Jennifer Pillay

Guidance on Performing Focused Ethnographies with an Emphasis on Healthcare Research

Focused ethnographies can have meaningful and useful application in primary care, community, or hospital healthcare practice, and are often used to determine ways to improve care and care processes. They can be pragmatic and efficient ways to capture data on a specific topic of importance to individual clinicians or clinical specialities. While many examples of focused ethnographies are available in the literature, there is a limited availability of guidance documents for conducting this research. This paper defines focused ethnographies, locates them within the ethnographic genre, justifies their use in healthcare research, and outlines the methodological processes including those related to sampling, data collection and maintaining rigour. It also identifies and provides a summary of some recent focused ethnographies conducted in healthcare research. While the emphasis is placed on healthcare research, focused ethnographies can be applicable to any discipline whenever there is a desire to explore specific cultural perspectives held by sub-groups of people within a context-specific and problem-focused framework. Keywords: Focused Ethnography, Healthcare Research, Qualitative Methodology, Guidance

Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis

In 2012, 29.1 million Americans had diabetes with costs of

Electrical Impedance to Distinguish Intraneural from Extraneural Needle Placement in Porcine Nerves during Direct Exposure and Ultrasound Guidance

245 billion (1), representing 11% of the total U.S. health care expenditure (2). Although tight glycemic control may reduce the risk for microvascular complications in type 2 diabetes mellitus (T2DM) (3), behavioral and pharmacologic management of body weight, blood pressure, and cholesterol levels are often needed to reduce the risk for mortality and macrovascular complications. Moreover, other patient-centered outcomes, such as diabetes-related distress and depression, are important to address (4). Health care experts recommend that anyone with diabetes adopt and adhere to multiple self-care behaviors, including healthy eating, being active, monitoring, taking medication, problem-solving, healthy coping, and reducing risks (5). Approaches to support behavior change include diabetes self-management education (DSME) with or without an added support (clinical, behavioral, psychosocial, or educational) phase, and lifestyle programs. Because knowledge acquisition insufficiently promotes behavioral changes (6), recommendations for DSME have shifted from traditional didactic educational services to more patient-centered methodologies that incorporate interaction, problem-solving, and other behavioral approaches. Although evidence shows that diabetes-specific behavioral interventions can be effective, which combination of program components and delivery mechanisms is most effective is unclear (711). We conducted a network meta-analysis to identify factors related to program components and delivery mechanisms that moderate the effectiveness of multicomponent behavioral programs for T2DM. Methods Key informants, a technical expert panel, and public commentary informed our methods. A protocol and a peer- and public-reviewed technical report were produced for the Agency for Healthcare Research and Quality (AHRQ) and are available online (www.ahrq.gov/research/findings/evidence-based-reports/). Data Sources and Searches A research librarian searched the following bibliographic databases from 1993 to January 2015: Ovid MEDLINE (Appendix Table 1) and Ovid MEDLINE In-Process & Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials via the Cochrane Library, EMBASE via Ovid, CINAHL Plus with Full Text via EBSCOhost, PsycINFO via Ovid, Scopus, and PubMed via the National Center for Biotechnology Information Databases. We reviewed the reference lists of relevant systematic reviews and of all included studies. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, relevant conference proceedings (2011 through 2014), and the U.S. Federal Register. Appendix Table 1. Search Strategy for MEDLINE* Study Selection We included studies conducted in highly developed countries published in English after 1993 (because medical management for diabetes intensified after this time). We included randomized, controlled trials done in community or outpatient health settings and involving adults that compared a behavioral program with usual care (medical management provided to all participants), an active control (intervention not meeting our definition of behavioral program), or another behavioral program (comparative effectiveness study). A behavioral program was a multicomponent, diabetes-specific program that included repeated interactions with trained individuals over at least 4 weeks, and that consisted of DSME using a behavioral approach or another program format including at least a structured dietary or physical activity intervention with another component (Appendix). We excluded abstracts and studies in which the intervention was a disease or care management program (for example, with active adjustment of diabetes-related medications) (12) or a quality improvement program incorporating strategies targeting health systems or providers (13). Other exclusion criteria included studies 1) focusing on patients with newly diagnosed (1 year) disease; 2) with no outcome of interest to this review (for example, only C-reactive protein), or in which the only difference between the study groups was a factor outside of the reviews scope (for example, low- vs. high-fat diet); and 3) in which 25% or