bluuebunny/crossref_metadata_2025 huggingface dataset:
Evolution of Hip Dysplasia in Pediatric Patients With Prader-Willi Syndrome Treated With Growth Hormone Early in Development
Authors: Laumonerie Pierre , Tibbo Meagan E. , Ibnoulkhatib Aissa , Kerezoudis Panagiotis , Diene Gwenaëlle , Thevenin Lemoine Camille , Accadbled Franck , Sales de Gauzy Jérôme
Published: September 2019

Background:

Prader-Willi syndrome (PWS) is a rare genetic disorder characterized by obesity, hypotonia, feeding difficulties, obesity, musculoskeletal manifestations including scoliosis, and hip dysplasia (HD). The aim of this study was to characterize the clinical and radiographic evolution of HD in the pediatric PWS population.

Methods:

The authors performed a retrospective cohort study of 72 patients (147 anteroposterior pelvic radiographs) between January 2004 and December 2016. Center-edge angle (CEA) of Wiberg, acetabular index (AI), and neck-shaft angle (NSA) were measures in all hips. The relationship between radiographic and demographic parameters of age, sex, and body mass index z-score (BMIzs) were assessed.

Results:

A total of 274 radiographic measurements were performed and analyzed in 72 patients. The mean CEA, AI, and NSA were 21.8±7.1 degrees (range, 5 to 35 degrees), 16.7±7 degrees (range, 5 to 45 degrees), and 142±8.5 degrees (range, 128 to 165 degrees), respectively. HD was diagnosed in 79 (29%) hip radiographs and varied significantly between the age groups (P<0.01). A statistically significant association was identified between age and CEA [β coef, 0.80; 95% confidence interval (CI), 0.6-1; P<0.01], AI (β coef, −0.90; 95% CI, −1.1 to −0.7; P<0.01), and NSA (β coef, −1.11; 95% CI, −1.4 to −0.9; P<0.01) angles. Sex and BMIzs were not identified as independent predictors of radiographic hip angles (P>0.1).

Conclusions:

The present study demonstrated favorable evolution of hip radiographic parameters in the PWS population treated with growth hormone early in development. This finding should prompt orthopedists to consider observation alone in the management algorithm for HD in patients with PWS.

Levels of Evidence:

Level III—a retrospective comparative study.
Total Artificial Heart: A Retrospective Descriptive Analysis of Functional Improvement Associated With Postsurgical Rehabilitation
Authors: Polley Caitlin A. , Oldenburg Hannah Y. , Bergstrom Jennifer L. , Musselman Maureen C. , Pyfferoen Mary D. , Privette Randi A. , Pifer Gina , Bellamkonda Erica
Published: September 2019

Purpose:

To identify rehabilitation course and functional outcomes in patients with an implanted total artificial heart (TAH).

Methods:

From 2012 to 2015, 10 patients with a TAH implantation at a quaternary care hospital were identified for inclusion. Patients were referred to occupational and physical therapy by the cardiothoracic surgery team. Retrospective data collection included the Boston University Activity Measure for Post-Acute Care (AM-PAC) “6-Clicks” inpatient short form based on the functional status documented weekly. Additional patient factors were reviewed specific to cognition, dysphagia, lymphedema, and skin integrity to obtain a comprehensive understanding of therapy scope.

Results:

The median acute hospitalization length of stay was 68 days. By the time of discharge, AM-PAC 6-Clicks functional mobility scores improved by 48% and AM-PAC 6-Clicks daily activity scores improved by 40%.

Conclusions:

Following TAH implantation, patients appear to safely participate in a comprehensive restorative rehabilitation program in the intensive and progressive care units. Patients with a TAH implant showed improvement in their mobility and activity performance by the time of discharge.
Cardiopulmonary Exercise Testing Following Open Repair for a Proximal Thoracic Aortic Aneurysm or Dissection
Authors: Hornsby Whitney E. , Norton Elizabeth L. , Fink Samantha , Saberi Sara , Wu Xiaoting , McGowan Cheri L. , Brook Robert D. , Jones Lee W. , Willer Cristen J. , Patel Himanshu J. , Eagle Kim A. , Lavie Carl J. , Rubenfire Melvyn , Yang Bo
Published: September 2019

Purpose:

There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake,

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2peak), and blood pressure.

