bluuebunny/crossref_metadata_2025 huggingface dataset:
Customized Precision Facial Assessment: An AI-assisted Analysis of Facial Microexpressions for Advanced Aesthetic Treatment
Authors: Li Chih-Wei , Wang Chao-Chin , Chou Che-Yi , Lin Chrang-Shi
Published: March 2020

We introduced a novel protocol based on an artificial intelligence (AI)-assisted analytic system for facial expressions, Customized Precision Facial Assessment (CPFA), to evaluate and quantify the microexpressions of aesthetic concern. With the help of CPFA, physicians may be able to conduct static and dynamic assessments for the microexpressions of the ir patients and perform quantitative measurements before and after the treatments. Through the detection of microexpressions and its active action units of facial muscles, physicians are more likely to optimize the treatment with minimal intervention by precise localization of the foci of aesthetic concern. We presented 3 cases who received neuromodulators and injectable fillers, and we showed the differences in the area of treatment and outcomes of procedures between the CPFA-oriented treatments and human-facilitated ones. We found negative facial expressions decreased in all 3 cases in the group of CPFA while they decreased in only case 1 and case 2 in the group of human facilitated treatment. The CPFA group has more significant decrease in negative facial expression scores than the human group. This pilot study demonstrates that CPFA can objectively recognize and quantify the facial action units associated with negative emotions, and the physician may be able to customize the treatment for individuals accordingly with promising results.
Determining and Comparing Neutron Spectra at Taiwan Photon Source before and after the Installation of Local Injection Shielding
Authors: Lin Yu-Chi , Chen Ang-Yu , Sheu Rong-Jiun
Published: March 2020

Accurate neutron spectrum measurements at light source facilities are difficult to perform because of relatively low and time-varying neutron intensities. A homemade Bonner cylinder spectrometer was used to determine the energy spectra of neutrons outside the lateral shielding wall of the Taiwan Photon Source before and after the installation of local injection shielding. The spectrometer, similar to the design of conventional Bonner spheres, features (1) highly sensitive neutron detection and (2) a wide-range response to neutrons with energies up to the GeV range. Neutron measurements were conducted by intentionally parking the injected 3-GeV electrons at the septum of the storage ring. On the basis of high-fidelity FLUKA simulations, neutron spectra at the measurement location under the experimental conditions were obtained and adopted as an initial guess for spectrum unfolding. The neutron spectra determined before and after the local shielding were comprehensively compared in terms of their intensities and characteristics. The local shielding resulted in overall reductions of approximately 44% and 38% in total neutron flux and dose rate, respectively. Both before and after the local shielding, high-energy neutrons (>10 MeV) were the dominant component of the radiation field, which contributed approximately 30% to 35% of the total neutron flux and 55% to 59% of the total neutron dose rate.
Radiation Safety Considerations in the Treatment of Canine Skeletal Conditions Using 153Sm, 90Y, and 117mSn
Authors: Wendt Richard E. , Selting Kimberly A. , Lattimer Jimmy C. , Wong Janine , Simón Jaime , Stevenson Nigel R. , Stearns Stanley D.
Published: March 2020

The treatment of pets, service animals, and pre-clinical research subjects with radionuclides raises concern for the safety of the people who interact with the animals after their treatment. Three treatments of skeletal conditions in dogs are considered in this study: 153Sm-1,4,7,10-tetraazacylcododecanetetramethylenephosphonic acid, which is a bone-seeking radiopharmaceutical; unencapsulated 90Y permanent interstitial implants, which are sometimes called “liquid brachytherapy”; and 117mSn radiosynoviorthesis, which is also called radiosynovectomy. External exposure rate readings of the 153Sm and 117mSn treatments, and Monte Carlo simulations of 117mSn at a distance of 1 m and of all three in direct contact with tissue were analyzed for doses. Dogs that have received any of these treatments using typically administered activities may be released from radiation safety isolation immediately after treatment from the standpoint of external exposure. People should avoid prolonged close proximity, such as sleeping with a treated dog, for three weeks following an 90Y interstitial implant or for a month following 117mSn radiosynoviorthesis. No such avoidance is necessary after treatment with 153Sm-1,4,7,10-tetraazacylcododecanetetramethylenephosphonic acid.
Haemophilus Species, a Rare Cause of Vertebral Osteomyelitis
Authors: Brooks Daniel R. , Zhou Shiwei , Kauffman Carol A.
Published: March 2020

Vertebral osteomyelitis secondary toHaemophilusspecies is rare. We report a case ofHaemophilus parainfluenzaevertebral osteomyelitis and review the English-language literature for cases ofH. parainfluenzaeandHaemophilus influenzaevertebral osteomyelitis. Fourteen previously reported cases are described alongside our case. The median age was 66 years. Twelve patients (80%) had infection involving the lumbar/sacral vertebrae. Nine (60%) had a possible predisposing factor, including prior respiratory infections and procedures involving mucosal surfaces. Only 4 patients were febrile, and another 4 had symptoms suggesting cord compression. The diagnosis was established by growth of the organism in samples obtained by percutaneous aspiration/biopsy of involved vertebrae in all but 1 patient.Haemophilus parainfluenzaewas associated with a faster clinical progression thanH. influenzae. Antibiotics alone were curative in 11 of the 15 patients; 4 also underwent a surgical procedure. Three of 5 patients withH. parainfluenzaeinfection required surgery. The infection was cured in all patients, including 1 patient who had a relapse after the initial course of antibiotics; only 1 patient had residual neurological symptoms of finger numbness.
Fungal Osteomyelitis of the Temporal Bone and the Importance of Prompt Histopathologic Evaluation in Diagnosis
Authors: Soleiman Aron , Farhat Nada , Cosetti Maura
Published: March 2020