more of the participants had type 1 diabetes mellitus (unless results were reported for those with T2DM). Two reviewers independently screened all titles and abstracts, and the full text of any publication marked for inclusion was retrieved. Two reviewers independently assessed the full texts by using a priori inclusion criteria and a standard form. We resolved disagreements by consensus or consultation with a third reviewer. Data Extraction and Quality Assessment One reviewer extracted data by using a structured form created in the Systematic Review Data Repository (available at http://srdr.ahrq.gov/) (14); a second reviewer verified data. Two reviewers independently applied the Cochrane risk of bias tool (15). Discrepancies were resolved through discussion. Data Synthesis and Analysis With input from technical experts, we categorized behavioral programs by various component and delivery factors (Table). We separated DSME and DSME plus support, in recognition that the support phase of the latter was often of lower intensity (less frequent contacts) and focused on different content, such as psychosocial support. Table. Categorization of Program Components and Delivery Factors To serve as an overview of program effectiveness and help interpret our primary analysis of program moderation, we performed pairwise meta-analyses by using the HartungKnappSidikJonkman random-effects model (16, 17) for multiple behavioral, clinical, and health outcomes, as well as health care utilization and program acceptability (the full report is available at www.ahrq.gov/research/findings/evidence-based-reports/). We defined thresholds for clinical importance where there was guidance: For hemoglobin A1c (HbA1c), we used a reduction of at least 0.4% (for example, 7.6% vs. 8.0%) (18); for quality-of-life measures and other patient-reported outcomes, we used a conservative value of one-half SD (19, 20). We then conducted a network meta-analysis that allowed simultaneous evaluation of a suite of comparisons and considered both direct and indirect evidence while preserving the within-study randomization. To assure the transitivity within the network, we categorized all behavioral programs and comparators into nodes. The nodes for behavioral programs were formed on the basis of different combinations of variables in our program categorization (Appendix Table 2); we identified all plausible nodes differing by only one variable (for example, a level within the intensity category) and then filled the nodes with the applicable interventions on the basis of our coding. The nodes for the comparator groups were categorized as usual care, active non-DSME control (education interventions not meeting our criteria), and active other control (for example, stand-alone dietary or physical activity interventions). Appendix Table 2. Characteristics of Studies of Behavioral Programs for T2DM Appendix Table 2Continued Appendix Table 2Continued Appendix Table 2Continued Appendix Table 2Continued Appendix Table 2Continued Appendix Table 2Continued Appendix Table 2Continued Appendix Table 2Continued The analysis was conducted by using a Bayesian network model to compare all interventions simultaneously and to use all available information on treatment effects in a single analysis (21, 22). These methods ensure that correlation in multigroup trials is preserved. Mean differences (MDs) were modeled using noninformative prior distributions. A normal prior distribution with mean 0 and large variance (10000) was used for each of the trial means, whereas their between study variance had a uniform prior with range 0 to 2. These priors were checked for influence with sensitivity analyses. Markov chain Monte Carlo simulations using WinBugs software were performed to obtain simultaneous estimates of all interventions compared with placebo, as well as estimates of which interventions were the best. A burn-in sample of 20000 iterations was followed by 300000 iterations used to compute estimates. A sensitivity analysis that thinned the amount of used data to every 10th iteration was also conducted to check for proper chain convergence. The analysis was checked for consistency by contrasting direct and indirect estimates in each triangular and quadratic loop by using the methods described by Veroniki and colleagues (23). Results are presented as estimates of the treatment effects (MD) relative to usual care, with 95% credible intervals. To examine different population subgroups, we conducted subgroup analyses of the pairwise meta-analysis results for HbA1c at longest follow-up in comparison with usual care and active controls; subgroups were defined on the basis of study-level baseline HbA1c (<7% vs. 7%), age (<65 vs. 65 years), and ethnicity (75 vs. <75% nonwhite), according to categories that were defined a priori. For baseline HbA1c level and age, we performed subgroup analyses of the network meta-analysis; the analysis was rerun for studies having a mean baseline HbA1c level of 7% or greater and for those with a mean participant age younger than 65 years. For subgroups based on race/ethnicity, the number of trials in either subgroup was insufficient to perform a network meta-analysis. Role of the Funding Source This project was funded under contract 290-2012-000131 from the AHRQ, U.S. Department of Health and Human Services. Staff at AHRQ participated in development of the scope of the work and reviewed drafts of the manuscript. Approval by AHRQ was required before the manuscript could be submitted for publication, but the authors are solely responsible for its content and the decision to submit for publication. AHRQ staff did not participate in the conduct of the review,