Methods:

Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection.

Results:

Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured

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2peak was <36% predicted normative values (19.2 mL·kg−1.min−1 vs 29.3 mL.kg−1.min−1, P < .0001); the most marked impairment in

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2peak was observed in the acute type A aortic dissection group (<40% normative values), which was significantly different from other groups (P < .05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups.

Conclusions:

We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection.

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2peak was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness.
Long-term Pattern of Red Cell Distribution Width in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention
Authors: Machado Guilherme Pinheiro , de Araujo Gustavo Nevas , Carpes Christian Kunde , Niches Matheus , Custodio Julia Luchese , Fracasso Julia Fagundes , Marques Felipe Pereira Lima , Bergoli Luiz Carlos Corsetti , Wainstein Rodrigo Vugman , Wainstein Marco Vugman
Published: September 2019

Red cell distribution width (RDW) is an indirect marker of inflammation and an independent predictor of long-term mortality. The aim of this study was to determine RDW values in patients with ST-elevation acute myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI) and evaluate its association with adverse outcomes. We measured RDW in STEMI patients before undergoing primary PCI and divided into low and high RDW. Patients were followed up to 3 years after their discharge for the occurrence of in-hospital, 30-days, and long-term major adverse cardiovascular events (MACEs) and mortality. We included 485 patients with a mean age of 61.1(±12.5) years, 62.9% were male. In multivariate analysis, RDW remained independent predictor of long-term mortality and MACE [relative risk (RR) 1.51; 95% confidence interval (95% CI) = 1.11–2.05; P = 0.007 and RR = 1.42; 95% CI = 1.30–1.82; P = 0.004. Area under the curve for long-term mortality was 0.65 (95% CI = 0.61–0.69; P < 0.0001). RDW < 13.4 had a negative predictive value of 87.4% for all-cause mortality. Patients who had worse outcomes remained with higher values of RDW during the follow-up. In conclusion, high RDW is an independent predictor of long-term mortality and MACE in patients with STEMI undergoing primary PCI. A low RDW has an excellent negative predictive value for long-term mortality. Patients with sustained elevated levels of RDW have worse outcomes at long-term follow-up.
Oral Liquid Potassium Chloride Dosing Pathway in a Tertiary Care Veteran Affairs Academic Medical Center
Authors: Benge Cassandra D. , Burka Abigail T.
Published: September 2019

Hypokalemia, defined as a serum potassium (K+) concentration of <3.5 mEq/L, is an electrolyte imbalance commonly found in hospitalized patients. Hypokalemia is associated with potentially severe complications, including arrhythmias, which necessitate careful monitoring and repletion with potassium. In the inpatient setting, serum K+ may be repleted via intravenous or oral routes, with oral administration preferred. Potassium chloride (KCl) for oral administration is widely available in both immediate as well as an extended release formulations. Immediate release liquid KCl is optimal for inpatient use since it demonstrates rapid absorption and subsequent increase in serum K+ levels. However, acquisition costs for unit dose oral liquid KCl have prompted some institutions to implement guidance for appropriate use of KCl oral liquid. In this article, we describe the creation of a clinical pathway for ordering of oral immediate release KCl for inpatients at a tertiary Veterans Affairs Academic Medical Center.
Unique Features of the US Department of Defense Multidisciplinary Concussion Clinics
Authors: Lee Katherine M. , Greenhalgh Walter M. , Sargent Paul , Chae Heechin , Klimp Scott , Engel Scot , Merritt Bryan P. , Kretzmer Tracy , Bajor Laura , Scott Steve , Pyne Scott
Published: September 2019