Fungal skull-base osteomyelitis of the temporal bone is an extremely rare condition associated with significant morbidity and mortality. Challenges in diagnosis, specifically accurate identification of pathogens, can complicate and delay appropriate treatment. This is a case of an 82-year-old man with a history of chronic kidney disease, prostate cancer, and type 2 diabetes mellitus. He had a history Bell palsy with complete facial paralysis 1 year prior and a 9-month history of worsening otalgia and otorrhea. Noncontrast computed tomography of the temporal bone revealed a well-developed, opacified mastoid with bone erosion in the stylomastoid foramen, mastoid tip, and extending into the temporomandibular joint. Decision for urgent surgical intervention was made. Histopathologic examination of intraoperative frozen section revealed diffuse fungal forms without bacteria or malignancy. Intraoperative specimens were analyzed with Gram stain (no bacteria identified), as well bacterial (aerobic and anaerobic) and fungal cultures, all with no growth. The cornerstone of diagnosis was pathologic visualization of fungus.
Relationship between non–high-density lipoprotein cholesterol/apolipoprotein A-I and monocyte/high-density lipoprotein cholesterol ratio and coronary heart disease
Authors: Li Ya , Li Shu , Ma Yulin , Li Jialing , Lin Mingying , Wan Jing
Published: March 2020

Objective

To investigate the association between non–high-density lipoprotein cholesterol/apolipoprotein A-I and monocyte/high-density lipoprotein cholesterol ratio and degree of coronary artery stenosis proven by coronary angiography.

Methods

A total of 1867 patients were enrolled into this study and analyzed retrospectively. Three hundred eighty-five non-coronary artery disease hospitalized patients were selected as control group, 1482 patients diagnosed as coronary artery disease were classified into three subgroups according to the tertiles of their SYNTAX score. We compared the level of non–high-density lipoprotein cholesterol/apolipoprotein A-I and monocyte/high-density lipoprotein cholesterol ratio among the three subgroups. The Spearman correlation was used to analyze the correlation between non–high-density lipoprotein cholesterol/apolipoprotein A-I and monocyte/high-density lipoprotein cholesterol ratio and SYNTAX, logistic regression was used for analyzing independent predictors of coronary artery disease.

Results

The level of non–high-density lipoprotein cholesterol/apolipoprotein A-I and monocyte/high-density lipoprotein cholesterol ratio was higher in coronary artery disease group compared with non-coronary artery disease group (P < 0.01). The Spearman correlation analysis showed that non–high-density lipoprotein cholesterol/apolipoprotein A-I and monocyte/high-density lipoprotein cholesterol ratio were significantly correlated with SYNTAX score (r = 0.081, P < 0.001; r = 0.216, P < 0.001). In multivariate logistic regression analysis showed that non–high-density lipoprotein cholesterol/apolipoprotein A-I and monocyte/high-density lipoprotein cholesterol ratio were independent predictors of coronary artery disease (odds ratio = 3.645, 95% confidence interval, 1.267–10.486; OR = 2.096, 95% confidence interval, 1.438–3.054).

Conclusion

Non–high-density lipoprotein cholesterol/apolipoprotein A-I and monocyte/high-density lipoprotein cholesterol ratio were associated with the severity of coronary artery lesions, which can be used as a biomarker for the evaluation of severity of coronary artery disease.
Families' Decision Making at End of Life in Rural Appalachia
Authors: Fornehed Mary Lou Clark , Mixer Sandra J. , Lindley Lisa C.
Published: March 2020

Caring for persons at the end of life has dramatically changed in the last 20 years. Improved chronic illness management and aggressive life-sustaining measures for once-fatal illnesses have significantly increased longevity. People with life-limiting illnesses and their families are asked to make complex and difficult decisions about end-of-life, palliative, and hospice care. The purpose of this study was to discover and describe the culture care expressions, patterns, and practices influencing rural Appalachian families making decisions at the end of life. The qualitative, ethnonursing research method was used to analyze data from 25 interviews. The 4 themes discovered provide insights that could help improve this underserved population's access to palliative and hospice care, which in turn could help them experience a dignified death. Recommendations for health care providers could help reduce rural Appalachians' health disparities and promote meaningful, culturally congruent end-of-life care.
Psychometric Properties of the Vietnamese Catquest-9 Short Form Questionnaire
Authors: To Quyen G. , Huynh Van Anh Ngoc , Do Dung Van , Do Vu Quoc , Congdon Nathan , Dingle Kaeleen , Hong Hiep Van , Nguyen Ho The , To Kien G.
Published: March 2020

SIGNIFICANCE

The Catquest-9 Short Form (SF) has good psychometric properties but was not available in Vietnamese. This study provides the Vietnamese Catquest-9SF and evidence supporting for its use in hospital settings along with clinical assessment to evaluate visual function.

PURPOSE

The purpose of this study was to evaluate the psychometric properties of the Vietnamese Catquest-9SF.