Cadaveric ultrasound imaging for training in ultrasound-guided peripheral nerve blocks: lower extremity.

Background:Intraneural injection during peripheral nerve blockade can cause neurologic injury. Current approaches to prevent or detect intraneural injection lack reliability and consistency, or only signal intraneural injection upon the event. A change in electrical impedance (EI) could be indicative of intraneural needle placement before injection. Methods:After animal care committee approval, eight pigs were anesthetized and kept spontaneously breathing. In four pigs (part 1), the sciatic nerves were exposed bilaterally for direct needle placement; in a further four pigs (part 2), the tissue was kept intact for ultrasound-guided needle placement. An insulated needle (Sprotte 24 gauge; Pajunk GmbH Medizintechnologie, Geisingen, Germany), attached to a nerve stimulator displaying EI (Braun Stimuplex HNS 12; B. Braun Medical, Bethlehem, PA), was placed extraneurally and then advanced to puncture the nerve sheath. Five punctures within approximately a 1-cm length of each nerve were performed. For each Part, overall EI at each compartment and EI after individual punctures were compared using a general linear model, with post hoc analysis using the Duncan multiple range test. Results:The EI was lower extraneurally compared with intraneurally during open dissection (12.1 ± 1.8 vs. 23.2 ± 4.4 k&OHgr;; P < 0.0001; n = 8) and when using ultrasound guidance (10.8 ± 2.9 vs. 18.2 ± 6.1 k&OHgr;; P < 0.0001; n = 7 nerves were visualized adequately). The EI difference was maintained despite performing five sequential punctures. Conclusions:With further study, EI could prove to be a quantifiable warning signal to alert clinicians to intraneural needle placement, preventing local anesthetic injection and subsequent nerve injury.

“I have to do what I believe”: Sudanese women’s beliefs and resistance to hegemonic practices at home and during experiences of maternity care in Canada

