1. Home Healthcare Workers' Occupational Exposures
Elizabeth Bien, Gordon Gillespie, Kermit Davis Home Healthc Now . 2020 Sep/Oct;38(5):247-253. doi: 10.1097/NHH.0000000000000891.
Home healthcare workers (HHCWs) belong to one of the fastest growing industries and have an unpredictable work environment, potentiating their risk of exposures to occupational hazards. More patients seeking care for chronic health conditions, and improvements in technology and medical advancements are allowing more complex patient care to be provided at home. A comprehensive integrative review was completed, identifying nine articles that provide an overview of the occupational hazards HHCWs face. Analysis of the articles indicates occupational hazards are similar across studies. Occupational exposures reported by HHCWs align within all the studies and include exposures to blood, saliva, dangerous conditions walking to and within the home, secondhand smoke, aggressive pets, violence, and ergonomic concerns. These studies have been methodologically limited to self-reports, including surveys, interviews, and focus groups but include quantitative and qualitative data. Future research can further describe and identify specific occupational exposures and health hazards, subsequently leading to modifications to protect the health and safety of HHCWs, personal care workers, and the informal caregivers who provide care in the home.
2. Percutaneous Interventions for Secondary Mitral Regurgitation
Donald R Lynch, Satya S Shreenivas, Dean J Kereiakes, Mahboob Ali, David N Pratt Circ Cardiovasc Interv . 2020 Aug;13(8):e008998. doi: 10.1161/CIRCINTERVENTIONS.120.008998.
Mitral regurgitation is frequently associated with ventricular dysfunction and carries a high mortality. Guideline-directed medical therapy, surgical mitral valve repair or replacement, and, in the setting of advanced heart failure, heart transplant and left ventricular assist devices have been the mainstay of treatment. However, rapid advancement in the field has resulted in approval of edge-to-edge mitral valve repair with the MitraClip, and there are several novel catheter-based percutaneous options in clinical trials. Percutaneous options, while promising, must be deployed in patients who are most likely to benefit, and thus, understanding the pathophysiology of specific subgroups of patients with functional mitral regurgitation (eg, disproportionate versus proportionate mitral regurgitation) is key to the success of new devices. We review the pathophysiology, percutaneous therapeutic treatment options, and ongoing clinical trials for functional mitral regurgitation.
3. Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial
Amie Kawasaki, Amanda Shaffer, Deborah L Myers, National Institute of Child Health and Human Development Pelvic Floor Disorders Network, Jeannine McCormick, Kelly Roney, Michael Bonidie, L Keith Lloyd, Annette Graham, Teresa Carney, Tamara L Terry, Steven Abo, Ellen Eline, Lorraine Flick, Barbara Bibb, Susan Meikle, Alayne D Markland, Mathew D Barber, Keisha Dyer, Susan Yount, Michael Albo, Lauren Klein Warren, Luohua Jiang, William E Whitehead, Tracy S Wilson, Brooke Gurland, Kathy Carter, Gary Sutkin, Daryl Matthews, Emily Lukacz, Donna Thompson, Heidi Harve, Kyle Wohlrab, Cassandra Carberry, Jutta Thornberry, James W Pickett, Lori Geraci, Michelle Kingslee, Karen Mislanovich, Yuko Komesu, Nicole Longoria, JoAnn Columbo, Jessica Carrington, Alayne Markland, R Edward Varner, Charles Nager, Ann S Meers, Benjamin Carper, Beri Ridgeway, Shawn Menefee, Alicia Ballard, Missy Lavender, Jasmine Tan-Kim, J Eric Jelovsek, Ryan E Whitworth, Karl Luber, Jonathan Shepherd, Anthony Visco, B Star Hampton, Cindy Furey, Ariana Smith, Kay Dickersin, Nazema Siddiqui, Geetha Krishnan, Gouri Diwadkar, Dennis Wallace, Rebecca G Rogers, Niti Mehta, Kendra Glass, Kristin Zaterka-Baxter, Nancy Saxon, Sara Cichowski, Pam Moalli, Julia Middendorf, Pamela Levin, Anthony G Visco, Yan Tang, Matthew D Barber, Susan E George, Kate Ryan, Risela Nava, John Eric Jelovsek, Vivian W Sung, Ashok Tuteja, Robert Holley, Patricia Riley, Brenda Hair, Leslie Rickey, Gena Dunivan, Uduak Umoh Andy, Lan Kong, Erin Yane, Paul Tulikangas, Donna McClish, Kevin A Wilson, Charles R Rardin, Velria Willis, Peter Jeppson, Marie G Gantz, Mark D Walters, Ingrid Harm-Ernandes, Holly E Richter, Mary Wang, Janet Harrison, Judy Gruss, Christy Miller, Alison Weidner, Cindy Amundsen, Shantae McLean, Susan F Meikle, Sherella Johnson, Lynda Tatum, David Shade, Lily Arya, Poonam Pande, Beth Klump, Kate O'Dell, Christopher Chermansky, Diane K Newman, Ly Pung, Amy Pannullo, Lindsay Morris, Marie Fidela R Paraiso, Halina M Zyczynski, Jennifer Maddocks, Massarat Zutshi Lancet Gastroenterol Hepatol . 2019 Sep;4(9):698-710. doi: 10.1016/S2468-1253(19)30193-1.