The US Department of Defense (DoD) and the Department of Veterans Affairs (VA) actively address care needs for a subset of service members (SMs) who experience prolonged symptoms and adverse sequelae interfering with their usual level of function after sustaining mild traumatic brain injury. The development of multidisciplinary concussion clinics and implementation of several reinforcing policies within the DoD and the VA address this unique patient population. A network known as the National Intrepid Center of Excellence and Intrepid Spirit Centers and the VA, primarily support these patients through intensive outpatient programs. The VA also has an inpatient program that utilizes specialized capabilities. The features unique to several of these centers are described in this article. While providing for similar patient care needs, each clinical setting implements unique evaluation and treatment modalities to target analogous goals of return to the highest functional level possible and develop life skills to enhance health, quality of life, and readiness to perform military duties. Currently, patient-reported outcomes are being collected.
Effects of Computerized Cognitive Training and Tai Chi on Cognitive Performance in Older Adults With Traumatic Brain Injury
Authors: Hwang Hei-Fen , Chen Chih-Yi , Wei Li , Chen Sy-Jou , Yu Wen-Yu , Lin Mau-Roung
Published: September 2019

Objective:

To compare the effects of computerized cognitive training (CCT) and tai chi (TC) with usual care (UC) on cognitive functions and secondary outcomes in older adults with traumatic brain injury.

Participants and Settings:

Ninety-six patients aged 55 years and older who had a diagnosis of traumatic brain injury requiring hospital admission.

Design:

Randomized controlled trial.

Main Measures:

The Mattis Dementia Rating Scale (MDRS), Mini-Mental State Examination, modified Telephone Interview of Cognitive Status, and Trail Making Tests A and B.

Results:

Compared with UC, CCT increased scores on the MDRS's total, attention, and memory and those on the Mini-Mental State Examination and Telephone Interview of Cognitive Status over the 6-month intervention; TC increased scores on the MDRS's total and conceptualization and those on the Mini-Mental State Examination over the 6-month intervention, while it also increased scores on the MDRS's total and initiation/preservation and those on the Telephone Interview of Cognitive Status and reduced the time to complete the Trail Making Test B over the 12-month study. Furthermore, compared with UC, CCT increased handgrip strength and TC reduced the time to complete 5 sit-to-stands over the 6-month intervention.

Conclusion:

Both CCT and TC may improve global cognition and different specific cognitive domains in older traumatic brain injury patients; the TC's effect may last for at least an additional 6 months.
PERIPAPILLARY MITOCHONDRIAL RETINOPATHY SECONDARY TO A NOVEL MITOCHONDRIAL DNA MUTATION
Authors: Akyol Engin , Oshallah Mohamed , Lotery Andrew
Published: September 2019

Purpose:

To report a case of pigmentary retinopathy associated with a novel mitochondrial DNA mutation.

Methods:

Patient and Results: Patient presented with reduced vision. Visual acuity, ophthalmic examination, color photographs, spectral domain optical coherence tomography, autofluorescence, and genetic testing were performed. Pigmentary retinopathy together with perifoveal atrophy characteristic of mitochondrial retinopathy was identified. Genetic testing confirmed a novel mitochondrial mutation.

Conclusion:

We report bilateral symmetric retinopathy caused by a novel mitochondrial DNA mutation m.16021_16022delCT MTTP (tRNA pro).
CASE REPORT OF ABIOTROPHIA DEFECTIVA ENDOPHTHALMITIS AFTER REPEATED INJECTIONS OF DEXAMETHASONE INTRAVITREAL IMPLANT (OZURDEX)
Authors: Cruz-Iñigo Yousef J. , Klein Kendra , Reddy Rahul K.
Published: September 2019

Purpose:

To present a case of endophthalmitis caused by Abiotrophia defectiva after repeated injections of dexamethasone intravitreal implant (Ozurdex), in a patient already on systemic immunosuppressive therapy, and discuss the management of this challenging situation.

Methods:

Case report and review of literature.

