bluuebunny/crossref_metadata_2025 huggingface dataset:
The Relationship Between the Learning and Patient Safety Climates of Clinical Departments and Residents’ Patient Safety Behaviors
Authors: Silkens Milou E.W.M. , Arah Onyebuchi A. , Wagner Cordula , Scherpbier Albert J.J.A. , Heineman Maas Jan , Lombarts Kiki M.J.M.H.
Published: May 2018

Purpose

Improving residents’ patient safety behavior should be a priority in graduate medical education to ensure the safety of current and future patients. Supportive learning and patient safety climates may foster this behavior. This study examined the extent to which residents’ self-reported patient safety behavior can be explained by the learning climate and patient safety climate of their clinical departments.

Method

The authors collected learning climate data from clinical departments in the Netherlands that used the web-based Dutch Residency Educational Climate Test between September 2015 and October 2016. They also gathered data on those departments’ patient safety climate and on residents’ self-reported patient safety behavior. They used generalized linear mixed models and multivariate general linear models to test for associations in the data.

Results

In total, 1,006 residents evaluated 143 departments in 31 teaching hospitals. Departments’ patient safety climate was associated with residents’ overall self-reported patient safety behavior (regression coefficient [b] = 0.33; 95% confidence interval [CI] = 0.14 to 0.52). Departments’ learning climate was not associated with residents’ patient safety behavior (b = 0.01; 95% CI = −0.17 to 0.19), although it was with their patient safety climate (b = 0.73; 95% CI = 0.69 to 0.77).

Conclusions

Departments should focus on establishing a supportive patient safety climate to improve residents’ patient safety behavior. Building a supportive learning climate might help to improve the patient safety climate and, in turn, residents’ patient safety behavior.
Oncocytic Melanoma: A Study of a Rare Entity
Authors: Donner Ludvik R. , Maximo Valdemar
Published: May 2018

The authors report the second case of oncocytic melanoma, one of the rarest known melanoma variants. The diagnosis was established by Fontana stain positivity, expression of S100 protein as well as gp100/HMB45, and demonstration of numerous mitochondria by ultrastructure. Because it is known that some oncocytic tumors of the thyroid gland and kidney contain point mutations and common deletions of mitochondrial DNA, the complete mitochondrial DNA of the reported oncocytic melanoma was also studied. It was normal except for 2 private separate point mutations, predicted to be not pathogenic, which do not seem to play any role in the tumor phenotype.
Transanal Total Mesorectal Excision vs Laparoscopic Total Mesorectal Excision in the Treatment of Low and Middle Rectal Cancer: A Propensity Score Matching Analysis
Authors: Persiani Roberto , Biondi Alberto , Pennestrì Francesco , Fico Valeria , De Simone Veronica , Tirelli Flavio , Santullo Francesco , D’Ugo Domenico
Published: May 2018

BACKGROUND:

Transanal total mesorectal excision is a novel and promising technique in the treatment of low and middle rectal cancer.

OBJECTIVE:

This study aimed to compare the safety and feasibility of transanal total mesorectal excision versus laparoscopic total mesorectal excision.

DESIGN:

This was a retrospective study using propensity score matching analysis.

SETTINGS:

This study was conducted in a single high-volume university hospital.

PATIENTS:

Patients with low and middle rectal cancer who underwent total mesorectal excision with curative intent between 2007 and 2017 were recruited.

INTERVENTIONS:

Laparoscopic total mesorectal excision and transanal total mesorectal excision had been performed.

MAIN OUTCOME MEASURES:

Intraoperative, pathological, and 30-day postoperative outcomes were compared between the transanal and laparoscopic groups.

RESULTS:

Overall, 105 patients were selected from the whole sample of 316 patients with rectal cancer. After propensity score matching analysis, 46 patients for each group were compared. Laparoscopic total mesorectal excision was associated with a higher conversion rate to open surgery (19.6% vs 0%, p = 0.002). Transanal total mesorectal excision showed a longer distal resection margin (15 mm vs 25 mm; p < 0.001), and similar results regarding the completeness of mesorectal excision and circumferential resection margin involvement, compared to laparoscopy. There were no statistically significant differences between the 2 groups in terms of postoperative complications.

LIMITATIONS:

The study was limited by its retrospective design and the small size of the sample.

CONCLUSIONS:

Transanal total mesorectal excision is a safe and feasible technique that results in a high-quality rectal cancer resection specimen and favorable 30-day postoperative outcomes.
Administration of an Oral Hydration Solution Prevents Electrolyte and Fluid Disturbances and Reduces Readmissions in Patients With a Diverting Ileostomy After Colorectal Surgery: A Prospective, Randomized, Controlled Trial
Authors: Migdanis Athanasios , Koukoulis Georgios , Mamaloudis Ioannis , Baloyiannis Ioannis , Migdanis Ioannis , Kanaki Maria , Malissiova Eleni , Tzovaras Georgios
Published: May 2018

BACKGROUND:

Patients with a newly formed ileostomy often develop electrolyte abnormalities and dehydration.

OBJECTIVE:

The study assessed the prophylactic effect of an isotonic hydration solution on dehydration and electrolyte abnormalities in patients with a newly formed ileostomy.

DESIGN:

This was a prospective, randomized, controlled trial (NCT02036346).

SETTINGS:

The study was conducted at a single surgical unit of a public university hospital.

PATIENTS:

Patients scheduled for elective rectosigmoid resection were considered for study inclusion.