THIS Images in Anesthesia feature demonstrates the image quality obtainable from scanning the lower extremity of a cadaver in order to facilitate ultrasound-guided peripheral nerve blocks (PNB). Training methods to improve the performance of ultrasound-guided PNB are required, but have yet to be sandardized.1 A novel approach is to use cadaveric model simulations, which provide the learner with anatomic examination and the ability to practice nerve blocks in a stress-free environment without time constraints and the potential for patient discomfort. Cadaveric ultrasound imaging can also help the learner of these techniques to acquire an in-depth knowledge of the relevant regional anatomy in order to facilitate successful identification of nerve structures under ultrasound guidance, and to acquire expertise and confidence in performing these blocks.2 Dissections can be performed to confirm nerve or blood vessel identity whenever uncertainty exists (e.g., small nerves of the periphery). The cadaver model can also be used to acquire the critical skills necessary to accurately align the needle and probe to ensure visibility of the entire needle,3,4 while tracking or following the needle to the target nerve.5 In order to successfully practice these needle insertion techniques, it is beneficial to have a knowledge of the ultrasonographic anatomy of both cadavers and living patients. This imaging article serves as a guide for this important initial process. A recently-published companion Images in Anesthesia feature demonstrated the similarities of ultrasound images obtained from cadaveric and live subjects, and identified the relevant regional anatomy and clinical issues for upper extremity blocks.6 Here, we consider these issues for the most common nerve blocks of the lower extremity, namely those of the femoral and sciatic nerves. Ultrasound images (MicroMaxx, SonoSite Inc, Bothel, WA, USA; HFL38 13-6MHz linear probe for femoral and popliteal and C60 5-2 MHz curved probe for sciatic) were obtained from the lower extremity of a male adult cadaver (embalmed six months previously in the usual manner6 at the authors’ institution) and were compared with the images from a living adult male. The cadaver was in legal custody of the Division of Anatomy of the authors’ institution at the time of the imaging. The embalming and imaging procedures were performed with permission from the Division of Anatomy and in compliance with the institutional ethical standards for the use of human material in medical education. Ethics approval was obtained from the local Institutional Research Ethics Board for ultrasound scanning on the volunteer (one of the authors). Gaining an appreciation of the correlation between ultrasound appearance and histological findings of muscles and tendons is important for interpreting ultrasound images. Silvestri et al. reported that nerve fascicles generally appear hypoechoic, where the hyperechoic background usually represents the connective tissue within and surrounding the nerves (including the bright adipose tissue).7 The connective septa surrounding the muscles is also hyperechogenic, as is the fascia of the compartmental membranes.8 This difference in echogenicity is likely due to the higher acoustic impedance of the denser connective tissue. In the periphery, the nerves tend to appear more hyperechoic which may be due to relatively more connective tissue than nerve tissue (i.e., fewer fascicles in periphery than centrally). However, the distinction between fascia and connective septa or perimysium will be challenging in most cases. There are several common elements related to the accompanying images. With many portable ultrasound 475

Ultrasound imaging in cadavers: training in imaging for regional blockade at the trunk.

BackgroundEvidence suggests that immigrant women having different ethnocultural backgrounds than those dominant in the host country have difficulty during their access to and reception of maternity care services, but little knowledge exists on how factors such as ethnic group and cultural beliefs intersect and influence health care access and outcomes. Amongst immigrant populations in Canada, refugee women are one of the most vulnerable groups and pregnant women with immediate needs for health care services may be at higher risk of health problems. This paper describes findings from the qualitative dimension of a mixed-methodological study.MethodsA focused ethnographic approach was conducted in 2010 with Sudanese women living in an urban Canadian city. Focus group interviews were conducted to map out the experiences of these women in maternity care, particularly with respect to the challenges faced when attempting to use health care services.ResultsTwelve women (mean age 36.6 yrs) having experience using maternity services in Canada within the past two years participated. The findings revealed that there are many beliefs that impact upon behaviours and perceptions during the perinatal period. Traditionally, the women mostly avoid anything that they believe could harm themselves or their babies. Pregnancy and delivery were strongly believed to be natural events without need for special attention or intervention. Furthermore, the sub-Saharan culture supports the dominance of the family by males and the ideology of patriarchy. Pregnancy and birth are events reflecting a certain empowerment for women, and the women tend to exert control in ways that may or may not be respected by their husbands. Individual choices are often made to foster self and outward-perceptions of managing one’s affairs with strength.ConclusionIn today’s multicultural society there is a strong need to avert misunderstandings, and perhaps harm, through facilitating cultural awareness and competency of care rather than misinterpretations of resistance to care.

Reduced injection pressures using a compressed air injection technique (CAIT): an in vitro study.

