The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition

A number of effective, low-cost strategies are available to identify and treat the person at risk for diabetic foot ulcers and lower-extremity amputation. These strategies must be more widely adopted by all diabetic care providers to maintain the integrity and function of the lower limb, and thus improve the quality of life for people with diabetes.

https://www.algeos.com/filemanager/research/Preventative%20foot%20care%20in%20people%20with%20diabetes.pdf

Preventive Foot Care in People With Diabetes

OBJECTIVE —To test the hypothesis that diabetes is independently associated with sleep-disordered breathing (SDB), and in particular that diabetes is associated with sleep abnormalities of a central, rather than obstructive, nature. RESEARCH DESIGN AND METHODS —Using baseline data from the Sleep Heart Health Study (SHHS), we related diabetes to 1 ) the respiratory disturbance index (RDI; number of apneas plus hypopneas per h of sleep); 2 ) obstructive apnea index (OAI; ≥3 apneas/h of sleep associated with obstruction of the upper airway); 3 ) percent of sleep time 2 saturation; 4 ) central apnea index (CAI; ≥3 apneas [without respiratory effort]/h sleep); 5 ) occurrence of a periodic breathing (Cheyne Stokes) pattern; and 6 ) sleep stages. Initial analyses excluding persons with prevalent cardiovascular disease (CVD) were repeated including these participants. RESULTS —Of the 5,874 participants included in this report, 692 (11.8%) reported diabetes or were taking oral hypoglycemic medications or insulin and 1,002 had prevalent CVD. Among the 4,872 persons without CVD, 470 (9.6%) had diabetes. Diabetic participants had worse CVD risk factor profiles than their nondiabetic counterparts, including higher BMI, waist and neck circumferences, triglycerides, higher prevalence of hypertension, and lower HDL cholesterol ( P 2 saturation, CAI, and periodic breathing ( P P CONCLUSIONS —These data suggest that diabetes is associated with periodic breathing, a respiratory abnormality associated with abnormalities in the central control of ventilation. Some sleep disturbances may result from diabetes through the deleterious effects of diabetes on central control of respiration. The high prevalence of SDB in diabetes, although largely explained by obesity and other confounders, suggests the presence of a potentially treatable risk factor for CVD in the diabetic population.

https://care.diabetesjournals.org/content/diacare/26/3/702.full.pdf

Diabetes and Sleep Disturbances: Findings from the Sleep Heart Health Study

Objective: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. Methods: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. Recommendations: The article is focused on a suggested glycemic control end point such that a blood glucose ≥150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤70 mg/dL) and to minimize glycemic variability. Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate mon itoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. Conclusions: While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infu sion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy. (Crit Care Med 2012; 40:3251–3276)

Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients

Objectives To review important patient safety practices for evidence of effectiveness, implementation, and adoption. Data sources Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders. Review methods The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption. Results From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption. Conclusions The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.

Making health care safer II: an updated critical analysis of the evidence for patient safety practices.

OBJETIVO: Analisar a confiabilidade e o desempenho da versao em portugues de instrumentos de avaliacao da adesao ao tratamento anti-hipertensivo. METODOS: Pacientes hipertensos atendidos de janeiro a setembro de 2010 em uma unidade de atencao primaria em Porto Alegre, RS, foram selecionados aleatoriamente (n = 206). Na avaliacao da adesao foram utilizadas versoes em portugues do Teste de Morisky-Green (TMG) e do Brief Medication Questionnaire (BMQ). Foram analisados consistencia interna, estabilidade temporal e desempenho com relacao a tres padroes-ouro: controle inadequado da pressao arterial (> 140/90 mmHg); taxa insuficiente de retirada de medicacao na farmacia da Unidade Basica de Saude ( 0,001. A baixa adesao ao BMQ esta associada a maiores niveis tensionais quando comparada com pacientes aderentes (148,4 [dp 20,1] vs 128,8 [dp 17,8], p < 0,001), mas nao para o TMG. CONCLUSOES: O BMQ apresentou melhor desempenho que o TMG, com maiores sensibilidade e especificidade. A avaliacao da adesao pode auxiliar o clinico na discriminacao entre uso inadequado da medicacao e esquema terapeutico insuficiente.