INTERVENTION:

Patients in whom a diverting ileostomy was created were randomly assigned to the intervention group (n = 39), which received an oral isotonic glucose-sodium hydration solution for 40 days postdischarge and the control group (n = 41) which did not receive an intervention. The 2 groups were compared with a group of patients who underwent rectosigmoid resection without diverting ileostomy (n = 37).

MAIN OUTCOME MEASURES:

Serum electrolyte and renal function markers were assessed preoperatively and at 20 and 40 days postdischarge.

RESULTS:

At 20 days postdischarge, the serum sodium of the control group appeared lower than the serum sodium of the intervention group and the nonileostomy group (p = 0.007). At the same time point, urea and creatinine levels of the control group were higher than the urea and creatinine levels of the other 2 groups (p = 0.01 and p = 0.02). At 40 days postdischarge, mean sodium and renal function markers improved in the control group, but sodium and creatinine continued to differ in comparison with the intervention and nonileostomy groups (p = 0.01 and p = 0.04). The readmission rate for fluid and electrolyte abnormalities was higher in the control group (24%) than in the other 2 groups, where no rehospitalization for such a reason was required (p = 0.001).

LIMITATIONS:

The study was limited by its single-center design.

CONCLUSION:

An oral isotonic drink postdischarge can have a prophylactic effect on patients with a newly formed ileostomy, preventing readmission for fluid and electrolyte abnormalities. See Video Abstract at http://links.lww.com/DCR/A603.
The Chimeric Versatility of the Subscapular System Revisited: Backup Options, Coverage for Bone Transplants and Vascularized Lymph Nodes
Authors: Schoenle Philipp , Gazyakan Emre , Kremer Thomas , Harhaus Leila , Kneser Ulrich , Hirche Christoph
Published: May 2018

Traumatic soft tissue and bone defects are demanding challenges for the reconstructive microsurgeons. Common and safe workhorses for these reconstructions are free microvascular flaps based on the subscapular system. In this article, we want to demonstrate the versatility of the serratus anterior muscle combined with other components of the subscapular system for reconstruction of complex lower extremity defects. Three patients with traumatic soft tissue and bone defects of the lower extremity were planned for reconstruction. The defects varied in size and could be covered by 1 or 2 slips of the serratus muscle or split muscle combined with latissimus dorsi muscle flap. In 1 case, the thoracodorsal lymph node package was included for addressing severe posttraumatic lymphedema after burn injury. In another case, the serratus slips served as coverage for a free scapula bone transplant. The chimeric flaps healed without complications; no further operations were needed for reconstruction. By the use of only 1 or 2 slips of the serratus muscle, we could prevent functional impairments for the patients and reduced further scarring compared with classic latissimus dorsi—(para-) scapular combinations.
Re-evaluating the Lejour Technique for Breast Reduction in Patients with Macromastia
Authors: Copeland-Halperin Libby R. , Smith Lauren , Copeland Michelle
Published: May 2018

Background:

Limited scar Lejour technique for breast reduction is conventionally used to remove less than 500 g of breast tissue per breast, but is effective for greater macromastia. Plastic surgery residents gain limited experience with this technique, and it is infrequently performed in the United States. To understand technique selection, we surveyed board-certified plastic surgeons and compared outcomes with the Lejour technique in 1 practice to those with other methods.

Methods:

We surveyed American Society of Plastic Surgeons members about techniques for breast reduction and compared outcomes with procedures performed by various techniques by a single surgeon (M.C.).

Results:

Of 321 survey respondents, 33% reported formal training in the Lejour technique. Over 70% used mainly the inferior pedicle Wise procedure; 14% used mainly the Lejour or modified Lejour technique. In a series of reduction mammaplasties by 1 surgeon in 119 patients between 1997 and 2006, 14 underwent inferior pedicle Wise pattern and 105 involved the Lejour technique. Mean tissue mass removal was 1,136 g/breast (range, 170–4,050 g). Major complications occurred in 1.74% overall, and 0% and 1.9% for the Wise and Lejour techniques, respectively (P = 0.46).

Conclusions:

Although most American Society of Plastic Surgeons respondents were not formally trained in the Lejour technique and seldom perform the procedure, it can be employed for reduction mammaplasty with no greater risk of complications than the Wise method. The Lejour technique should be incorporated during residency training as an alternative for reduction mammaplasty.
NOVEL BEST1 MUTATIONS DETECTED BY NEXT-GENERATION SEQUENCING IN A CHINESE POPULATION WITH VITELLIFORM MACULAR DYSTROPHY
Authors: Guo Jingli , Gao Fengjuan , Tang Wenyi , Qi Yuhe , Xuan Yi , Liu Wei , Li Lei , Ye Xiaofeng , Xu Gezhi , Wu Jihong , Zhang Yongjin
Published: May 2018

Purpose:

To characterize novel BEST1 mutations and the phenotype–genotype correlations in vitelliform macular dystrophy in a Chinese population.

Methods:

Seventeen individuals affected by vitelliform macular dystrophy underwent detailed ophthalmic examinations, including a best-corrected visual acuity test, slit-lamp biomicroscopy, fundus photography, spectral-domain optical coherence tomography, fundus autofluorescence, fluorescein angiography, and optical coherence tomography angiography. Next-generation sequencing was used to screen 790 genes frequently involved in common inherited nonsyndromic eye diseases in all participants. Sanger sequencing was used to identify possible disease-causing variants.

