute GVHD or relapse. CONCLUSIONS We did not detect significant survival differences between peripheral-blood stem-cell and bone marrow transplantation from unrelated donors. Exploratory analyses of secondary end points indicated that peripheral-blood stem cells may reduce the risk of graft failure, whereas bone marrow may reduce the risk of chronic GVHD. (Funded by the National Heart, Lung, and Blood Institute–National Cancer Institute and others; ClinicalTrials.gov number, NCT00075816.

The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement

BACKGROUND: Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations' Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners. MAIN BODY: Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health. CONCLUSION: These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that - in any context - a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden

An Analysis of the Adoption and Implementation of Breastfeeding Policies in Washington State Clinics

Thesis (Master's)--University of Washington, 2016-12Background: The benefits of breastfeeding for the mother-infant dyad and broader society are well documented. While U.S. breastfeeding initiation rates have improved over the past decade, rates for exclusive breastfeeding and breastfeeding duration remain low, particularly for families from communities of color, low income households, and rural regions. Given the social and environmental barriers many families face, breastfeeding policies are a promising systems-level approach to address the disparities in breastfeeding support. Within the healthcare sector, increased coordination of care across healthcare settings can improve the consistency of support for families. While there have been increased efforts to improve hospital maternity care practices, less attention has been focused on the adoption and implementation of similar breastfeeding support strategies in clinics that reach families during prenatal and postnatal care. To achieve breastfeeding equity, breastfeeding policy initiatives must incorporate policy process research pertaining to clinics. Objective: To investigate how the process of developing evidence-based breastfeeding policies and practices is supported or hindered in clinic settings. Methods: This article describes a secondary qualitative analysis derived from a larger breastfeeding policy study in Washington State. For the primary study, the interview guide and coding scheme were developed based upon the Greenhalgh “Diffusion of Innovation in Service Organization Framework”. Members of a study advisory board initially invited clinic breastfeeding stakeholders to participate in the study; research team members followed-up with interested participants. Qualitative, semi-structured interviews were conducted with 19 clinic staff at 17 Washington state clinics via phone or in-person. Interviews were audio-recorded, transcribed, and analyzed using Atlas.ti software and thematic content analysis. The secondary analysis included an independent thematic content analysis of coded clinic transcripts and synthesis of the themes using the Greenhalgh framework. Results: Five components of the Greenhalgh framework help to describe the complex dynamics of policy adoption in clinics included characteristics of the innovation (in this case clinic breastfeeding policies), system antecedents, system readiness, communication & influence, and outer context. Factors that hindered breastfeeding policy adoption and implementation included negative perceptions of breastfeeding policies, inadequate knowledge-sharing networks, limited devoted resources, and lack of leadership buy-in. Components that facilitated the adoption of breastfeeding policies included positive perceptions of breastfeeding policies, engaged champions, adequate staff training, and external motivation through incentives and mandates. External mandates and incentives were catalysts for change. Discussion: The Greenhalgh framework provided an organization-level model to capture the complex dynamics in breastfeeding policy adoption and implementation. This study can inform future qualitative research and intervention strategies to increase the adoption and effective implementation of breastfeeding policies. The study findings support the need for coordinated breastfeeding services throughout the healthcare system, comprehensive mandates/incentives from accrediting bodies, and adequate technical support from public agencies. Conclusion: The systematic evaluation of dynamic breastfeeding policy adoption and implementation provides valuable insight into the drivers and obstacles of policy development. Clinics play an integral role in the breastfeeding continuum of care and would benefit form further policy process research, inclusion in breastfeeding initiatives, and adequate financial and technical support

Nursing Management of the Patient Undergoing Focused Ultrasound: A New Treatment Option for Essential Tremor.

Essential tremor (ET) is among the most common neurological movement disorders that causes postural or action tremors, with an estimated prevalence nationwide of less than 3% of the population. The incidence of ET increases with age but often affects younger adults and has a familial trait association. Depending on disease progression, ET can cause significant limitations for individuals, in many cases, significantly limiting their ability to perform activities of daily living and occupational responsibilities. Until recently, treatment of ET heavily relied on medication management and invasive surgery, such as deep brain stimulation. With advances in the use of focused ultrasound (FUS) for treatment of various medical conditions, recent clinical trials have revealed positive outcomes with the use of FUS as a less invasive approach to treat patients with medication-refractory ET. In a large academic medical center in the mid-Atlantic region, the Department of Neurosurgery conducted a continued access study, recently approved by the Food and Drug Administration, to evaluate the effectiveness of transcranial FUS thalamotomy for the treatment of medication-refractory ET. One patient's experience will be introduced, including discussion of evidence-based treatment options for ET and information on the nursing management of the patient undergoing FUS thalamotomy