METHODS

Literate patients with unilateral/bilateral cataract, without severe systemic and ocular comorbidities, aged 50+ years, and scheduled for first-eye surgery were screened and recruited at the University of Medicine and Pharmacy at Ho Chi Minh City and Trung Vuong Hospital. Age, sex, and education were self-reported. The Catquest-9SF and the 25-item National Eye Institute Visual Function Questionnaire were used to assess vision-related quality of life (VRQOL). Best-corrected unilateral and bilateral log of the minimum angle of resolution (logMAR) visual acuity was measured, as was best-corrected Pelli-Robson contrast sensitivity. Rasch analysis was performed on the Vietnamese version of the Catquest-9SF. Criterion validity and convergent validity were also evaluated.

RESULTS

Andrich thresholds and response categories on each Catquest-9SF item were ordered, indicating that patients were able to discriminate VRQOL levels. Person separation index and reliability were 2.51 and 0.86, respectively, indicating that the Catquest-9SF was able to distinguish between patients with low- and high-vision difficulties. The tool was unidimensional, with all items fitting well within the construct. There was no evidence of differential item functioning by sex, age group, or cataract status. The tool also showed criterion validity, correlating significantly with visual acuity in the better eye (r = −0.46), the worse eye (r = −0.39), and both eyes (r = −0.44), and with contrast sensitivity for the better eye (r = 0.41), the worse eye (r = 0.32), and both eyes (r = 0.39). A strong correlation between the Catquest-9SF and the 25-item National Eye Institute Visual Function Questionnaire (r = 0.87) indicated convergent validity.

CONCLUSIONS

The Vietnamese Catquest-9SF is valid and psychometrically robust for assessing VRQOL among cataract patients.
Use and Outcomes of Nasotracheal Intubation Among Patients Requiring Mechanical Ventilation Across U.S. PICUs*
Authors: Christian Claire E. , Thompson Nathan E. , Wakeham Martin K.
Published: March 2020

Objectives:

The use and outcomes of nasotracheal intubation in pediatric patients requiring mechanical ventilation have not been quantified. Our goal is to identify prevalence of use, associated factors, and outcomes of nasotracheal versus orotracheal intubation in patients requiring mechanical ventilation.

Design:

Retrospective cohort study using deidentified data from the Virtual Pediatric Systems database. Data from PICU admissions from January 1, 2015, to December 31, 2016 were analyzed.

Setting:

One hundred twenty-one PICUs located within the United States.

Patients:

PICU admissions requiring an endotracheal tube—either nasotracheal or orotracheal—were included. Those with a tracheostomy tube present at admission were excluded from the study.

Interventions:

Not applicable.

Measurements and Main Results:

Among the 121 PICUs included in the study, 64 PICUs (53%) had zero nasotracheal intubations during the reviewed time period. There were 12,088 endotracheal intubations analyzed, and 680 of them (5.6%) were nasotracheal. Of those patients nasotracheally intubated, most were under 2 years old (88.1%), and 82.2% of them were classified as a cardiac patient. Among these young cardiac patients, the rate of unplanned extubation was 0% in the nasotracheal intubated versus 2.1% in the orotracheal intubated group (p < 0.001)

Conclusions:

Nasotracheal intubation is used in a minority of U.S. PICUs and mainly among young cardiac patients. Nasotracheal intubation is associated with a lower rate of unplanned extubations in this patient population. Future prospective studies analyzing the benefits and complications of nasotracheal versus orotracheal intubation in pediatric patients requiring mechanical ventilation are indicated.
Epidemiology of Community-Onset Severe Bacterial Infections in Children and Its Evolution: A Population-Based Study in France*
Authors: Lorton Fleur , Chalumeau Martin , Martinot Alain , Assathiany Rémy , Roué Jean-Michel , Bourgoin Pierre , Chantreuil Julie , Boussicault Gérald , Gaillot Théophile , Saulnier Jean-Pascal , Caillon Jocelyne , Levy Corinne , Cohen Robert , Gras-Le Guen Christèle , Launay Elise
Published: March 2020

Objectives:

To describe the epidemiology of community-onset severe bacterial infections in children and its recent evolution.

Design:

Prospective, observational, population-based study from 2009 to 2014.

Setting:

An administrative area accounting for 13% of the French pediatric population.

Patients:

All children 1 month to 16 years old who died before admission or were admitted to a PICU for a community-onset severe bacterial infection.

Interventions:

None.

Measurements and Main Results:

The incidence and mortality rate of community-onset severe bacterial infections were compared with data from a reference population-based study conducted between 2000 and 2006, that is, before national recommendations for antimeningococcal C and antipneumococcal generalized vaccinations. Among the 261 children included (median age 25 mo), 28 (10.7%) died. The main diagnoses were meningitis (n = 85; 32%) and purpura fulminans (n = 59; 22%). The most common isolated bacteria were Neisseria meningitidis (n = 75; 29%), including 47 (63%) cases of serogroup B and 15 (20%) serogroup C, Streptococcus pneumoniae (n = 49, 19%), and Staphylococcus aureus (n = 15; 6%). The incidence of community-onset severe bacterial infections was three per 100,000 person-years (95% CI, 2.6–3.3) and had decreased by 53% from the reference period. Mortality rate was 0.3 per 100,000 person-years (95% CI, 0.2–0.4) and had decreased by 73% from the reference period. The incidence of community-onset severe bacterial infections caused by N. meningitidis and S. pneumoniae was 0.8 and 0.5 per 100,000 person-years and had decreased by 70% and 67% from the reference period. The incidence of community-onset severe bacterial infections–related to Staphylococcus aureus was 0.16 per 100,000 person-years and had increased by 220% from the reference period.