Results:

The mean ± SD age of the patients was 44.20 ± 15.09 (range: 16–69) years. Seven novel BEST1 mutations were identified: six heterozygous missense (p.Thr307Asn, p.Ile295The, p.Leu75Pro, p.Thr2Ser, p.Ser79Tyr, and p.Val81Leu) and one frameshift (p.Glu115GlufsX120) mutation. Choroidal neovascularization was detected in two probands. One individual presented with subfoveal focal choroidal excavation. Arden ratios obtained by electrooculography were less than the 1.5 cutoff value in 7 patients. No mutations were identified in 2 patients, one of whom had a fundus appearance typical of vitelliform macular dystrophy and a decreased Arden ratio (1.2/1.2).

Conclusion:

Patients with the same heterozygous BEST1 mutations exhibited varying phenotypes. Our results have expanded the BEST1 mutation spectrum in a Chinese population with vitelliform macular dystrophy.
“From ear to trunk”—magnetic resonance imaging reveals referral of pain
Authors: Forstenpointner Julia , Wolff Stephan , Stroman Patrick W. , Jansen Olav , Rehm Stefanie , Baron Ralf , Gierthmühlen Janne
Published: May 2018

Referred and projecting pain can be observed in acute and chronic pain states. We present the case of a 69-year-old female patient with postherpetic neuralgia in dermatome Th2/3 who reported that touching the ipsilateral earlap (dermatome C2) would enhance pain and dynamic mechanical allodynia in the affected Th2/3-dermatome. The aim was to investigate possible underlying mechanisms of this phenomenon using the capsaicin experimental pain sensitization model, quantitative sensory testing, and functional spinal and supraspinal magnetic resonance imaging. The presented study provides evidence that a referral of pain from the ear to the trunk is possible. We discuss whether the observed phenomenon in combination with activation of pain-modulating areas on functional magnetic resonance imaging suggests either (1) a shift of descending pathways from inhibitory towards facilitating mode or (2) a deafferentation-induced reorganization of somatotopic maps, as the ear and the trunk are adjacent areas of the sensory homunculus. The results and a review about projection of pain in head–neck area are provided.
Sleep Quality During and After Cardiothoracic Intensive Care and Psychological Health During Recovery
Authors: Caruana Nittaya , McKinley Sharon , Elliott Rosalind , Gholizadeh Leila
Published: May 2018

Background:

Intensive care patients experience poor sleep quality. Psychological distress and diminished health-related quality of life (HRQOL) are also common among former intensive care unit (ICU) patients. Coronary artery bypass graft (CABG) surgery is a frequent reason adults require treatment in ICU. The effect of on- versus off-pump surgery on sleep and recovery has not been reported.

Objective:

The aim of this study was to assess sleep quality of CABG patients during and after ICU, psychological well-being, HRQOL during recovery, and whether on- versus off-pump surgery affects sleep and recovery.

Methods:

Data were collected in the ICU and hospital ward, and 2 and 6 months after hospital discharge using validated self-report questionnaires.

Results:

The sample (n = 101) had a mean age of 66.6 ± 11.1 years, was 79% male, and had a median ICU stay of 2 (2–4) days and a mean body mass index of 27.3 ± 4.3; 75% underwent on-pump surgery. Poor sleep was reported by 62% of the patients at 6 months and by 12% of the patients at all time points. Off-pump CABG patients had fewer posttraumatic stress symptoms (P = .02) and better physical HRQOL (P = .01). In multivariate analysis, prehospital insomnia (P = .004), and physical (P < .0005) and mental (P < .0005) HRQOL were independently associated with sleep quality at 6 months. There was no association between on- versus off-pump CABG and sleep quality at 6 months.

Conclusions:

Sleep quality of postoperative CABG patients was poor in the ICU and hospital ward and up to 6 months after discharge from the hospital. Poor sleep quality at 6 months was associated with prehospital insomnia, and physical and mental HRQOL at 6 months, but not with on- versus off-pump surgery.
Pain Management in Athletes With Impairment: A Narrative Review of Management Strategies
Authors: Grobler Lara , Derman Wayne , Blauwet Cheri A. , Chetty Sean , Webborn Nick , Pluim Babette
Published: May 2018

Objective:

To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population.

Data Sources:

A comprehensive literature search was performed linking pain with terms related to different impairment types.

Main Results:

There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete.

Conclusions:

It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.
Chylothorax From Gorham-Stout Disease
Authors: Kotaru Arun C. , Rajput Ashok K.
Published: May 2018

Chylothorax is one of the presenting features in many disorders including malignancy. Thorough investigation is often required for establishing the etiology of chylothorax. Unfortunately, despite appropriate work-up etiology of pleural effusion cannot be established. We report a case of chylothorax associated with multiple lytic bony lesions, finally diagnosed as a case of Gorham-Stout disease.
The optimal time of day for statin administration: a review of current evidence
Authors: Awad Kamal , Banach Maciej
Published: May 2018

Purpose of review

In humans, cholesterol biosynthesis varies diurnally, reaching its peak at night. Therefore, choosing the time of statin administration is critical because of their different half-lives. Dose timing becomes more important in patients with polypharmacy because it might affect their adherence to the statin therapy.

Recent findings

Herein, we narratively summarized the available clinical studies (n = 17) and meta-analyses (n = 2) that compared the morning with the evening dose of statins in terms of safety and efficacy, with special focus on their low-density lipoprotein-lowering effects. We also explained the difference in efficacy results in case of short-acting compared with the long-acting statins and highlighted how flexibility in choosing the time of statin administration is important for better adherence.