Background:Well designed, large comparative effectiveness trials assessing the efficacy of primary interventions for faecal incontinence are few in number. The objectives of this study were to compare different combinations of anorectal manometry-assisted biofeedback, loperamide, education, and oral placebo.Methods:In this randomised factorial trial, participants were recruited from eight clinical sites in the USA. Women with at least one episode of faecal incontinence per month in the past 3 months were randomly assigned 0·5:1:1:1 to one of four groups: oral placebo plus education only, placebo plus anorectal manometry-assisted biofeedback, loperamide plus education only, and loperamide plus anorectal manometry-assisted biofeedback. Participants received 2 mg per day of loperamide or oral placebo with the option of dose escalation or reduction. Women assigned to biofeedback received six visits, including strength and sensory biofeedback training. All participants received a standardised faecal incontinence patient education pamphlet and were followed for 24 weeks after starting treatment. The primary endpoint was change in St Mark's (Vaizey) faecal incontinence severity score between baseline and 24 weeks, analysed by intention-to-treat using general linear mixed modelling. Investigators, interviewers, and outcome evaluators were masked to biofeedback assignment. Participants and all study staff other than the research pharmacist were masked to medication assignment. Randomisation took place within the electronic data capture system, was stratified by site using randomly permuted blocks (block size 7), and the sizes of the blocks and the allocation sequence were known only to the data coordinating centre. This trial is registered with ClinicalTrials.gov, numberNCT02008565.Findings:Between April 1, 2014, and Sept 30, 2015, 377 women were enrolled, of whom 300 were randomly assigned to placebo plus education (n=42), placebo plus biofeedback (n=84), loperamide plus education (n=88), and the combined intervention of loperamide plus biofeedback (n=86). At 24 weeks, there were no differences between loperamide versus placebo (model estimated score change -1·5 points, 95% CI -3·4 to 0·4, p=0·12), biofeedback versus education (-0·7 points, -2·6 to 1·2, p=0·47), and loperamide and biofeedback versus placebo and biofeedback (-1·9 points, -4·1 to 0·3, p=0·092) or versus loperamide plus education (-1·1 points, -3·4 to 1·1, p=0·33). Constipation was the most common grade 3 or higher adverse event and was reported by two (2%) of 86 participants in the loperamide and biofeedback group and two (2%) of 88 in the loperamide plus education group. The percentage of participants with any serious adverse events did not differ between the treatment groups. Only one serious adverse event was considered related to treatment (small bowel obstruction in the placebo and biofeedback group).Interpretation:In women with normal stool consistency and faecal incontinence bothersome enough to seek treatment, we were unable to find evidence against the null hypotheses that loperamide is equivalent to placebo, that anal exercises with biofeedback is equivalent to an educational pamphlet, and that loperamide and biofeedback are equivalent to oral placebo and biofeedback or loperamide plus an educational pamphlet. Because these are common first-line treatments for faecal incontinence, clinicians could consider combining loperamide, anal manometry-assisted biofeedback, and a standard educational pamphlet, but this is likely to result in only negligible improvement over individual therapies and patients should be counselled regarding possible constipation.Funding:Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health.
