Learning in a Virtual Environment to Improve Type 2 Diabetes Outcomes: Randomized Controlled Trial

BACKGROUND

Given the importance of self-management in type 2 diabetes mellitus (T2DM), a major aspect of health is providing diabetes self-management education and support. Known barriers include access, availability, and the lack of follow through on referral to education programs. Virtual education and support have increased in use over the last few years.

OBJECTIVE

The purpose of the Diabetes Learning in a Virtual Environment (LIVE) study was to compare the effects of the LIVE intervention (educational 3D world) to a diabetes self-management education and support control website on diet and physical activity behaviors and behavioral and metabolic outcomes in adults with T2DM over 12 months.

METHODS

The LIVE study was a 52-week multisite randomized controlled trial with longitudinal repeated measures. Participants were randomized to LIVE (n=102) or a control website (n=109). Both contained the same educational materials, but the virtual environment was synchronous and interactive, whereas the control was a flat website. Data were collected at baseline and 3, 6, and 12 months using surveys and clinical, laboratory, and Fitbit measures. Descriptive statistics included baseline characteristics and demographics. The effects of the intervention were initially examined by comparing the means and SDs of the outcomes across the 4 time points between study arms, followed by multilevel modeling on trajectories of the outcomes over the 12 months.

RESULTS

This trial included 211 participants who consented. The mean age was 58.85 (SD 10.1) years, and a majority were White (127/211, 60.2%), non-Hispanic (198/211, 93.8%), married (107/190, 56.3%), and female (125/211, 59.2%). Mean hemoglobin A1c (HbA1c) level at baseline was 7.64% (SD 1.79%) and mean BMI was 33.51 (SD 7.25). We examined weight loss status versus randomized group, where data with no weight change were eliminated, and the LIVE group experienced significantly more weight loss than the control group (P=.04). There were no significant differences between groups in changes in physical activity and dietary outcomes (all P>.05), but each group showed an increase in physical activity. Both groups experienced a decrease in mean HbA1c level, systolic and diastolic blood pressure, cholesterol, and triglycerides over the course of 12 months of study participation, including those participants whose baseline HbA1c level was 8.6% or higher.

CONCLUSIONS

This study confirmed that there were minor positive changes on glycemic targets in both groups over the 12-month study period; however, the majority of the participants began with optimal HbA1c levels. We did find clinically relevant metabolic changes in those who began with an HbA1c level >8.6% in both groups. This study provided a variety of resources to our participants in both study groups, and we conclude that a toolkit with a variety of services would be helpful to improving self-care in the future for persons with T2DM.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02040038; https://clinicaltrials.gov/ct2/show/NCT02040038.

A retrospective longitudinal study and comprehensive review of adult patients with glycogen storage disease type III

INTRODUCTION

A deficiency of glycogen debrancher enzyme in patients with glycogen storage disease type III (GSD III) manifests with hepatic, cardiac, and muscle involvement in the most common subtype (type a), or with only hepatic involvement in patients with GSD IIIb.

OBJECTIVE AND METHODS

To describe longitudinal biochemical, radiological, muscle strength and ambulation, liver histopathological findings, and clinical outcomes in adults (≥18 years) with glycogen storage disease type III, by a retrospective review of medical records.

RESULTS

Twenty-one adults with GSD IIIa (14 F & 7 M) and four with GSD IIIb (1 F & 3 M) were included in this natural history study. At the most recent visit, the median (range) age and follow-up time were 36 (19-68) and 16 years (0-41), respectively. For the entire cohort: 40% had documented hypoglycemic episodes in adulthood; hepatomegaly and cirrhosis were the most common radiological findings; and 28% developed decompensated liver disease and portal hypertension, the latter being more prevalent in older patients. In the GSD IIIa group, muscle weakness was a major feature, noted in 89% of the GSD IIIa cohort, a third of whom depended on a wheelchair or an assistive walking device. Older individuals tended to show more severe muscle weakness and mobility limitations, compared with younger adults. Asymptomatic left ventricular hypertrophy (LVH) was the most common cardiac manifestation, present in 43%. Symptomatic cardiomyopathy and reduced ejection fraction was evident in 10%. Finally, a urinary biomarker of glycogen storage (Glc4) was significantly associated with AST, ALT and CK.