The current limited evidence suggests that short-acting statins should be given in the evening whereas long-acting statins could be given at any time of the day with allowing more patient-based choice (of timing) for better adherence. Lager RCTs with longer durations are recommended to extend and confirm the current evidence.
Comparison of Fasting Human Pancreatic Polypeptide Levels Among Patients With Pancreatic Ductal Adenocarcinoma, Chronic Pancreatitis, and Type 2 Diabetes Mellitus
Authors: Nagpal Sajan Jiv Singh , Bamlet William R. , Kudva Yogish C. , Chari Suresh T.
Published: May 2018

Objectives

Human pancreatic polypeptide (HPP) is a hormone secreted by the ventral pancreas. While postprandial HPP levels have been studied in chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC), there are limited data on fasting HPP in these diseases.

Methods

Fasting serum HPP was measured in the following groups of patients: CP with diabetes mellitus (DM) (n = 16), CP without DM (n = 34), PDAC with new-onset DM (n = 50), PDAC without DM (n = 49), new-onset type 2 DM (n = 50), and controls without DM (n = 49). Sixty-six had type 3c DM (CP with DM, n = 16; PDAC with new-onset DM, n = 50).

Results

Median fasting HPP levels (in picograms per milliliter) were similar among all groups. Median (interquartile range) HPP levels in new-onset type 2 DM (n = 50; 288.3 [80.1–1072.1]) were similar to those in type 3c DM (n = 66; 242.3 [64.9–890.9]) (P = 0.71). In PDAC (n = 99), HPP values were similar in pancreatic head (n = 75) versus body/tail (n = 24) tumors (245.3 [64.3–1091.3] vs 334.7 [136.1–841.5]; P = 0.95), regardless of DM.

Conclusions

Fasting HPP levels are similar in CP, PDAC, and controls regardless of glycemic status.
Speculations on the Future of Psychiatric Diagnosis
Authors: Rush A. John , Ibrahim Hisham M.
Published: May 2018

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V), criterion symptom listings are frequently used in clinical practice as checklists to make diagnoses. However, most DSM-V conditions are, in fact, syndromes, that is, collections of signs and symptoms that commonly occur together in the clinic. This report discusses the value of syndromes in medicine and psychiatry. It is argued that a more precise future enumeration of brain circuits and the pathogenesis of psychiatric conditions will help us better understand and treat psychiatric syndromes, but they are unlikely to eliminate the need to categorize psychiatric conditions. We expect that biomarkers will play an increasingly critical role in psychiatric diagnosis. Beyond a better mechanistic understanding of the DSM-V syndromes, future diagnostic efforts will need to increase the focus on function and address risk factors for nonresponse and relapse. We suggest that new artificial intelligence advances will increase the efficiency and acceptability of psychiatric diagnosis and assist with treatment delivery.
Evidence for the Perception of Time Distortion During Episodes of Alice in Wonderland Syndrome
Authors: Jia Yu , Miao Ying
Published: May 2018

Alice in Wonderland syndrome (AIWS) is a rare perceptual disorder associated with sensation of one or several visual and/or auditory perceptual distortions including size of body parts, size of external objects, or passage of time (either speeding up or slowing down). Cause for AIWS is yet to be widely agreed, and the implications are widely varied. One of the research difficulties is the brevity of each episode, typically not exceeding few tens of minutes. This article presents a male adult in late 20s who has apparently experienced AIWS episodes since childhood, and infection has been ruled out. Reaction speed tests were conducted during and after AIWS episodes, across a span of 13 months. Statistically significant evidence is present for delayed response time during AIWS episodes when the patient claims to experience a sensation of time distortion: where events seem to move faster and people appear to speak quicker.
Countertransference and Psychological Assessment
Authors: Laverdière Olivier , Beaulieu-Tremblay Thalie , Descôteaux Jean , Simard Valérie
Published: May 2018

Countertransference (CT) is usually conceptualized as emerging in the course of psychotherapy. This study explores whether CT manifests itself in the context of assessment and if the modality of exposure to participants (interviewer and observer) affects the intensity and nature of CT. Evaluators either led (direct exposure) or observed (indirect exposure) a 6-hour interview with a subject focusing on attachment and personality. Interviewers and evaluators then completed a measure of CT, the Therapist Response Questionnaire for a total of 43 subjects. Results show significant CT reactions for both interviewers and observers that were globally as intense in both conditions, although lower positive/satisfying and helpless/inadequate CTs were reported by observers. Moreover, intraclass correlations suggest that interviewers' and observers' CT reactions toward the same interviewee show an important degree of similarity. These results highlight the presence of CT in assessment contexts and support the existence of an objective part to CT reactions.
A Survey of American Psychiatrists' Attitudes Toward Classic Hallucinogens
Authors: Barnett Brian S. , Siu Willie O. , Pope Harrison G.
Published: May 2018