Results:

A 70-year-old female patient with history of idiopathic pulmonary fibrosis presented for urgent evaluation due to left eye vision loss and mild discomfort 12 days after receiving her seventh dexamethasone implant injection. Ocular history was pertinent for recurrent macular edema resulting from a remote branch vein occlusion. Twelve days after her last injection, visual acuity decreased from 20/30 to counting fingers at 5 feet. Slit-lamp examination showed anterior chamber cell without fibrinoid membranes or hypopyon. Within hours, the patient's clinical appearance progressed. A vitreous tap followed by intravitreal injection of vancomycin (1 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL) was performed. The culture from the vitreous sample revealed heavy growth of A. defectiva. Owing to limited improvement, patient was taken to the operating room, and the presence of a full-thickness scleral defect at the site of most recent dexamethasone implant injection was confirmed. Vitrectomy with removal of implant, closure of all sclerotomies, including nonhealing full-thickness scleral defect, and repeated intravitreal antibiotic injection were performed. At the 3-month follow-up, no inflammation was observed, but visual acuity remained poor.

Conclusion:

Intravitreal dexamethasone implant–associated endophthalmitis in the setting of systemic immunosuppression is a rare and challenging situation. Both local and systemic immunosuppression may delay wound healing, predisposing to wound leakage and consequent endophthalmitis. Despite repeated intravitreal antimicrobial injection and vitrectomy with implant removal, A. defectiva endophthalmitis carried a poor visual outcome.
White Sclera Painted Contact Lens for Masking of Conjunctival Neovascularization and Hyperemia Following Cosmetic Eye Whitening Procedure
Authors: Singh Gemini A. , Magone M. Teresa
Published: September 2019

We describe a case of a 37-year-old veteran with recurrent conjunctival hyperemia 5 years after an eye-whitening conjunctivectomy procedure with mitomycin C who desired to have a repeat procedure by the original surgeon. Instead, the patient was counseled and successfully fitted with white sclera painted contact lenses to mask the regrowth of his conjunctival vasculature with excellent cosmetic results and comfort. Further eye-whitening surgery was, therefore, avoided. We conclude that hand-painted white sclera contact lenses with regular ocular surface health monitoring can be offered as a cosmetic, safer, and economical alternative to patients in order to avoid eye-whitening procedures known to induce ocular ischemia.
Risk Factors for Severe Alcohol Withdrawal Syndrome in an Acute Hospital Population
Authors: Benson George , McCallum Jacqueline , Roberts Nicola J.
Published: September 2019

Background

The literature lacks consensus to the factors that increase the risk of a patient developing severe alcohol withdrawal syndrome (SAWS).

Aim

The study set out to identify the variables that increase the risk of SAWS in patients who have alcohol dependence syndrome.

Methods

A case–control study was designed to investigate the variables associated with SAWS in an acute hospital setting. Three hundred eighty-two case and 382 control patients were randomly selected retrospectively from referrals to the acute addiction liaison nursing service during a 12-month period (January 1, 2015, to December 31, 2015). Statistical significance (p < .05) and association with SAWS were calculated using chi-square, Cramer’s V test, odds ratio, and Levene’s test.

Results

Twenty-four variables have been identified as associated with SAWS development. Five of the 24 variables had a moderate-to-strong association with SAWS risk: Fast Alcohol Screening Test, Glasgow Modified Alcohol Withdrawal Scale score, AWS admission, hours since the last drink, and systolic blood pressure. The study also identified that comorbidity was associated with not developing SAWS.

Conclusion/Recommendations

These findings confirm that noninvasive variables collected in the emergency department are useful in identifying a person’s risk of developing SAWS. The results of this study are a useful starting point in the exploration of SAWS and the development of a tool for use in the emergency department that can stratify risk into high and low and is the next stage of this program of work.
Clients’ Views on the Importance of a Nurse-Led Approach and Nurse Prescribing in the Development of the Healthy Addiction Treatment Recovery Model
Authors: Comiskey Catherine , Galligan Karen , Flanagan Jean , Deegan Joan , Farnann Jane , Hall Aine
Published: September 2019

Globally, from America to Europe and beyond, the need for the expansion of the role of nurse practitioners has been recognized within the healthcare professions. However, little emphasis has been placed on assessing the views of clients, and within the addiction services, the voice of clients can be additionally marginalized as a result of treatment philosophies, stigma, and resource constraints. The aims of this study were to establish from clients their nursing needs and to use these findings alongside an objective measurement of clients’ health, to inform the development of a nurse-led treatment model.