Purpose: The unique strategy of using cadaveric models for teaching ultrasound-guided blocks has been described for blocks of the upper and lower extremities. This report considers the parallels between cadaveric and live imaging relevant to scanning of the trunk. The inter-individual variation between subjects (particularly for epidural blocks) is also considered, for practicing ultrasound-guided or supported trunk and central neuraxial techniques.Technical features: Ultrasound images using a portable machine C60 5-2 MHz curved array probe or HFL38 13-6 MHz linear array probe were obtained from scanning the trunk of a male adult cadaver, and were compared with ultrasound and magnetic resonance images from an adult male volunteer.Observations: Ultrasound imaging at the midline of the spine in the transverse/coronal plane provided an overview of the vertebral column, while scanning in a medial-to-lateral direction using longitudinal/sagittal plane sequentially localized the spinous, articular and transverse process. At the thoracic spine, further lateral longitudinal scanning will identify costal structures with the rib necks alternating with the hyperechoic ligamentous tissue of the costovertebral joints. Ultrasound imaging in the live subject in the paramedian longitudinal plane could be used at the thoracic and lumber spinal levels to capture the optimal ultrasound window of the epidural space. Imaging in the cadaver, especially when viewing the epidural space, is primarily limited by the tissue rigidity and lack of spine flexibility.Conclusion: Cadavers may provide viable training options for practicing ultrasound imaging and real-time ultrasound needle guidance for nerve blocks at the trunk and epidural space. The training can be performed in a stress-free pre-clinical environment without time constraints and the potential for patient discomfort.RésuméObjectif: La stratégie exceptionnelle qui consiste à utiliser des modèles cadavériques pour enseigner les blocs échoguidés a été décrite précédemment pour les blocs des membres supérieurs et inférieurs. Ce compte-rendu fait état des parallèles entre l’imagerie pertinente au balayage du tronc sur des cadavres ou des sujets vivants. La variation inter-individuelle entre les sujets (particulièrement dans le cas des blocs périduraux) est également prise en compte pour l’exercice des techniques échoguidées ou écho-assistées pour le tronc et le rachis.Éléments techniques: Les images par ultrason prises à partir d’une machine portable avec sonde à déphasage courbe C60 5-2 MHz ou avec sonde à déphasage linéaire HFL38 13-6 MHz ont été obtenues du balayage du tronc d’un cadavre adulte de sexe masculin et ont été comparées avec des images par ultrason ou résonance magnétique d’un volontaire adulte de sexe masculin.Observations: L’échographie au milieu de la colonne sur le plan transversal/coronal a procuré une vue d’ensemble de la colonne vertébrale, alors que le balayage effectué avec une orientation médiane à latérale utilisant un plan longitudinal/sagittal a permis de localiser l’une après l’autre les apophyses épineuses, articulaires et transverses. Au niveau de la colonne thoracique, un balayage latéral longitudinal plus poussé permettra d’identifier les structures costales avec les extrémités des côtes alternant avec le tissu ligamentaire hyperéchogène des articulations costovertébrales. L’échographie pratiquée sur un sujet vivant sur le plan paramédian longitudinal pourrait être utilisée aux niveaux thoracique et lombaire de la colonne pour saisir la fenêtre optimale par ultrason de l’espace péridural. Les limites principales de l’échographie pratiquée sur un cadavre, particulièrement lorsqu’on visionne l’espace péridural, sont la rigidité tissulaire et le manque de flexibilité au niveau de la colonne.Conclusion: La pratique sur des cadavres pourrait constituer une option de formation viable pour exercer l’échographie et l’échoguidage de l’aiguille pour les blocs nerveux pratiqués au niveau du tronc et dans l’espace péridural. La formation peut se faire dans un environnement pré-clinique sans stress, sans contrainte de temps ni inconfort possible pour le patient.

Behavioral Programs for Type 1 Diabetes Mellitus: A Systematic Review and Meta-analysis

Background and Objectives: High injection pressures have been associated with intraneural injection and persistent neurological injury in animals. Our objective was to test whether a reported simple compressed air injection technique (CAIT) would limit the generation of injection pressures to below a suggested 1,034 mm Hg limit in an in vitro model. Methods: After ethics board approval, 30 consenting anesthesiologists injected saline into a semiclosed system. Injection pressures using 30 mL syringes connected to a 22 gauge needle and containing 20 mL of saline were measured for 60 seconds using: (1) a typical “syringe feel” method, and (2) CAIT, thereby drawing 10 mL of air above the saline and compressing this to 5 mL prior to and during injections. All anesthesiologists performed the syringe feel method before introduction and demonstration of CAIT. Results: Using CAIT, no anesthesiologist generated pressures above 1,034 mm Hg, while 29 of 30 produced pressures above this limit at some time using the syringe feel method. The mean pressure using CAIT was lower (636 ± 71 vs. 1378 ± 194 mm Hg, P = .025), and the syringe feel method resulted in higher peak pressures (1,875 ± 206 vs. 715 ± 104 mm Hg, P = .000). Conclusions: This study demonstrated that CAIT can effectively keep injection pressures under 1,034 mm Hg in this in vitro model. Animal and clinical studies will be needed to determine whether CAIT will allow objective, real‐time pressure monitoring. If high pressure injections are proven to contribute to nerve injury in humans, this technique may have the potential to improve the safety of peripheral nerve blocks.