Recent years have seen renewed interest and research about the use of hallucinogens as possible agents in the treatment of psychiatric disorders. However, we are unaware of studies assessing the current attitudes of American psychiatrists regarding hallucinogens. Therefore, we e-mailed surveys to 1000 members of the American Psychiatric Association—250 resident-fellows and 750 attending psychiatrists. The response rate was 32.4%. Respondents tended to perceive hallucinogens as potentially hazardous and appropriately illegal for recreational purposes. However, a large minority expressed optimism about the potential use of hallucinogens for psychiatric treatment. Male and trainee respondents, as compared with female and attending respondents, reported less concern about the risks of hallucinogens and greater optimism about their therapeutic potential. Younger psychiatrists also seemed more optimistic. Optimism among trainees and younger psychiatrists may possibly reflect greater exposure to recent positive publications about hallucinogens and less awareness of more negative past reports.
The Use of Technology for Sexually Transmitted Disease Partner Services in the United States: A Structured Review
Authors: Kachur Rachel , Hall Wendasha , Coor Alexandra , Kinsey Jennine , Collins Dayne , Strona F.V.
Published: May 2018

Background

Since the late 1990s, health departments and sexually transmitted disease (STD) programs throughout the United States have used technologies, such as the Internet and mobile phones, to provide services to persons with a sexually transmitted infection, including human immunodeficiency virus (HIV), and their sex partners, also known as partner services. This study reviewed the published literature to assess and compare partner services outcomes as a result of using technology and to calculate cost savings through cases averted.

Methods

We conducted a structured literature review of all US studies that examined the use of technology to notify persons exposed to an STD (syphilis, chlamydia, gonorrhea), including HIV, by health care professionals in the United States from 2000 to 2017. Outcome measures, including the number of partners notified, screened or tested; and new positives identified, were captured and cost savings were calculated, when data were available.

Results

Seven studies were identified. Methods used for partner services differed across studies, although email was the primary mode in 6 (83%) of the 7 studies. Only 2 of the 7 studies compared use of technology for partner services to traditional partner services. Between 10% and 97% of partners were successfully notified of their exposure through the use of technology and between 34% and 81% were screened or tested. Five studies reported on new infections identified, which ranged from 3 to 19. Use of technology for partner serves saved programs between US $22,795 and US $45,362 in direct and indirect medical costs.

Conclusions

Use of technology for partner services increased the number of partners notified, screened or tested, and new infections found. Importantly, the use of technology allowed programs to reach partners who otherwise would not have been notified of their exposure to an STD or HIV. Improved response times and time to treatment were also seen as was re-engagement into care for previous HIV positive patients. Data and outcome measures across the studies were not standardized, making it difficult to generalize conclusions. Although not a replacement for traditional partner services, the use of technology enhances partner service outcomes.
Accidental Carbon Monoxide Poisoning While Driving
Authors: Fisher-Hubbard Amanda O. , Appleford Colin , Kesha Kilak , Schmidt Carl J. , Gupta Avneesh
Published: May 2018

Carbon monoxide (CO) is the cause of a significant percentage of fatal poisonings in many countries. It is known that fatalities resulting from CO poisoning are underreported and/or misclassified. Carbon monoxide exposure while driving can occur due to faulty exhaust systems, defective ventilation systems, emission from other vehicles, and even cigarette smoking. We report the case of a 23-year-old woman who was involved in a low-speed motor vehicle collision and was found unresponsive in her vehicle due to CO poisoning. A review of the literature revealed rare vehicle-related accidental CO poisonings.
Disclosure Coaching: An Ask-Tell-Ask Model to Support Clinicians in Disclosure Conversations
Authors: Shapiro Jo , Robins Lynne , Galowitz Pamela , Gallagher Thomas H. , Bell Sigall
Published: May 2018

Error disclosure is a high-stakes, emotionally charged interaction for patients and families as well as clinicians. A failed disclosure can result in emotional distress, reduced patient and family trust, litigation, and lost opportunities to learn from and prevent subsequent errors. However, many clinicians have little expertise in handling these challenging interactions and can inadvertently make a bad situation worse. Even those clinicians who have had formal disclosure training may have trouble remembering what they were taught when faced with the need to actually discuss an error with patients. Providing just-in-time coaching to clinicians is recommended by national standards. However, there is scant training material to guide error disclosure coaches. Therefore, we developed an “Ask-Tell-Ask” model and materials to guide the disclosure coaching process. The Ask-Tell-Ask model is well-suited to provide clinicians with targeted interactive teaching immediately before a disclosure without overwhelming them with lecture-style facts that they are unlikely to retain. Such teaching would ideally be provided by trained disclosure coaches, available for just-in-time support of clinicians throughout the disclosure process. The Ask-Tell-Ask model can also help risk managers, department heads, clinical managers, attending physicians, service chiefs, and others who assist clinicians with error disclosure. Here, we describe a comprehensive approach to coaching developed over years of coaching experience that incorporates the model, its rationale, step-by-step coaching strategies and guidance (including sample scripts), and organizational considerations regarding implementation of a coaching program to support patient-centered transparent communication after harmful events.
Lack of Virological Suppression Among Young HIV-Positive Adults in Botswana
Authors: Novitsky Vlad , Gaolathe Tendani , Mmalane Mompati , Moyo Sikhulile , Chakalisa Unoda , Yankinda Etienne Kadima , Marukutira Tafireyi , Holme Molly Pretorius , Sekoto Tumalano , Gaseitsiwe Simani , Musonda Rosemary , van Widenfelt Erik , Powis Kathleen M. , Khan Nealia , Dryden-Peterson Scott , Bennett Kara , Wirth Kathleen E. , Tchetgen Eric Tchetgen , Bachanas Pam , Mills Lisa A. , Lebelonyane Refeletswe , el-Halabi Shenaaz , Makhema Joseph , Lockman Shahin , Essex M.
Published: May 2018

Background:

HIV-1 RNA load is the best biological predictor of HIV transmission and treatment response. The rate of virologic suppression among key subpopulations can guide HIV prevention programs.