Conclusions:

The incidence and mortality rate of community-onset severe bacterial infections, except for S. aureus infection, have decreased in France. N. meningitidis and S. pneumoniae continue to account for many infections, which indicates the need for better vaccination coverage and spectrum.
Energy Expenditure in Mechanically Ventilated Korean Children: Single-Center Evaluation of a New Estimation Equation*
Authors: Jhang Won Kyoung , Park Seong Jong
Published: March 2020

Objectives:

Accurate assessments of energy expenditure are vital for determining optimal nutritional support, especially in critically ill children. We evaluated current methods for energy expenditure prediction, in comparison with indirect calorimetry, and developed a new estimation equation for mechanically ventilated, critically ill Korean children.

Design:

Single-center retrospective study.

Setting:

Fourteen-bed pediatric medical ICU in a tertiary care children’s hospital.

Patients:

Pediatric patients admitted to the PICU between October 2017 and September 2019 with a measured energy expenditure by indirect calorimetry.

Interventions:

None.

Measurements and Main Results:

A total 95 pediatric patients (70 in derivation cohort for development of a new predictive equation and 25 in validation cohort) were included. Mean measured energy expenditure of group A was 66.20 ± 15.35 kcal/kg/d. All previously established predictive equations underestimated the predicted energy expenditure, compared with the measured energy expenditure, except the Food and Agriculture/World Health Organization/United Nations University equation. The Schofield-Height and Weight equation showed the best performance among the tested predictive equations for the entire cohort (least bias, –68.58 kcal/d; best percentage, 108.46% ± 33.60%) compared with the measured energy expenditure. It was also the best performing predictive equation in subgroup analysis by age, sex, nutritional status, and organ failure. Because some discrepancies remained between the measured energy expenditure and predicted energy expenditures, we developed a new estimation equation using multiple regression analysis and those variables significantly associated with our current measured energy expenditures: Energy expenditure = –321.264 + 72.152 × (body weight, kg)–1.396 × (body weight)2+ 5.668 × height (cm) + organ dysfunction* (*hematologic, 76.699; neurologic, –87.984). This new estimation equation showed the least bias and best percentage compared with previous predictive equations (least bias, 15.51 kcal/d; best percentage, 102.30% ± 28.10%).

Conclusions:

There are significant disparities between measured and calculated energy expenditures. We developed a new estimation equation based on measured energy expenditure data that shows better performance in mechanically ventilated Korean children than other equations. This new estimation equation requires further prospective validation in pediatric series with a range in body habitus.
Envisioning Distinctive Professional Identity for Critical Care Advanced Practice Providers: Fostering Integrative Transformation Beyond Orientation
Authors: Jain Parag N. , Jones Melissa B. , Thammasitboon Satid
Published: March 2020

The roles played by nurse practitioners and physician assistants have expanded exponentially during the last decade. Although existing professional advancement models for nurse practitioners/physician assistants have led to enhanced integration in different patient care units, the development of a distinctive professional identity formation is lacking. This perspective proposes a new framework to guide the planning of an educational program that provides not only clinical knowledge and technical skills but also opportunities for enhancing leadership and research skills, along with strong career mentorship. Such a program will lead to formation of a distinctive identity for critical care nurse practitioners and physician assistants, which in turn can improve job satisfaction and employee retention.
Adding Contralaterally Controlled Electrical Stimulation of the Triceps to Contralaterally Controlled Functional Electrical Stimulation of the Finger Extensors Reduces Upper Limb Impairment and Improves Reachable Workspace but not Dexterity
Authors: Knutson Jayme S. , Makowski Nathaniel S. , Harley Mary Y. , Hisel Terri Z. , Gunzler Douglas D. , Wilson Richard D. , Chae John
Published: March 2020

Objective

Different methods of neuromuscular electrical stimulation may be used for poststroke upper limb rehabilitation. This study evaluated the effects of contralaterally controlled functional electrical stimulation of the triceps and finger extensors.

Design

This is a randomized controlled trial of 67 participants who were less than 2 yrs poststroke and assigned to the following: (a) arm + hand contralaterally controlled functional electrical stimulation, (b) hand contralaterally controlled functional electrical stimulation, or (c) arm + hand cyclic neuromuscular electrical stimulation. Participants were prescribed 10 sessions/week of assigned electrical stimulation at home plus 24 sessions of functional task practice in the laboratory for 12 wks. The primary outcome measure was the Box and Blocks Test. Secondary measures included reachable workspace, Upper Extremity Fugl-Meyer, Stroke Upper Limb Capacity Scale, Arm Motor Abilities Test, and Motor Activity Log.

Results

There were no significant between-group differences on the Box and Blocks Test. At 6 mos after treatment, arm + hand contralaterally controlled functional electrical stimulation improved reachable workspace more than hand contralaterally controlled functional electrical stimulation, between-group difference of 264 (95% confidence interval = 28–500) cm2 and more than arm + hand cyclic neuromuscular electrical stimulation, between-group difference of 281 (95% confidence interval = 22–540) cm2. Arm + hand contralaterally controlled functional electrical stimulation improved Upper Extremity Fugl-Meyer score more than hand contralaterally controlled functional electrical stimulation, between-group difference of 6.7 (95% confidence interval = 0.6–12.7). The between-group differences on the Stroke Upper Limb Capacity Scale and Arm Motor Abilities Test were not significant.