A cross-sectional survey with open-ended questions on client nursing needs was conducted in 2017 within a representative sample of six clinics in Dublin, Ireland. A convenience sample of 131 clients were interviewed. Interviews were analyzed using thematic analysis.

Findings were both as expected and surprising. Clients articulated the role of the nurse in their physical care; however, unexpectedly, clients identified nurses as an essential source of psychological support and expressed the wish for the role to be expanded in terms of managing methadone treatment and accessing additional services and resources.

Results contributed to the formation of the nurse-led, client mental-health-focused, Healthy Addiction Treatment Recovery Model for addiction nursing services. In terms of national policies, findings provided new evidence articulated by service users on their desire for the expansion of nurse prescribing in addiction services and an expansion of the role to more adequately address client needs.
Getting Addiction Into the Nursing Education “Water Supply”: A U.K. Case Study
Authors: Clancy Carmel , Oyefeso Adenekan
Published: September 2019

Evidence remains fundamentally unchanged over the last 30 years that nurses are not sufficiently prepared during their undergraduate education to work with alcohol and other drug (AOD) use. Employing a mixed-methods longitudinal panel design, our study objectives were to (a) explore perceptions among entry level nursing students regarding AOD work and (b) explore whether current alcohol and drug education efforts impact on the perception of AOD by nursing students over time. Two hundred forty-two students were recruited (94% response rate). Most (86%) of the study participants identified AOD training as relevant/extremely relevant to their future practice. After exposure to AOD sessions in the nursing curriculum, there was no significant change to participants' score on either alcohol or drug role security between T1 and T2/T3. However, there was a statistically significant improvement in alcohol therapeutic commitment between T1 and T2/T3 (F(2, 136) = 5.87, p < .01), but not between T2 and T3; conversely, drug therapeutic commitment was significantly higher at T2 but signficantly lower at T3 (F(2, 149) = 254.19, p < .0001). There was no significant difference in alcohol or drug role security between the three nurse training pathways. However, alcohol and drug therapeutic commitment scores at T1 were significantly higher in students taking the mental health field/track (F(2, 160) = 9.45, p < .001, and F(2, 236) = 15.23, p < .0001). Although the positive message is that students recognize the importance of the topic to their future practice, concerns remain regarding the impact and efforts of readiness for practice. Over a 3-year training period, no significant gains were made in increasing students' knowledge and skills, and their training experiences in clinical practice appear to have a negative effect on “therapeutic commitment” influenced by exposure/contact to patients with drug use disorders specifically and less than positive mentoring experiences with qualified nursing staff. How to address these issues is explored including the need to perhaps shift the focus of attention from “negative attitudes” held by students to exploring the barriers and obstacles in upskilling nursing faculty and clinical mentors so that they feel able and willing to teach and be a role model of good practice in this area.
Methamphetamine Use
Authors: Fogger Susanne A.
Published: September 2019

Background

The ongoing drug crisis in the United States continues to be headlined with numbers of deaths related to opioid overdose. Less known to the public and health care providers is the rise in methamphetamine use, often in conjunction with opioids or adulterated with fentanyl. An old practice with a new twist is the use of methamphetamine in conjunction with an opioid such as heroin.

Purpose

Although there are no Food and Drug Administration-approved medications to treat individuals with stimulant use disorders, a review of available studies suggests a few promising medications that may be helpful for patients in early recovery from methamphetamine.

