Faculty Bibliography

INTRODUCTION/BACKGROUND:Understanding context and how this can be systematically assessed and incorporated is crucial to successful implementation. We describe how context has been assessed (including exploration or evaluation) in Global Alliance for Chronic Diseases (GACD) implementation research projects focused on improving health in people with or at risk of chronic disease and how contextual lessons were incorporated into the intervention or the implementation process. METHODS:Using a web-based semi-structured questionnaire, we conducted a cross-sectional survey to collect quantitative and qualitative data across GACD projects (n = 20) focusing on hypertension, diabetes and lung diseases. The use of context-specific data from project planning to evaluation was analyzed using mixed methods and a multi-layered context framework across five levels; 1) individual and family, 2) community, 3) healthcare setting, 4) local or district level, and 5) state or national level. RESULTS:Project teams used both qualitative and mixed methods to assess multiple levels of context (avg. = 4). Methodological approaches to assess context were identified as formal and informal assessments, engagement of stakeholders, use of locally adapted resources and materials, and use of diverse data sources. Contextual lessons were incorporated directly into the intervention by informing or adapting the intervention, improving intervention participation or improving communication with participants/stakeholders. Provision of services, equipment or information, continuous engagement with stakeholders, feedback for personnel to address gaps, and promoting institutionalization were themes identified to describe how contextual lessons are incorporated into the implementation process. CONCLUSIONS:Context is regarded as critical and influenced the design and implementation of the GACD funded chronic disease interventions. There are different approaches to assess and incorporate context as demonstrated by this study and further research is required to systematically evaluate contextual approaches in terms of how they contribute to effectiveness or implementation outcomes.

Objective: Sodium bicarbonate therapy (SBT) is provided in the emergency department (ED) for a variety of indications but its use is controversial. Some authors recommend SBT for overdoses of salicylates and sodium channel antagonists (e.g. tricyclic antidepressants [TCAs]). Due to its effect in lowering serum potassium, however, SBT administration may prolong the QTc interval and potentially cause increased rates of adverse cardiovascular events (ACVE), such as ventricular dysrhythmias. To quantify this risk, we evaluated an emergency department (ED) overdose patient population for the association between SBT and ACVE.
Method(s): We prospectively analyzed consecutive ED patients with acute drug overdose who were given SBT at two urban teaching hospitals from 2015-present. Data included SBT indication, dose, duration, and QTc (initial/peak from computer generated Bazett correction) during hospital stay. We used median values to dichotomize total dose (high/low) and total duration (long/short) of SBT. Patients were prospectively followed to hospital discharge for the occurrence of the primary outcome: ACVE and/or mortality. The previously validated definition of ACVE was used for in-hospital occurrence of any of the following: ventricular dysrhythmia, myocardial infarction, shock requiring vasopressors, and cardiac arrest [1]. Severe QTc prolongation was defined as previously validated using the cut off >=500ms. Occurrence of ventricular dysrhythmia was adjudicated by a blinded cardiologist.
Result(s): Indications for SBT in 30 patients analyzed were: salicylism (n= 5), sodium channel antagonist (6 TCA, 5 other), wide QRS in absence of known drug (n= 9), acidosis or cardiac arrest (n= 3), and unknown (n= 2). After SBT, severe QTc prolongation occurred in 6 (20%), ACVE in 17 (57%), and 6 patients (20%) died. There was a significant association between severe QTc prolongation in-hospital for both high dose and long duration groups (p < 0.05 for both). There was a significant correlation between both SBT dose (83% high, 38% low, p < 0.05) and SBT duration (100% long, 25% short, p < 0.05) with the primary outcome.
Conclusion(s): ED patients with acute drug overdose receiving SBT had very high rates of mortality and ACVE, which were strongly associated with higher dose and longer duration of SBT. Severity of overdose may represent a limitation to interpretation as a potential confounder. Overall, these results are consistent with the hypothesis that SBT may cause unintended ACVE, and validates previous safety concerns regarding the administration of SBT to overdose patients

Background: In ED patients who present with acute drug overdose, severe QTc prolongation (>500 ms) has been shown to be a predictor of adverse cardiovascular events (ACVE). However, it is unclear what clinical factors are associated with delayed severe QTc prolongation (dsQTp), and it is unknown whether dsQTp can predict ACVE. This study aims to: (1) Define clinical factors associated with dsQTp, and (2) test whether dsQTp is an independent predictor for ACVE.
Method(s): This was a prospective cohort study at 2 urban tertiary care EDs. Data was collected by trained research assistants, and included demographics, drug exposure, medication administration, initial and repeat ECG data, lab data, and outcome measures. dsQTp was defined as presence of initial QTc 499. The primary study outcome was the composite of ACVE defined as in-hospital occurrence of any of the following: MI, shock, ventricular dysrhythmia, and cardiac arrest. Univariate statistics and multivariable logistic regression calculations were made using SPSS version 24. With a fixed sample size of 1670, we calculated that we would have 99% power to show a 3-fold increase in risk with 0.05 alpha.
Result(s): Out of 2311 patients screened, 641 were excluded (age 500) leaving 1670 patients for analysis. The dsQTp group (N = 27) was found to be older than the control group (N = 1643)(40.1 vs 51.6, P
Conclusion(s): This cohort study reveals a subset of ED patients who are at greater risk of overdose-related ACVE but not immediately apparent by the initial ECG. Further study is needed to identify which patients are at risk for dsQTp, as they may require prolonged observation and repeated ECGs. Limitations include missing repeat QTc measurements, and inability to control for overdose severity as a surrogate for repeat ECGs. Future study is warranted to further characterize patients at risk for dsQTp to evaluate other exposure-related factors as yet undiscovered

OBJECTIVE:To describe available models of HIV and noncommunicable disease (NCD) care integration in sub-Saharan Africa (SSA). DESIGN/METHODS:Narrative review of published articles describing various models of HIV and NCD care integration in SSA. RESULTS:We identified five models of care integration across various SSA countries. These were integrated community-based screening for HIV and NCDs in the general population; screening for NCDs and NCD risk factors among HIV patients enrolled in care; integration of HIV and NCD care within clinics; differentiated care for patients with HIV and/or NCDs; and population healthcare for all. We illustrated these models with descriptive case studies highlighting the lessons learned and evidence gaps from the various models. CONCLUSION/CONCLUSIONS:Leveraging existing HIV infrastructure for NCD care is feasible with various approaches possible depending on available program capacity. Process and clinical outcomes for existing models of care integration are not yet described but are urgently required to further advise policy decisions on HIV/NCD care integration.

OBJECTIVE:The extent to which diabetes (DM) practice guidelines, often based on evidence from high-income countries (HIC), can be implemented to improve outcomes in low- and middle-income countries (LMIC) is a critical challenge. We carried out a systematic review to compare type 2 DM guidelines in individual LMIC versus HIC over the past decade to identify aspects that could be improved to facilitate implementation. RESEARCH DESIGN AND METHODS:Eligible guidelines were sought from online databases and websites of diabetes associations and ministries of health. Type 2 DM guidelines published between 2006 and 2016 with accessible full publications were included. Each of the 54 eligible guidelines was assessed for compliance with the Institute of Medicine (IOM) standards, coverage of the cardiovascular quadrangle (epidemiologic surveillance, prevention, acute care, and rehabilitation), translatability, and its target audiences. RESULTS:< 0.001). CONCLUSIONS:A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.