Compressed air injection technique to standardize block injection pressures

Type 1 diabetes mellitus (T1DM), one of the most common chronic diseases in childhood and adolescence, is increasing in prevalence in the United States (1). The landmark DCCT (Diabetes Control and Complications Trial) and its related longitudinal study (EDIC [Epidemiology of Diabetes Interventions and Complications]) found that intensive glycemic control prevents development and progression of micro- and macrovascular complications (2, 3) and death (4). However, the intervention was initiated early (duration of T1DM <3 years for prevention group) in relatively young (mean age, 27 years), healthy patients. A meta-analysis of 12 trials of intensive control in diverse patient populations confirmed only a reduction in development of microvascular complications. Authors of that analysis stressed that benefits may apply only for interventions initiated early and should be weighed against risks for severe hypoglycemia (5). Factors other than glycemic control appear necessary to improve outcomes. For instance, intensive lowering of blood pressure has reduced major cardiovascular events by 11% (6). In addition, findings from 2 large cross-national studies support interventions to address other outcomes of importance for patients, such as diabetes-related distress (7). All patients with diabetes are encouraged to adopt and adhere to many self-care behaviors (8, 9). This is particularly challenging for those with T1DM, who require lifelong insulin therapy and therefore should undertake rigorous self-monitoring and regulation of blood glucose levels through frequent adjustments to insulin dose, diet, and physical activity (10). Approaches for supporting patients to change several behaviors include diabetes self-management education (DSME) with or without added support (11) and lifestyle programs (12). Because knowledge acquisition alone is insufficient for behavioral changes (13, 14), the focus for DSME has shifted from traditional didactic approaches to more patient-centered methods that incorporate interaction, problem-solving, and other behavioral approaches and techniques (11, 1517). Moreover, programs need to be tailored to the needs of the target population, such as developmental milestones in children or unique personal challenges during adolescence or adulthood (18). Few systematic reviews on education and training in T1DM have been conducted over the past decade (1921). Most reviews assessed only the effects on glycemic control, included highly didactic interventions, or reviewed interventions conducted outside the health care setting (such as summer camps) (1923). All focused on children and adolescents. When calculated, effect sizes demonstrated very modest improvement at longest follow-up (21, 23). An updated evaluationone that focuses on programs incorporating behavioral approaches and targeting several behaviorsis required to determine whether shifts in practice have translated into better outcomes for patients of all ages with T1DM. Anticipating high diversity in program content and delivery mechanisms, our evaluation also explores effect modification by program factors. Methods With assistance from key informants, a technical expert panel, and public commentary, we developed and followed a standard protocol. A peer- and public-reviewed technical report with additional details is available online on the Agency of Healthcare Research and Qualitys (AHRQs) Effective Healthcare Web site (24). Data Sources and Searches Our librarian searched the following bibliographic databases from 1993 to 15 January 2015: Ovid MEDLINE and Ovid MEDLINE In-Process & Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials via Cochrane Library, EMBASE via Ovid, CINAHL Plus with Full Text via EBSCOhost, PsycINFO via Ovid, and PubMed (2014 only) via the National Center for Biotechnology Information Databases (MEDLINE strategy is presented in Appendix Table 1). On 3 June 2015, we updated the search in MEDLINE. We reviewed the reference lists of relevant systematic reviews and all included studies, searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, and searched relevant conference proceedings (2011 through 2014) and the U.S. Federal Register. Appendix Table 1. Search Strategy for MEDLINE* Study Selection We included studies that were conducted in highly developed countries (25) and were published in English after 1993 (reflecting intensification of medical management based on the DCCT) (2). We included prospective comparative studies (that is, randomized, controlled trials [RCTs]; nonrandomized controlled trials; prospective cohort studies; controlled beforeafter studies) that enrolled participants of any age and compared a behavioral program with usual care (that is, medical management provided to all participants), an active control (intervention beyond usual care but not meeting our definition of a behavioral program), or another behavioral