CONCLUSION

GSD III is a multisystem disorder in which a multidisciplinary approach with regular clinical, biochemical, radiological and functional (physical therapy assessment) follow-up is required. Despite dietary modification, hepatic and myopathic disease progression is evident in adults, with muscle weakness as the major cause of morbidity. Consequently, definitive therapies that address the underlying cause of the disease to correct both liver and muscle are needed.

Perceptions of Glove Use During Vaccination: A Cross-Sectional Study

PURPOSE

To better understand clinic attendees' perceptions of nonsterile glove (NSG) use during vaccination and their concern for the environment.

DESIGN

This was a cross-sectional, self-administered, in-person survey.

METHODS

A nonrandom volunteer sample of vaccination clinic attendees (n = 789) completed a survey assessing their perception of NSG use during influenza vaccination administration and their concern for the environment.

FINDINGS

Nearly all respondents equated NSG use with increased safety and professionalism. More than half of respondents reported feeling concerned about environmental waste associated with NSG use.

CONCLUSIONS

NSG are not indicated for routine vaccination. Adherence to evidence-based practices on NSG use during vaccination can substantially reduce associated medical waste. Nurses can lead by example by only using NSG when indicated.

Machine Learning Algorithms to Predict Mortality and Allocate Palliative Care for Older Patients With Hip Fracture

OBJECTIVES

To evaluate a machine learning model designed to predict mortality for Medicare beneficiaries aged >65 years treated for hip fracture in Inpatient Rehabilitation Facilities (IRFs).

DESIGN

Retrospective design/cohort analysis of Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility-Patient Assessment Instrument data.

SETTING AND PARTICIPANTS

A total of 17,140 persons admitted to Medicare-certified IRFs in 2015 following hospitalization for hip fracture.

MEASURES

Patient characteristics include sociodemographic (age, gender, race, and social support) and clinical factors (functional status at admission, chronic conditions) and IRF length of stay. Outcomes were 30-day and 1-year all-cause mortality. We trained and evaluated 2 classification models, logistic regression and a multilayer perceptron (MLP), to predict the probability of 30-day and 1-year mortality and evaluated the calibration, discrimination, and precision of the models.

RESULTS

For 30-day mortality, MLP performed well [acc = 0.74, area under the receiver operating characteristic curve (AUROC) = 0.76, avg prec = 0.10, slope = 1.14] as did logistic regression (acc = 0.78, AUROC = 0.76, avg prec = 0.09, slope = 1.20). For 1-year mortality, the performances were similar for both MLP (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.96) and logistic regression (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.95).

CONCLUSION AND IMPLICATIONS

A scoring system based on logistic regression may be more feasible to run in current electronic medical records. But MLP models may reduce cognitive burden and increase ability to calibrate to local data, yielding clinical specificity in mortality prediction so that palliative care resources may be allocated more effectively.

Influence of Frailty on Discharge Setting for Older Adults With Hip Fracture at Inpatient Rehabilitation Facilities

Inpatient rehabilitation Facilities (IRFs) provide intensive rehabilitation therapy to patients to reduce functional impairment, enhance independence and return patients back to the community. Determination of eligibility for IRF is currently based on a preadmission screening. Frailty, a pervasive characteristic in older adults with hip fractures has not been examined as a clinical factor influencing function and discharge destination IRF outcomes. This study purpose was to determine the prevalence of frailty among older adult IRF patients with hip fractures and determine the association between frailty and function and discharge destination among IRF hip fracture patients. A retrospective cohort study design using CMS 2014 Inpatient Rehabilitation Facility-Patient Assessment Instrument file. Frailty was measured using a Frailty Index of 30 items. The final sample included 26,134 patients. Frailty, pre-frailty, and nonfrailty were present in 0.92% (n=24043), 3.3% (n=862), and .076% (n=199) of hip fracture patients, respectively. The majority (65%) of the patients were discharged home. There were significantly greater proportion of females than males discharged home and those of white race, 65 to 74 years of age, and those with higher functional status. Regression analysis showed significantly lower functional status at discharge (p < .0001) for males and those of non-white race, older age and frail. Study implications include the use of frailty status to identify hip fracture patients at high risk for adverse outcomes and need for future studies to explore the potential of frailty to provide value-added utility to IRF clinical settings and identify ongoing opportunities to guide person-centered care.