/pdf/teste-de-morisky-green-e-brief-medication-questionnaire-para-2c9ud5yuq8.pdf

Teste de Morisky-Green e Brief Medication Questionnaire para avaliar adesão a medicamentos

Background: Intensive insulin therapy (IIT) has been shown to reduce morbidity and mortality in critically ill patients. Little investigation has been done to find out whether it improves the prognosis of patients with severe traumatic brain injury (STBI). Methods: We conducted a prospective controlled study where adult patients with blunt STBI, with Glasgow Coma Scale ≤8, admitted to the intensive care unit (ICU) were randomly assigned to receive either IIT (maintenance of blood glucose between 80 mg/dL and 110 mg/dL with continuous insulin infusion) or conventional glycemic therapy (CGT) (maintenance of blood glucose below 180 mg/dL with subcutaneous insulin and insulin infusion only if blood glucose levels exceeded 220 mg/dL). The main outcome was Glasgow outcome scale 6 months after trauma. Secondary measures were hypoglycemia, incidence of infections, and days in ICU. Results: Of the 88 patients randomized, 42 were assigned to IIT and 46 to CGT. There was no difference (p = 0.63) in neurologic outcomes between the treatment groups: Glasgow outcome scale >3 was observed in 16 patients (41%) in the IIT and in 13 patients (32.5%) in the CGT group. More patients in the IIT group had hypoglycemia: 32 (82.1%), compared with 7 (17.5%) in the CGT group (p < 0.001). There were no differences in the number of days spent in the ICU (18.2 ± 27.6 vs. 12.9 ± 12.7) or in the sepsis rates (84.6% vs. 80%) between the groups. Conclusion: In our study, IIT did not improve the neurologic outcome of patients with STBI but did increase the risk of hypoglycemia compared with CGT.

Intensive insulin therapy in severe traumatic brain injury: a randomized trial.

OBJECTIVE: To analyze the reliability and performance of the Portuguese version of questionnaires used to evaluate adherence to hypertensive treatment. METHODS: Hypertensive patients attending a primary healthcare unit in Porto Alegre, Southern Brazil, from January to September 2010, were randomly selected (n = 206). To evaluate adherence, Portuguese versions of the Morisky-Green test (MGT) and the Brief Medication Questionnaire (BMQ) were used. The analysis considered internal consistency, temporal stability and performance compared to three gold standards, which are: inadequate control of blood pressure (BP > 140/90 mmHg); insufficient rate of medication acquisition at the institution's pharmacy ( 0.001. Low adherence per the BMQ is associated with higher blood pressure levels when compared to adherent patients (148.4 [SD 20.1] vs 128.8 [SD 17.8]; p <0.001), but not for the MGT. CONCLUSIONS: The BMQ showed better performance than the MGT, with greater sensitivity and specificity. Evaluation of adherence may help clinicians discriminate between inadequate use of medication and insufficient treatment regimen.

/pdf/the-brief-medication-questionnaire-and-morisky-green-test-to-56r12uxjoy.pdf

The Brief Medication Questionnaire and Morisky-Green test to evaluate medication adherence.

OBJECTIVE: To analyze the reliability and performance of the Portuguese version of questionnaires used to evaluate adherence to hypertensive treatment. METHODS: Hypertensive patients attending a primary healthcare unit in Porto Alegre, Southern Brazil, from January to September 2010, were randomly selected (n = 206). To evaluate adherence, Portuguese versions of the Morisky-Green test (MGT) and the Brief Medication Questionnaire (BMQ) were used. The analysis considered internal consistency, temporal stability and performance compared to three gold standards, which are: inadequate control of blood pressure (BP ≥ 140/90 mmHg); insuf ﬁ cient rate of medication acquisition at the institution’s pharmacy ( 0.001. Low adherence per the BMQ is associated with higher blood pressure levels when compared to adherent patients (148.4 [SD 20.1] vs 128.8 [SD 17.8]; p <0.001), but not for the MGT.

/pdf/teste-de-morisky-green-e-brief-medication-questionnaire-para-4782fubudl.pdf

Teste de Morisky-Green e Brief Medication Questionnaire para avaliar adesão a medicamentos The Brief Medication Questionnaire and Morisky-Green Test to evaluate medication adherence

Cristina Rolim Neumann

Papers

Teste de Morisky-Green e Brief Medication Questionnaire para avaliar adesão a medicamentos

Intensive insulin therapy in severe traumatic brain injury: a randomized trial.

The Brief Medication Questionnaire and Morisky-Green test to evaluate medication adherence.

Teste de Morisky-Green e Brief Medication Questionnaire para avaliar adesão a medicamentos The Brief Medication Questionnaire and Morisky-Green Test to evaluate medication adherence

Nocturnal oxygen desaturation in diabetic patients with severe autonomic neuropathy.