program. A behavioral program was operationally defined as a multicomponent, diabetes-specific program with repeated interactions by trained individuals, a duration of 4 weeks or longer, and DSME that entailed a behavioral approach or another program format that included at least a structured dietary or physical activity intervention with another component (Appendix Table 2). Appendix Table 2. Operational Definitions of Behavioral Program and Comparators We excluded studies in which the intervention was a disease or care management program (for example, those with active adjustment of diabetes-related medications) (26) or other quality improvement programs targeting health systems or providers (27). Studies were also excluded if they 1) focused on newly diagnosed (1 year) patients, 2) focused on psychological counseling or treatment without explicitly targeting several diabetes self-care behaviors, 3) had no outcomes of interest to this review (for example, reporting on only insulin sensitivity), 4) had study groups that differed only by a factor outside the reviews scope (for example, low- vs. high-fat diet), and 5) included a study sample in which 25% of participants had type 2 diabetes (unless results were reported for T1DM). Two reviewers independently screened all titles and abstracts. We retrieved the full text of any publications marked for inclusion by either reviewer. Two reviewers independently assessed the full texts using a priori inclusion criteria and a standard form. We resolved disagreements by consensus or by consulting another team member. Data Extraction and Quality Assessment One reviewer extracted data by using a structured form created in the Systematic Review Data Repository (http://srdr.ahrq.gov/) (28); a second reviewer verified all data. Two reviewers independently assessed methodological quality. Discrepancies were resolved through discussion. We used the Cochrane Risk of Bias tool (29) for RCTs and nonrandomized controlled trials and used the NewcastleOttawa Scale (30) for prospective cohort studies and controlled beforeafter studies. Data Synthesis and Analysis Characteristics of included studies are presented in summary tables. Our key outcomes were glycemic control (that is, glycosylated hemoglobin [HbA1c]); quality of life; development of micro- and macrovascular complications; all-cause mortality; adherence to diabetes self-management behaviors; and changes in body composition, physical activity, or dietary or nutrient intake. Secondary outcomes included episodes of severe hypo- or hyperglycemia, depression, anxiety, control of blood pressure and lipids, health care utilization, and program acceptability (via participant attrition). Harms included activity-related injury. We defined thresholds for clinical importance when the literature provided guidance; for HbA1c we used a between-group difference of 0.4percentage point change (for example, 7.6% vs. 8.0%) (31); for patient-reported outcomes represented by continuous data, we used a one-half SD based on the mean SD from the pooled studies (32, 33). With input from our technical experts, we categorized the behavioral programs by various component and delivery factors (Appendix Table 3). Programs not classified as DSME or DSME with added support (both incorporating education or training on several diabetes self-care behaviors) were considered lifestyle because they generally consisted of structured dietary and physical activity interventions. Appendix Table 3. Categorization of Program Components and Delivery Factors When possible we used (or computed) change from baseline values. If SDs were not given, they were computed from P values, 95% CIs, z statistics, or t statistics or were estimated from upper-bound P values, ranges, interquartile ranges, or (as a last resort) imputation using the largest reported SD from the other studies in the same meta-analysis. When computing SDs for change from baseline values, we assumed a correlation of 0.5; we conducted post hoc sensitivity analyses using correlations of 0.25 and 0.75. We pooled results for all ages and for subgroups based on age (that is, youth [aged 18 years] and their families, young adults [aged 19 to 30 years], adults [aged 31 to 64 years], and older adults (aged 65 years]) when there was more than 1 trial in each age category. We used the HartungKnappSidikJonkman random-effects model (34, 35) using Stata 11.2 (Stata Corp.) and Excel 2010 (Microsoft) software. We calculated weighted mean differences (MDs) or standardized mean differences (SMDs), as appropriate, with corresponding 95% CIs. We analyzed outcomes at the end of intervention to 1-month follow-up (EOI), and at 1 to no more than 6 months (6-month), more than 6 to 12 months (12-month), more than 12 to 24 months (12-month), and more than 24 months (24-month) after the intervention. If a study included more than 1 follow-up time point in each stratum, we used the longer follow-up. We did not include observational stud