Conclusions

Adding contralaterally controlled elbow extension to hand contralaterally controlled functional electrical stimulation does not improve on gains in hand dexterity, but it further reduces upper limb impairment and improves reachable workspace measured in the laboratory. However, these additional benefits may not be large enough to be perceived by stroke survivors when they are performing activities of daily living at home.
Utilization of Outpatient Physical and Occupational Therapy in People With Spinal Cord Injury in Germany
Authors: Martini Luiza , Maus Uwe , Bökel Andrea , Geng Veronika , Kalke Yorck-Bernhard , Liebscher Thomas , Weidner Norbert , Hoffmann Falk
Published: March 2020

Objective

The aim of the study was to assess factors determining the utilization of physical and occupational therapy in people with spinal cord injury.

Design

Data from the German Spinal Cord Injury study conducted in 2017 were analyzed. The 12-mo prevalence of physical therapy and occupational therapy utilization was determined. To identify underlying determinants, multivariable logistic regression was used.

Results

Of 1479 participants (response = 26.4%), 72.9% were male, with a mean (SD) age of 55.3 (14.6) yrs and a mean (SD) time since injury of 14.0 (12.0) yrs; 51.2% were people with paraplegia and 66.3% had an incomplete spinal cord injury. In the past 12 mos, 78.1% received physical and 29.3% occupational therapy. Physical therapy and occupational therapy were significantly associated with time since spinal cord injury occurrence, participation in lifelong care programs, and electric wheelchair dependency. Spinal cord injury characteristics, level of impairment, and time since spinal cord injury had a greater impact on occupational therapy than on physical therapy utilization.

Conclusions

The use of physical therapy and occupational therapy is much higher in Germans with spinal cord injury than in the general population and in people with similar neurological conditions. Further research should focus on the frequency of use and the types of interventions. Guidelines for lifelong care should include recommendations on physical therapy and occupational therapy.
New Guidelines for Electrical Stimulation Parameters in Adult Patients With Knee Osteoarthritis Based on a Systematic Review of the Current Literature
Authors: Novak Sarah , Guerron Gabriela , Zou Zhiwei , Cheung Gavin , Berteau Jean-Philippe
Published: March 2020

Objective

The goal of this systematic review was to provide guidelines for treatment parameters regarding electrical stimulation by investigating its efficacy in improving muscle strength and decreasing pain in patients with knee osteoarthritis.

Design

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standard, three electronic databases (CINAHL, PubMed, and PEDro) and gray literature were used. Randomized control trials comparing electrical stimulation and conservative physical therapy were critically appraised using the 2005 University of Oxford standard.

Results

Nine randomized control trials were included in our review. First, our review confirmed that neuromuscular electrical stimulation is the most effective electrical stimulation treatment in the management of knee OA, and its efficiency is higher when combined with a strengthening program. Second, frequency of at least 50 Hz and no more than 75 Hz with a pulse duration between 200 and 400 μs and a treatment duration of 20 mins is necessary for successful treatment.

Conclusions

For the first time, our review provides standardized clinical treatment parameters for neuromuscular electrical stimulation to be included in a strengthening program for the adult patient with knee OA.

To Claim CME Credits

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME

CME Objectives

Upon completion of this article, the reader should be able to: (1) Recall the impact of quadriceps femoris weakness on joint stability; (2) Summarize the mechanism of action of neuromuscular electrical stimulation (NMES) on reducing pain and increasing muscle strength; and (3) Plan the clinical treatment parameters of NMES to be included in a strengthening program for an adult patient with knee osteoarthritis.

Level

Advanced.

Accreditation

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Patients’ Perspectives of Diagnostic Error: A Qualitative Study
Authors: Sacco Alden Y. , Self Quinn R. , Worswick Erica L. , Couperus Cody J. , Kolli Sree S. , Muñoz Sergio A. , Carney Jan K. , Repp Allen B.
Published: March 2020

Objectives

The Institute of Medicine (IOM) defines diagnostic error as the failure to establish an accurate or timely explanation for the patient’s health problem(s) or effectively communicate the explanation to the patient. Using this definition, we sought to characterize diagnostic errors experienced by patients and describe patient perspectives on causes, impacts, and prevention strategies.

Methods

We conducted interviews of adults hospitalized at an academic medical center. We used the framework of the IOM definition of diagnostic error to perform thematic analysis of qualitative data. Descriptive statistics were used to summarize quantitative data.

Results

Based on the IOM’s definition of diagnostic error, 27 of the 69 included patients reported at least one diagnostic error in the past 5 years. The errors were distributed evenly across the following three dimensions of the IOM definition: accuracy, communication, and timeliness. Limited time with doctors, communication, clinical assessment, and clinical management emerged as major themes for causes of diagnostic error and for strategies to reduce diagnostic error. Impacts of errors included emotional distress, adverse health outcomes, and impaired activities of daily living.