Methods:

The Botswana Combination Prevention Project performed a population-based household survey among adults in 30 communities in Botswana. Data collected included knowledge of HIV-positive status, antiretroviral therapy (ART) coverage, and virologic suppression (HIV-1 RNA ≤400 copies per milliliter). Individuals aged 16–29 years were considered young adults.

Results:

Among 552 young people living with HIV enrolled with RNA load data and ART status available, 51% (n = 279) had undetectable HIV-1 RNA, including 54% of young women and 32% of young men [sex prevalence ratio (PR): 0.53; 95% confidence interval (CI): 0.43 to 0.80; P < 0.001]. Compared with older adults (30–64 years old), young HIV-infected adults were significantly less likely to have undetectable HIV-1 RNA (PR: 0.65; 95% CI: 0.59 to 0.70; P < 0.0001), including both men (PR: 0.43; 95% CI: 0.34 to 0.56; P < 0.0001) and women (PR: 0.67; 95% CI: 0.62 to 0.74; P < 0.0001). Among a subset of people living with HIV receiving ART, young adults also were less likely to have undetectable HIV-1 RNA load than older adults (PR: 0.93; 95% CI: 0.90 to 0.95; P = <0.0001). Analysis of the care continuum revealed that inferior HIV diagnosis and suboptimal linkage to care are the primary reasons for low virologic suppression among young adults.

Conclusions:

Young adults in Botswana are significantly less likely to have undetectable HIV-1 RNA load compared with older adults. In the era of broad scale-up of ART, interventions able to diagnose young adults living with HIV and link them to effective therapy are urgently needed.
HIV-1 Drug Resistance Among Ugandan Adults Attending an Urban Out-Patient Clinic
Authors: von Braun Amrei , Sekaggya-Wiltshire Christine , Bachmann Nadine , Ssemwanga Deogratius , Scherrer Alexandra U. , Nanyonjo Maria , Kapaata Anne , Kaleebu Pontiano , Günthard Huldrych F. , Castelnuovo Barbara , Fehr Jan , Kambugu Andrew
Published: May 2018

Background:

Little is known about prevalence of drug resistance among HIV-infected Ugandans, a setting with over 15 years of public sector access to antiretroviral therapy (ART) and where virological monitoring was only recently introduced.

Setting:

This study was conducted in the adults' out-patient clinic of the Infectious Diseases Institute, Kampala, Uganda.

Methods:

HIV genotyping was performed in ART-naive patients and in treatment-experienced patients on ART for ≥6 months with virological failure (≥1000 copies/mL).

Results:

A total of 152 ART-naive and 2430 ART-experienced patients were included. Transmitted drug resistance was detected in 9 (5.9%) patients. After a median time on ART of 4.7 years [interquartile range: 2.5–8.7], 190 patients (7.8%) had virological failure with a median viral load of 4.4 log10 copies per milliliter (interquartile range: 3.9–4.9). In addition, 146 patients had a viral load between 51 and 999 copies per milliliter. Most patients with virological failure (142, 74.7%) were on first-line ART. For 163 (85.8%) ART-experienced patients, genotype results were available. Relevant drug-resistance mutations were observed in 135 (82.8%), of which 103 (63.2%) had resistance to 2 drug classes, and 11 (6.7%) had resistance to all drug classes available in Uganda.

Conclusion:

The prevalence of transmitted drug resistance was lower than recently reported by the WHO. With 92% of all patients virologically suppressed on ART, the prevalence of virological failure was low when a cutoff of 1000 copies per milliliter is applied, and is in line with the third of the 90-90-90 UNAIDS targets. However, most failing patients had developed multiclass drug resistance.
Raltegravir 1200 mg Once Daily vs 400 mg Twice Daily, With Emtricitabine and Tenofovir Disoproxil Fumarate, for Previously Untreated HIV-1 Infection: Week 96 Results From ONCEMRK, a Randomized, Double-Blind, Noninferiority Trial
Authors: Cahn Pedro , Sax Paul E. , Squires Kathleen , Molina Jean-Michel , Ratanasuwan Winai , Rassool Mohammed , Bloch Mark , Xu Xia , Zhou Yan , Homony Brenda , Hepler Deborah , Teppler Hedy , Hanna George J. , Nguyen Bach-Yen , Greaves Wayne ,   for the ONCEMRK Study Group
Published: May 2018

Background:

Raltegravir 1200mg (2×600mg tablets) once daily (QD) demonstrated noninferior efficacy and similar safety to raltegravir 400mg twice daily (BID) at week 48 of the ONCEMRK trial. Here, we report the week 96 results from this study.

Methods:

ONCEMRK is a phase 3, multicenter, double-blind, noninferiority trial comparing raltegravir 1200mg QD with raltegravir 400mg BID in treatment-naive HIV-1–infected adults. Participants were assigned (2:1) to raltegravir 2×600mg QD or 400mg BID, both with emtricitabine and tenofovir disoproxil fumarate (FTC/TDF) for 96 weeks. Randomization was stratified by screening HIV-1 RNA and hepatitis B/C status. Efficacy was assessed as the proportion of participants with HIV-1 RNA <40 copies per milliliter (Food and Drug Administration Snapshot approach); the noninferiority margin was 10 percentage points.