Analysis of Citation Patterns and Impact of Predatory Sources in the Nursing Literature

PURPOSE

This study was undertaken to learn how predatory journal articles were cited in articles published in legitimate (nonpredatory) nursing journals. The extent of citation and citation patterns were studied.

DESIGN

A two-phase approach was used.

METHODS

In Phase 1, 204 articles published in legitimate nursing journals that cited a predatory publication were randomly selected for analysis from a list of 814 articles with predatory journal citations. In Phase 2, the four predatory journal articles that were cited most frequently were analyzed further to examine their citation patterns.

FINDINGS

The majority (n = 148, 72.55%) of the articles that cited a predatory publication were research reports. Most commonly, the predatory article was only cited once (n = 117, 61.58%). Most (n = 158, 82.72%) of the predatory articles, though, were used substantively, that is, to provide a basis for the study or methods, describe the results, or explain the findings. The four articles in Phase 2 generated 38 citations in legitimate journals, published from 2011 to 2019, demonstrating persistence in citation. An evaluation of the quality of these articles was mixed.

CONCLUSIONS

The results of this study provide an understanding of the use and patterns of citations to predatory articles in legitimate nursing journals. Authors who choose predatory journals as the channel to disseminate their publications devalue the work that publishers, editors, and peer reviewers play in scholarly dissemination. Likewise, those who cite these works are also contributing to the problem of predatory publishing in nursing.

CLINICAL RELEVANCE

Nurse authors should not publish their work in predatory journals and should avoid citing articles from these journals, which disseminates the content through the scholarly nursing literature.

Citations of articles in predatory nursing journals

BACKGROUND

Nursing journals from predatory publication outlets may look authentic and seem to be a credible source of information. However, further inspection may reveal otherwise.

PURPOSE

The purpose of this study was to analyze publication and dissemination patterns of articles published in known predatory nursing journals.

METHOD

Using Scopus, reference lists were searched for citations from seven identified predatory nursing journals. Bibliographic information and subsequent citation information were then collected and analyzed.

FINDINGS

A total of 814 citations of articles published in predatory nursing journals were identified. Further analysis indicated that these articles were cited in 141 nonpredatory nursing journals of various types.

DISCUSSION

Predatory nursing journals continue to persist, yet fewer may now be in existence. Education and information may help authors and reviewers identify predatory journals, thereby discouraging submissions to these publications and hesitancy among authors to cite articles published in them.

Predicting Colorectal Cancer Screening among Adults Who Have Never Been Screened: Testing the Interaction between Message Framing and Tailored Risk Feedback

Providing adults tailored risk estimates of getting colorectal cancer (CRC) can increase screening. A concern is that receipt of lower risk estimates will demotivate screening; this effect may be curbed by matching level of risk with message framing. Theoretically, pairing lower risk estimates with gain-frame messages, and higher risk estimates with loss-frame messages, should increase screening and screening intentions more than pairing lower risk estimates with loss-frame messages/higher risk estimates with gain-frame messages. These effects may be mediated by how screening is construed (e.g., to find health problems vs. to reaffirm one is healthy). These predictions were tested experimentally among 560 men and women ages 50-75 who have never screened. Participants at baseline received online a tailored comparative risk estimate with gain- or loss-frame information on screening. Screening was assessed six months later. Among the 400 reached at six months, 9.5% reported screening. There were no main effects or interactions between risk feedback and framing predicting construals, screening intentions, or screening. Worry about getting CRC and screening intentions predicted screening. While hypothesized interactions were not found, future research should explore further mechanisms through which online interventions utilizing risk feedback and framing motivate screening among adults who have never screened.

Guidance Provided to Authors on Citing and Formatting References in Nursing Journals

Reference citations should be accurate, complete, and presented in a consistent format. This study analyzed information provided to authors on preparing citations and references for manuscripts submitted to nursing journals (n = 209). Half of the journals used the American Psychological Association reference style. Slightly more than half provided examples of how to cite articles and books; there were fewer examples of citing websites and online journals. Suggestions on improving accuracy of references are discussed.