Harms of Antipsychotics in Children and Young Adults: A Systematic Review Update

PurposePresently, no standardized technique exists to monitor injection pressures during peripheral nerve blocks. Our objective was to determine if a compressed air injection technique, using an in vitro model based on Boyle’s law and typical regional anesthesia equipment, could consistently maintain injection pressures below a 1293 mmHg level associated with clinically significant nerve injury.MethodsInjection pressures for 20 and 30 mL syringes with various needle sizes ( 18G, 20G, 21 G, 22G, and 24G) were measured in a closed system. A set volume of air was aspirated into a saline-filled syringe and then compressed and maintained at various percentages while pressure was measured. The needle was inserted into the injection port of a pressure sensor, which had attached extension tubing with an injection plug clamped “off”. Using linear regression with all data points, the pressure value and 99% confidence interval (CI) at 50% air compression was estimated.ResultsThe linearity of Boyle’s law was demonstrated with a high correlation, r = 0.99, and a slope of 0.984 (99% CI: 0.967-1.001). The net pressure generated at 50% compression was estimated as 744.8 mmHg, with the 99% CI between 729.6 and 760.0 mmHg. The various syringe/needle combinations had similar results.ConclusionBy creating and maintaining syringe air compression at 50% or less, injection pressures will be substantially below the 1293 mmHg threshold considered to be an associated risk factor for clinically significant nerve injury. This technique may allow simple, real-time and objective monitoring during local anesthetic injections while inherently reducing injection speed.ObjectifPrésentement, aucune technique normalisée ne permet de vérifier les pressions d’injection pendant les blocages nerveux périphériques. Nous voulions vérifier si une technique d’injection d’air comprimé, utilisant un modèle in vitro fondé sur la loi de Boyle et du matériel propre à l’anesthésie régionale, pouvait maintenir avec régularité les pressions d’injection sous les 1293 mmHg, pression associée à une lésion nerveuse cliniquement significative.MéthodeLes pressions d’injection pour des seringues de 20 et 30 mL et diverses tailles d’aiguilles (18G, 20G, 21G, 22G et 24G) ont été mesurées dans un système fermé. Un volume défini d’air a été aspiré dans une seringue rempli de solution saline, puis comprimé et maintenu à des pourcentages variés pendant la mesure de la pression. L’aiguille a été insérée dans l’ouverture à injection d’un détecteur de pression muni d’une extension avec un bouchon d’injection en position fermée. La valeur de la pression et l’intervalle de confiance de 99 % (IC) pour une compression d’air à 50 % ont été évalués en utilisant une régression linéaire avec tous les points de données.RésultatsLa linéarité de la loi de Boyle a été démontrée avec une forte corrélation, r = 0,99 et une pente de 0,984 (IC de 99 % : 0,967-1,001) La pression nette générée sous une compression de 50% a été de 744,8 mmHg avec un IC de 99 % entre 729,6 et 760,0 mmHg. Les diverses combinaisons de seringues et d’aiguilles ont présenté des résultats similaires.ConclusionEn créant et en maintenant dans la seringue une compression d’air à 50% ou moins, les pressions d’injection seront dans l’ensemble sous le seuil des 1293 mmHg associé à un facteur de risque de lésion nerveuse cliniquement significative. Cette technique peut permettre une surveillance simple, objective et en temps réel pendant les injections d’anesthésiques locaux tout en réduisant fondamentalement la vitesse d’injection.