Results:

Of the 797 participants who received study therapy (84.6% were men, 59.3% were white, and mean age was 35.9 years), 694 completed 96 weeks of treatment (87.6% QD; 84.4% BID), with few discontinuations because of lack of efficacy (1.1% for both groups) or adverse events (1.3% QD; 2.3% BID). At week 96, 81.5% (433/531) of QD recipients and 80.1% (213/266) of BID recipients achieved HIV-1 RNA <40 copies per milliliter (difference 1.4%, 95% confidence interval: −4.4 to 7.3). CD4+ T-cell counts increased >260 cells/mm3 from baseline in both groups. Resistance to raltegravir was infrequent, occurring in 0.8% of each treatment group through week 96. Adverse event rates were similar for the 2 regimens.

Conclusions:

In HIV-1–infected treatment-naive adults receiving FTC/TDF, raltegravir 1200mg QD demonstrated noninferior efficacy to raltegravir 400mg BID that was durable to week 96, with a safety profile similar to raltegravir 400mg BID.
Patterns and Correlates of Participant Retention in a Multi-City Pre-Exposure Prophylaxis Demonstration Project
Authors: Doblecki-Lewis Susanne , Liu Albert Y. , Feaster Daniel J. , Cohen Stephanie E. , Elion Richard , Bacon Oliver , Coleman Megan , Cardenas Gabriel , Kolber Michael A.
Published: May 2018

Background:

Safe and effective use of pre-exposure prophylaxis (PrEP) depends on retention in care after initial engagement.

Setting:

The United States PrEP Demonstration Project offered daily oral tenofovir/emtricitabine to participants in San Francisco, Miami, and Washington, D.C. for 48 weeks from 2012 to 2014.

Methods:

The Demo Project participants' patterns of retention were assigned to 1 of 3 categories: early loss to follow-up (ELTF) within the first 12 weeks of the study, retention throughout the study, or intermittent retention in which missed or delayed visits resulted in gaps in medication availability. For each group, baseline characteristics were tabulated. A two-step multivariable analysis was performed.

Results:

Overall, 366/554 (66.1%) of enrolled participants were retained for all study visits, 127/554 (22.9%) had intermittent retention, and 61/554 (11.0%) ELTF. In multivariable analysis, Miami compared with San Francisco site was associated with ELTF rather than full retention [aOR 2.84; confidence interval (CI): 1.24 to 6.47] and also with intermittent rather than full retention (aOR 2.70; CI: 1.43 to 5.11). Younger age was associated with ELTF (aOR 1.80 for each 10-year decrement in age; CI: 1.26 to 2.57) and intermittent retention (aOR 1.47; CI: 1.17 to 1.84) compared with full retention. Factors associated with ELTF (but not intermittent retention) compared with full retention were black compared with white (aOR 3.32; CI: 1.09 to 10.16), reporting sex work (aOR 4.67; CI: 1.49 to 14.58), lack of regular employment (aOR 2.53; CI: 1.27 to 5.05), and lack of previous PrEP awareness (aOR 2.01; CI: 1.01 to 3.96).

Conclusions:

Tailored interventions addressing causes and risk factors for loss from PrEP care may improve retention and consistency of PrEP use.
A Successful Model of Expedited Antiretroviral Therapy for Clinically Stable Patients Living With HIV in Haiti
Authors: Guiteau Moise Colette , Rivera Vanessa R. , Hennessey Kelly A. , Bellot Clovy , Nicholas Chris , Fang Anna P. , Verdier Rose Irène , Severe Patrice , Sainvil Alix , Charles Benedict , Dorval Derothy , St. Amour Juseline , Pape Jean W. , Koenig Serena P.
Published: May 2018

Background:

Recommendations for universal antiretroviral therapy have greatly increased the number of HIV-infected patients who qualify for treatment, particularly with early clinical disease. Less intensive models of care are needed for clinically stable patients.

Setting:

A rapid pathway (RP) model of expedited outpatient care for clinically stable patients was implemented at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) Center, Port-au-Prince, Haiti. Expedited visits included nurse-led assessments and point-of-service antiretroviral therapy dispensing.

Methods:

We conducted a retrospective analysis including patients who initiated RP care between June 1, 2014, and September 30, 2015, comparing outcomes of patients with timely visit attendance (never >3 days late) with patients with ≥1 nontimely visit within 6 months before RP enrollment. We calculated retention in care and adherence at 12 months, and assessed predictors of both outcomes.

Results:

Of the 2361 patients who initiated RP care during the study period, 1429 (61%) had timely visit attendance and 932 (39%) had ≥1 nontimely visit before RP enrollment. Among RP-enrolled patients, 94% were retained at 12 months and 75% had ≥90% adherence, with higher proportions in those with timely pre-RP visits (95% vs. 92%; 87% vs. 55%). In multivariable analysis, pre-RP visit timeliness was associated with both retention (adjusted odds ratio: 1.67; 95% confidence interval: 1.08 to 2.59) and adherence (adjusted odds ratio: 4.53; 95% confidence interval: 3.58 to 5.72).