Conclusions

This study uses the recent IOM definition of diagnostic error to provide insights into diagnostic error from the patient perspective. We found that diagnostic errors were commonly reported by hospitalized adults and have a profound impact on patients’ well-being. Patients’ insights regarding potential causes and prevention strategies may help identify opportunities to reduce diagnostic errors.
Observational Study of Drug Formulation Manipulation in Pediatric Versus Adult Inpatients
Authors: Spishock Samantha , Meyers Rachel , Robinson Christine A. , Shah Pooja , Siu Anita , Sturgill Marc , Kimler Katelin
Published: March 2020

Objectives

Medications often require manipulations to measure and administer the correct dose for pediatric patients. These manipulations pose medication safety risks. The objective of this study was to determine the frequency of drug formulation manipulations in the pediatric inpatient population and compare the findings to a parallel adult inpatient population.

Methods

Observations were conducted at four sites with 1 day of data collection per week by a randomized schedule for 5 weeks. All pediatric inpatients at each study site were included as well as an equivalent number of medication orders from adult inpatients with similar levels of care. The percentage of medication orders requiring a manipulation were evaluated and compared between pediatric and adult patients.

Results

A total of 15,722 medication orders were analyzed. Drug formulation manipulation was required in 3925 (49.9%) of 7861 pediatric orders versus 1301 of 7861 adult orders (16.6%) (P < 0.05). By pediatric service, drug manipulations were required most frequently (71.5% of orders) in the neonatal intensive care unit. The most common dosage forms requiring manipulation for pediatric patients were oral liquids (45.7% of orders) and intravenous medications (44.6% of orders). By pediatric patient age, drug manipulation was required most often in patients aged 1 to 12 months (69.8% of orders).

Conclusions

Drug formulation manipulation was three times more common in pediatric inpatient practice compared with adult inpatient practice in this study. This study demonstrated a statistically significant difference in the prevalence of drug formulation manipulation between pediatric and adult inpatients.
Reason for Exam Imaging Reporting and Data System: Consensus Reached on Quality Assessment of Radiology Requisitions
Authors: Tofighi Salar , Abedi Aidin , Salehi Sana , Myers Lee , Reddy Sravanthi , Gholamrezanezhad Ali
Published: March 2020

Objective

The aim of this study was to reach consensus on quality assessment of clinical information in imaging requisitions using Reason for exam Imaging Reporting and Data System (RI-RADS).

Methods

A Delphi study was conducted in September 2018 with a panel of 87 radiologists with diverse levels of experience from various settings (community hospitals, private hospitals, university hospitals, and clinics), of which 74.7% completed the survey. The agreement was assessed in the following subjects: (a) presumed effect of standardization, (b) the standardized system for information, (c) the scoring system for evaluation of requisitions, and (d) the implementation of RI-RADS. The consensus threshold was set at 51% responding (strongly) agree. The rate of lawsuits preventable with clinical information was also assessed.

Results

Consensus was reached on all objectives of the study with a high level of agreement. Radiologists agreed on the need for standardization of imaging requisitions and attributed it to increased speed and accuracy of interpretations. Three categories of information were determined as key indicators of quality: impression, clinical findings, and clinical question. The scoring system is intended to grade requisitions based on the presence of these categories. Radiologists also agreed that RI-RADS will encourage physicians to improve requisitions. Among radiologists who responded to the survey, 12.6% had experienced at least one lawsuit potentially preventable with sufficient information in requisitions.

Conclusions

Reason for exam Imaging Reporting and Data System can be used as a standard for quality assessment of requisitions. Its use may improve the quality of patient care and reduce lawsuits against radiologists.
Dealing With Adverse Events: A Meta-analysis on Second Victims’ Coping Strategies
Authors: Busch Isolde M. , Moretti Francesca , Purgato Marianna , Barbui Corrado , Wu Albert W. , Rimondini Michela
Published: March 2020

Objectives

Despite the critical need to understand the diverse responses by second victims to adverse events, there has not been a meta-analysis examining coping by second victims. We aimed to analyze the coping strategies applied by second victims in the aftermath of adverse events.

Methods

We performed a systematic search of nine electronic databases up to October 2018 and screened additional sources, such as gray databases. Two independent reviewers conducted the search, selection process, quality appraisal, data extraction, and synthesis. In case of dissent, a third reviewer was involved to reach consensus. Quantitative studies of the frequency with which coping strategies were applied by second victims were eligible for inclusion. We calculated the overall frequency of coping strategies andI2statistic using random effects modeling.

Results

Of 10,705 records retrieved, 111 full-text articles were assessed for eligibility and 14 studies eventually included. The five most frequent coping strategies wereChanging work attitude(89%, 95% confidence interval [CI] = 80–94), Following policies and guidelines more accurately and closely(89%, 95% CI = 54–98), Paying more attention to detail(89%, 95% CI = 78–94) (task oriented),Problem-solving/concrete action plan(77%, 95% CI = 59–89) (task oriented), andCriticizing or lecturing oneself(74%, 95% CI = 47–90) (emotion oriented).

Conclusions

Second victims frequently used task- and emotion-oriented coping strategies and, to a lesser degree, avoidance-oriented strategies. To better support second victims and ensure patient safety, coping strategies should be evaluated considering the positive and negative effects on the clinician’s personal and professional well-being, relationships with patients, and the quality and safety of healthcare.
Safety Analysis of 13 Suspicious Deaths in Intensive Care: Ergonomics and Forensic Approach Compared
Authors: Tartaglia Riccardo , Prineas Stavros , Poli Daniela , Albolino Sara , Bellandi Tommaso , Biancofiore Gianni , Bertolini Guido , Toccafondi Giulio
Published: March 2020

Objectives

Thirteen suspicious deaths occurred in an intensive care unit of Tuscany, Italy, in 2015. All patients developed sudden unexplained coagulopathy leading to severe bleeding. None of them had been prescribed heparin, but supertherapeutic concentrations of heparin were found. After a nurse was arrested on suspicion of murdering Human Factor and Ergonomics (HF/E) experts received a mandate to identify system failures. According to the judgment of the Court of First Instance on April 2019, the nurse was found guilty.