Quality of Author Guidelines in Nursing Journals

Purpose

The aims of this study were to (a) describe the information provided in author guidelines in nursing journals, (b) assess the completeness of this information, and (c) identify the extent and types of reporting guidelines used in nursing journals.

Design

Content analysis of author guidelines for 245 nursing journals included in the Directory of Nursing Journals maintained at the International Academy of Nursing Editors website.

Methods

Using Research Electronic Data Capture, data on 19 criteria for completeness were extracted from published author guidelines. Additional details about journal requirements, such as allowed length of manuscripts and format for the abstract, were also recorded. Reliability was established by simultaneous review of 25 journals (10%) by the research assistant and a senior member of the research team.

Findings

Author guidelines were easily accessible at journal websites or through links to download the information. A majority (73.5%) had completeness scores of 75% or higher; six journals had guidelines that were 100% complete. Half of the journals used the American Psychological Association reference style, and 26.3% used the American Medical Association style. Less than one fourth had stated requirements to use reporting guidelines such as Consolidated Standards of Reporting Trials (CONSORT) and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA).

Conclusions

Author guidelines for nursing journals are generally complete and informative. Although specific reporting guidelines such as CONSORT and PRISMA improve the accuracy and completeness of manuscripts on various types of studies, most nursing journals do not indicate use of these for manuscript preparation. Editors who want to improve their author guidelines should use the 19 criteria for completeness as a gauge for updating and revision.

Clinical Relevance

Nurses rely on the published literature to inform their practice and ensure that it is based on evidence. Guidelines for publishing in the scholarly literature assist clinicians and scholars to ensure that published articles are complete, current, concise, and accurate.

Reactions to online colorectal cancer risk estimates among a nationally representative sample of adults who have never been screened

Data on the public's reactions to online tailored colorectal cancer (CRC) risk estimates are sparse. We assessed among 560 men and women aged 50-75 with no CRC screening history reactions to online tailored CRC estimated comparative risk (i.e., self vs. other their age and sex). Assessed were reactions to estimate (i.e., repeating back estimate, match between perceived comparative risk and estimate, accuracy and usefulness of estimate, emotional reactions), risk appraisals and screening intentions. 73% of the sample accurately repeated back their estimate; the match between perceived comparative risk and the estimate was lowest among those informed of being at higher risk. Higher estimates were viewed as less useful and evoked more negative emotions. Viewing the estimate as more useful and experiencing more negative emotions were related with higher risk appraisals and, in turn, screening intentions. These data indicate that adults at higher comparative risk resist accepting a higher risk status.

Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes: A Cluster-Randomized Trial

IMPORTANCE

New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls.

OBJECTIVE

To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS).

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls.

INTERVENTIONS

CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality's Falls Management Program.

MAIN OUTCOMES AND MEASURES

Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate.

RESULTS

Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration.

CONCLUSIONS AND RELEVANCE

An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00636675.

Four Conversations: A randomized control trial of an online, shared decision making curriculum among the metastatic breast cancer community

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Background: Evidence shows that shared decision making is effective in improving the quality of end of life care, and that it rarely happens; new interventions are needed. Four Conversations is an evidence-based, online curriculum that facilitates shared decision making. This presentation will report the impact of Four Conversations on key outcomes. Methods: Individuals with metastatic breast cancer and caregivers are being recruited nationally. Consenting participants are randomized 1:1 to the treatment or wait-listed control arm. Treatment arm participants access content online; required activities included viewing interactive videos and completing workbook activities. Surveys are administered at Baseline, Week-4, and Week-8 via REDCap to assess for: decision making self-efficacy and conflict; and program satisfaction. An independent-samples t-test was conducted to compare change in decision making outcomes in treatment and usual care conditions at Week-4. A paired-samples t-test was used to access for changes in outcomes from Baseline to Week-8 among the treatment arm. Results: Participants (n = 138) were: mean age 53.2 (11.8) years; 96% female; 91% white; 72% married. There was significant improvement in decision making self-efficacy and reduction in conflict among the treatment arm at follow-up (p < .05). There was no significant change in decision making self-efficacy and conflict scores for treatment and wait-listed control conditions at the end of the intervention (p > .05). Among treatment arm participants who did not already have an advanced care directive, most (56%) completed one. Most participants (88%) would recommend Four Conversations to others and felt that the program better prepared them to make better decisions. Conclusions: While these results are preliminary (i.e., data collection continues through 9/2017), they suggest that Four Conversations may effect decision-making outcomes for metastatic breast cancer patients and caregivers. Additional research is recommended with larger and more diverse samples following completion of this study. Clinical trial information: NCT02944344.