Conclusions:

RP care was associated with high levels of retention and adherence for clinically stable patients. Timeliness of pre-RP visits was predictive of outcomes after RP initiation.
Cognitive Burden of Common Non-antiretroviral Medications in HIV-Infected Women
Authors: Rubin Leah H. , Radtke Kendra K. , Eum Seenae , Tamraz Bani , Kumanan Krithika N. , Springer Gayle , Maki Pauline M. , Anastos Kathryn , Merenstein Daniel , Karim Roksana , Weber Kathleen M. , Gustafson Deborah , Greenblatt Ruth M. , Bishop Jeffrey R.
Published: May 2018

Objective:

The aging HIV population has increased comorbidity burden and consequently non-antiretroviral medication utilization. Many non-antiretroviral medications have known neurocognitive-adverse effects (“NC-AE medications”). We assessed the cognitive effects of NC-AE medications in HIV+ and HIV− women.

Methods:

One thousand five hundred fifty-eight participants (1037 HIV+; mean age 46) from the Women's Interagency HIV Study completed a neuropsychological test battery between 2009 and 2011. The total number of NC-AE medications and subgroups (eg, anticholinergics) were calculated based on self-report. Generalized linear models for non-normal data were used to examine the cognitive burden of medications and factors that exacerbate these effects.

Results:

HIV+ women reported taking more NC-AE medications vs. HIV− women (P < 0.05). NC-AE medication use altogether was not associated with cognitive performance. However, among NC-AE medication subgroups, anticholinergic-acting medications, but not opioids or anxiolytics/anticonvulsants, were negatively associated with performance. HIV status moderated the association between these NC-AE medication subgroups and performance (P's < 0.05). HIV-serostatus differences (HIV− < HIV+) in global, learning, fluency, and motor function were greatest among women taking >1 anticholinergic medications. HIV-serostatus differences in performance on learning and psychomotor speed were also greatest among women taking 1 or more anxiolytics/anticonvulsants and 1 or more opioids, respectively.

Conclusions:

HIV+ women have increased cognitive vulnerabilities to anticholinergic, anxiolytic/anticonvulsant, and opioid medications. Potential synergy between these medications and HIV may explain some HIV-related cognitive impairments. It may be important clinically to consider these specific types of medications as a contributor to impaired cognitive performance in HIV+ women and assess the cost/benefit of treatment dosage for underlying conditions.
Barbed Hyoglossomandibulopexia: A Preclinical Study on Human Anatomic Models
Authors: Mantovani Mario , Rinaldi Vittorio , Torretta Sara , Trojsi Roberto , Carioli Daniela , Pignataro Lorenzo
Published: May 2018

The retrobasilingual space is the one of the most frequent sites of obstruction in patients with severe obstructive sleep apnea hypopnea syndrome, and several multilevel surgical procedures have been developed. The authors tested by means a preclinical study the feasibility of a new experimental surgical procedure called barbed hyoglossomandibulopexia (B.Hy.G.M.P.) which aims at advancing the tongue base with the hyoid bone (hyo-glossopexia) by multiple plicatures at the oral floor muscles.

B.Hy.G.M.P. was performed during cadaveric dissection on 12 human models. Retrobasilingual space enlargement was assessed by means of nasopharyngeal fiberendoscopy.

A 25% to 50% enlargement in the retrobasilingual space was documented by means of nasopharyngeal fiberendoscopy in all the patients.

The authors’ preclinical study documents the feasibility of the B.Hy.G.M.P. procedure on human models, and suggests the possible usefulness of this approach in obstructive sleep apnea hypopnea syndrome patients with retrobasilingual collapse. Dedicated clinical studies on living subjects are needed to assess the effectiveness and safety of this technique.
An Innovative and Easy Dome Holding Technique for Transdomal Suture in Rhinoplasty
Authors: Seneldir Sureyya , Durna Yusuf Muhammed
Published: May 2018

Suture tip plasty is one the most used methods in nasal tip surgery. Transdomal suture (TDS) used for this purpose is utilized for providing the dome symmetry, thinning the nasal tip, and enhancing the nasal tip projection and rotation. However, there are not sufficient visual data on what the dome position should be during TDS. In this study, it was aimed to be directive in tip plasty and to define the convenient dome holding technique during TDS. Patients, 510 male and 621 female at the age of 18 to 50 years, who underwent the open technique septorhinoplasty between the years of 2003 to 2015 were included in the authors’ study. The length of the patient follow-up varies between 1 and 10 years. Patients, on which the lateral crural strut graft was used and which underwent dome division/vertical dome division in tip surgery, and patients who were diagnosed with the alar cartilage asymmetry and underwent dome excision for any pathological reason to demonstrate the effectiveness of the TDS holding technique. During the TDS, the dome area was administered with 5/0 polydioxanone by being held at an angle close to the cranial in the posterior and the caudal in the anterior with a dentated forceps. In this study according the authors’ pre and postoperative conclusions, the authors consider that this is a sufficient visual data on what the dome position should be during TDS by presenting video.
Imitating Incidents
Authors: Macrae Carl
Published: May 2018

Summary Statement

One of the most fundamental principles of patient safety is to investigate and learn from the past in order to improve the future. However, healthcare organizations can find it challenging to develop the robust organizational processes and work practices that are needed to rigorously investigate and learn from safety incidents. Key challenges include difficulties developing specialist knowledge and expertise, understanding complex incidents, coordinating collaborative action, and positively changing practice. These are the types of challenges that simulation is commonly used to address. As such, this article proposes that there are considerable opportunities to integrate simulation more deeply and systematically into routine efforts to investigate and learn from safety incidents. This article explores how this might be performed by defining five key areas where simulation could be productively integrated throughout the investigation and learning process, drawing on examples of current practice and analogous applications in healthcare and other industries.