Methods

The HF/E group used a two-pronged safety analysis: understanding the conditions in which the healthcare practitioners were working in the period when the suspicious deaths emerged and reviewing the clinical records.

Results

Fourteen patients admitted to the intensive care unit in 2014 and 2015 were selected on the basis of markedly abnormal coagulation tests (n = 13) or a family member’s complaint (n = 1). In 13 cases, a massive, abrupt hemorrhage in the presence of an unexpected abnormality of coagulation tests occurred, whereas the fourteenth patient had the only prolongation of coagulation markers without bleeding. All cases examined classified as adverse events related to a coagulation disorder. Human factor and ergonomics analysis identified a number of latent and active failures that contributed to the event and provided a set of important recommendations for safety improvement.

Conclusions

When presented with a manifest, albeit suspected, wrongdoing with lethal consequences for patients, forensic investigators and safety investigators have distinctly different goals and methods. We believe that a memorandum of understanding between HF/E and forensic investigative teams provides an operative framework for allowing co-existence and fosters collaboration. The pursuit of safe care as a new emerging right for patients and balancing the right to legal justice with the right to safer healthcare merit further investigation and discussion.
Ranking Quality and Patient Safety Challenges: A Nationwide Survey of Healthcare Quality Experts From General Hospitals in Spain
Authors: Gordo Cristina , Mateo Ricardo , Labiano Juana , Núñez-Córdoba Jorge M.
Published: March 2020

Objective

The aim of the study was to identify and rank leading healthcare quality and patient safety challenges of general hospitals in Spain.

Methods

A novel online cross-sectional survey for hospitals with 150 or more beds carried out between June and September 2018. Sample frame is hospitals of the National Catalogue of Hospitals of the Ministry of Health in Spain (N = 888). Eligibility criteria are quality experts of clinical quality and/or patient safety services of general hospitals with 150 or more beds. Challenges were ranked using a risk priority number (RPN) calculated from the product of severity, frequency, and detectability scores.

Results

Targeted hospitals were 234. The contact rate was 97.4%, representing 63% of total beds nationwide. One hundred hospitals completed the questionnaire. According to the RPN, the top five challenges were incorrect hand hygiene of health professionals (mean RPN = 334.5, SD = 198.5), ineffective interprofessional communication (mean RPN = 334.3, SD = 169.5), medication errors in transitions of care (mean RPN = 254.0, SD = 151.0), low reporting rates of patient safety incidents and adverse events (mean RPN = 252.3, SD = 176.3), and antimicrobial resistance due to inappropriate use of antibiotics (mean RPN = 243.5, SD = 158.7).

Conclusions

This pioneer study of ranking quality and patient safety challenges of hospitals in Spain provides an evidence-based and context-specific foundation for quality improvement decision-making.
Does an Orthopedic Ward Round Pro Forma Improve Inpatient Documentation?
Authors: Vukanic Danilo , Kelly Enda G. , Cleary Susan May
Published: March 2020

Introduction

Thorough documentation is of utmost importance in a patient hospital experience. It forms an accurate record of an inpatient stay, facilitates handover between medical colleagues, and is also a legal document. Medical notes tend to be detailed and insightful on admission, but the daily ward round notes have often fallen short of expectation. With most patient records entered by junior level of staff, it is important to ensure that adequate documentation occurs.

Methods

We analyzed notes entered in patient charts at set periods and compared them against standards set out in the Royal College of Surgeons Ireland and England, as well as Medical Council guidelines from the two countries. After this, a pro forma was established to standardize the medical record keeping on patient ward rounds. Compliance with guidelines was assessed by comparing notes before introduction of the pro forma and after their introduction.

Results

Before its introduction, 0% of notes fulfilled the full criteria selected for the pro forma documentation. After intervention, there was a good initial response, with notes capturing an average 86% of the required information. A reaudit of compliance 2 months after introduction showed a 9% decrease of information completeness to 75%.

Conclusions

Introduction of a pro forma for the documentation of daily ward rounds improved compliance of ward round notes when compared with internationally recognized guidelines, with no additional time required during ward rounds. Despite improved compliance, continued effort is needed to achieve a better standard of care.
Evaluation of the Green Cross Method Regarding Patient Safety Culture and Incidence Reporting
Authors: Källman Ulrika , Rusner Marie , Schwarz Anneli , Nordström Sophia , Isaksson Stina
Published: March 2020

Objectives

The Green Cross (GC) method is a visual method for health service staff to recognize risks and preventable adverse events (PAEs) on a daily basis. The aim was to compare patient safety culture and the number of reported PAEs in units using the GC method with units that do not.

Methods

This study has a retrospective cross-sectional design in the setting of psychiatric and somatic care departments in a Swedish hospital. In total, 1476 staff members from 62 different units participate in the study.