Quality of articles published in predatory nursing journals

BACKGROUND

Predatory journals exist in nursing and lack the safeguards of traditional publishing practices.

PURPOSE

To examine the quality of articles published in predatory nursing journals.

METHOD

Randomly selected articles (n = 358) were reviewed for structural content and eight quality indicators.

FINDINGS

Two-thirds (67.4%) of the articles were published between 2014 and 2016, demonstrating the acceleration of publications in predatory nursing journals. The majority (75.9%) of the articles were research reports. Most followed the IMRAD presentation of a research report but contained errors, or the study was not pertinent to the nursing discipline.

CONCLUSIONS

Nursing research published in predatory journals may appear legitimate by conforming to an expected structure. However, a lack of quality is apparent, representing inadequate peer review and editorial processes. Poor quality research erodes the scholarly nursing literature.

A randomized control trial (RCT) of an online, symptom self-management curriculum (Reimagine) among breast cancer survivors

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Background: Chronic pain, depression, and fatigue are common effects resulting from the cancer experience (e.g., disease, treatment); new interventions are needed. Reimagine is an online symptom self-management program that teaches coping skills. This presentation will report on the impact of Reimagine on key health outcomes. Methods: Adult breast cancer survivors with chronic pain were recruited from the Susan Love Army of Women volunteer registry. Consenting participants were randomized 1:1 to the treatment or usual care condition and completed surveys at Baseline and 18 weeks (post-intervention). Treatment arm participants accessed content online; required activities included viewing online videos, attending online group meetings, and completing cognitive reframing exercises. Surveys were administered via REDCap to assess for pain severity and interference (primary outcome), depression, fatigue, and program satisfaction. An independent-samples t-test was conducted to compare change in pain, depression, and fatigue outcomes in treatment and usual care conditions. Results: Participants (n = 91) were: mean age 56.4 ± 8.8 years; 99% female; 94% white; 67% married; 46% employed; mean time since diagnosis 7.9 ± 6.4 years; and 89% were in remission or cured of their breast cancer. There was a significant difference in the change in depression scores for treatment (M = -1.7, SD = 4.7) and usual care (M = 0.3, SD = 3.8) conditions; t (82) = -2.1, p = 0.035. Difference in the change in fatigue scores was significant for treatment (M = 4.8, SD = 9.1) and usual care (M = 1.2, SD = 6.6) conditions; t (84) = 2.1, p = .038. No significant differences were found in the change in pain outcomes for treatment and usual care conditions (p > .05). Most treatment arm participants (94%) would recommend Reimagine to others and 85% felt more resilient at study completion. Conclusions: These results suggest that Reimagine has an effect on depression and fatigue symptoms for breast cancer survivors. Additional research is recommended with larger and more diverse samples. Trial (NCT02465892) was funded by Pfizer, Inc. Clinical trial information: NCT02465892.

Amplification with molecular beacon primers and reverse line blotting for the detection and typing of human papillomaviruses

A novel method for the detection and typing of human papillomavirus (HPV) was developed using molecular beacon primers. The method is based on the use of HPV-specific primers containing a hairpin loop structure in which fluorescent donor and quencher groups are held in close proximity such that fluorescence is quenched. Amplification of the target sequence results in the opening of the loop and the resulting fluorescence can be detected on a sequence detector system (SDS) 7700 (Applied Biosystems), as used for TaqMan assays. Fluorescent amplicons were identified on the SDS 7700 and then typed by a single hybridisation with specific probes immobilised in lines on a nylon membrane and detected on a fluorescent scanner. This novel beacon primer method compared well with conventional PCR for cervical scrape specimens. The combination of the beacon primer method and reverse line blotting should enable large-scale population studies of HPV infection.