Results

Units who had implemented the GC method scored higher than non-GC units in overall quality. The dimensions Feedback and communication about error, Nonpunitive response to errors, Organizational learning-continuous improvement, Handoffs and transitions between units and shifts, and Teamwork within units scored significantly higher in GC units. More risks were reported in the incident reporting system in GC units than in non-GC units, but the number of PAEs was similar. Units with nursing staff who used the GC method scored higher on patient safety culture than those who did not use the method. This difference was not seen in physician units.

Conclusions

The implementation of the GC method has a positive impact on patient safety culture and PAE reporting. However, the method does not seem to have the same impact in physician units as in units with nursing staff, which calls for further investigation.
HIV protease inhibitor ritonavir induces renal fibrosis and dysfunction: role of platelet-derived TGF-β1 and intervention via antioxidant pathways
Authors: Laurence Jeffrey , Elhadad Sonia , Gostynska Sandra , Yu Zhongxin , Terry Hunter , Varshney Rohan , Fung Kar-Ming , Choi Mary E. , Ahamed Jasimuddin
Published: March 2020

Objective:

Chronic kidney disease (CKD) with tubular injury and fibrosis occurs in HIV infection treated with certain protease inhibitor-based antiretroviral therapies. The pathophysiology is unclear.

Design:

We hypothesized that fibrosis, mediated by platelet-derived transforming growth factor (TGF)-β1, underlies protease inhibitor-associated CKD. We induced this in mice exposed to the protease inhibitor ritonavir (RTV), and intervened with low-dose inhaled carbon monoxide (CO), activating erythroid 2-related factor (Nrf2)-associated antioxidant pathways.

Methods:

Wild-type C57BL/6 mice and mice deficient in platelet TGF-β1, were given RTV (10 mg/kg) or vehicle daily for 8 weeks. Select groups were exposed to CO (250 ppm) for 4 h after RTV or vehicle injection. Renal disorder, fibrosis, and TGF-β1-based and Nrf2-based signaling were examined by histology, immunofluorescence, and flow cytometry. Renal damage and dysfunction were assessed by KIM-1 and cystatin C ELISAs. Clinical correlations were sought among HIV-infected individuals.

Results:

RTV-induced glomerular and tubular injury, elevating urinary KIM-1 (P = 0.004). It enhanced TGF-β1-related signaling, accompanied by kidney fibrosis, macrophage polarization to an inflammatory phenotype, and renal dysfunction with cystatin C elevation (P = 0.008). Mice lacking TGF-β1 in platelets were partially protected from these abnormalities. CO inhibited RTV-induced fibrosis and macrophage polarization in association with upregulation of Nrf2 and heme oxygenase-1 (HO-1). Clinically, HIV infection correlated with elevated cystatin C levels in untreated women (n = 17) vs. age-matched controls (n = 19; P = 0.014). RTV-treated HIV+ women had further increases in cystatin C (n = 20; P = 0.05), with parallel elevation of HO-1.

Conclusion:

Platelet TGF-β1 contributes to RTV-induced kidney fibrosis and dysfunction, which may be amenable to antioxidant interventions.
Organ transplantation in persons with HIV
Authors: Kumar Rebecca N. , Stosor Valentina
Published: March 2020

With current antiretroviral therapy, the lifespan of newly diagnosed persons with HIV (PWH) approaches that of uninfected persons. However, metabolic abnormalities related to both the disease and the virus itself, along with comorbidities of aging, have resulted in end-organ disease and organ failure as a major cause of morbidity and mortality. Solid organ transplantation is a life-saving therapy for PWH who have organ failure, and the approval of the HIV Organ Policy Equity Act has opened and expanded opportunities for PWH to donate and receive organs. The current environment of organ transplantation for PWH will be reviewed and future directions of research and treatment will be discussed.
Myocardial Mechanics Parameters That Predict Left Ventricular Outflow Tract Obstruction in Patients With Hypertrophic Cardiomyopathy: A Cardiovascular Magnetic Resonance Feature Tracking Analysis
Authors: Huang Lei , Que Lifeng , Xi Yue , Zhuang Jian , Yuan Haiyun , Liu Hui , Li Jinglei , Dong Yuhao , Jia Qianjun , Lin JiJin
Published: March 2020

Objective

To identify left ventricular (LV) myocardial mechanics predictors of LV outflow tract obstruction (LVOTO) in patients with hypertrophic cardiomyopathy (HCM).

Methods

Thirty-nine adults with HCM and 21 controls underwent cardiovascular magnetic resonance. The feature tracking (FT) analysis results of HCM patients with and without LVOTO and controls were compared.

Results

Global radial strain measured on the short-axis slice (GRS-SAX) (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.02–1.15; P < 0.01), global longitudinal strain measured on the long-axis slice (GLS-LAX) (OR, 1.81; 95% CI, 1.21–2.73; P < 0.01) and GRS measured on the long-axis slice (GRS-LAX) (OR, 1.07; 95% CI, 1.01–1.13; P = 0.02) were independent predictors of LVOTO. The combination of GRS-SAX plus GLS-LAX and GRS-LAX showed great discriminatory power for identifying LVOTO with an area under the receiver operating characteristic curve value of 0.91 (95% CI: 0.81–1.00).

Conclusions

In adult HCM patients, GRS-SAX, GLS-LAX, and GRS-LAX were independent predictors of LVOTO. The combination of GRS-SAX plus GLS-LAX and GRS-LAX showed great discriminatory power for identifying LVOTO.