Outcome

Some individuals are more likely to respond to medications such as long-acting naltrexone, bupropion, and mirtazapine, who have light-to-moderate use of methamphetamine. Naloxone kits should be considered for all patients who are actively using stimulants because of a high potential of adulterated methamphetamine.
The International Nurses Society on Addictions
Authors: Clancy Carmel , Fornili Katherine
Published: September 2019

The International Nurses Society on Addictions (IntNSA) believes that nurses are key to improving the well-being of individuals affected by substance use, including their families and friends and the society within which they live. It is essential that nurses are able to effectively influence change at local, organizational, systems, national, regional, and international levels.

Historically, IntNSA has drawn its membership from within the United States, reflective of its origins as a national organization. In recognition of the potential for a wider international impact, members voted to formally expand its membership and status to international in 2000. In 2014, members elected its first international member to the Board, and the Board established an International Development Task Force.

In 2015, the IntNSA Board outlined its plan for increasing opportunities for nurses around the world to collaborate to change and shape responses to addictions at all levels. In 2019, IntNSA's Board reviewed its progress, updated its plan, and developed consensus for further actions to be undertaken.

This Policy Watch column provides a transparent overview of IntNSA's plans for global development and an update on its current progress. Its aim is to keep current and potential IntNSA members, our agency partners and interdisciplinary colleagues, and nurses in all specialties, including addictions nurses, informed about this important work. These strategies will ensure that IntNSA will achieve its stated vision “to be a global leader in addictions nursing” and accomplish its mission “to advance excellence in addictions nursing practice through advocacy, collaboration, education, research and policy development” (www.intnsa.org).
Patient-controlled Sedation During Flexible Bronchoscopy
Authors: Grossmann Benjamin , Nilsson Andreas , Sjöberg Folke , Nilsson Lena
Published: September 2019

Background:

Patient-controlled sedation (PCS) is a documented method for endoscopic procedures considered to facilitate early recovery. Limited data have been reported, however, on its use during flexible bronchoscopy (FB).

Methods:

This study hypothesized that PCS with propofol during FB would facilitate early recovery, with similar bronchoscopist and patient satisfaction compared with nurse-controlled sedation (NCS) with midazolam. A total of 150 patients were randomized 1:1:1 into a control group (premedication with morphine-scopolamine and NCS with midazolam), PCS-MS group (premedication with morphine-scopolamine and PCS with propofol), and PCS-G group (premedication with glycopyrronium and PCS with propofol).

Results:

The procedures included transbronchial biopsy, transbronchial needle aspiration, cryotherapy/biopsy, and/or multistation endobronchial ultrasound. FB duration values in median (range) were 40 (10 to 80), 39 (12 to 68), and 44 (10 to 82) minutes for the groups NCS, PCS-MS, and PCS-G, respectively. An overall 81% of the patients in the combined PCS groups were ready for discharge (modified Post Anaesthetic Discharge Scoring System, score 10) 2 hours after bronchoscopy compared with 40% in the control group (P<0.0001). Between PCS groups, 96% of the PCS-G group patients were ready for discharge compared with 65% in the PCS-MS group (P=0.0002) at 2 hours. Bronchoscopists’ and patients’ satisfaction scores were high in all groups. Postdischarge quality scores showed no differences among the groups.

Conclusion:

PCS with propofol during FB is feasible, as it shortened recovery time without compromising procedure conditions for bronchoscopists or patients. A rapid postsedation stabilization of vital signs facilitates surveillance before the patient leaves the hospital.
Predictors of Intraprocedural Respiratory Bronchoscopy Complications
Authors: May Anna M. , Kazakov Jordan , Strohl Kingman P.
Published: September 2019

Purpose:

Sleep apnea can increase adverse outcomes during ambulatory surgery but not during gastrointestinal endoscopy. We hypothesize that STOP-BANG is associated with intraprocedural bronchoscopy respiratory complications.

Methods:

Consecutive patients undergoing bronchoscopy under moderate sedation were prospectively administered the STOP-BANG questionnaire. Participants were assessed for intraprocedural complications including hypoxemia (oxygen saturation≤85%), bradypnea (respiratory rate<8), premature procedure cessation as well as the use of nonrebreather mask, bag-mask ventilation, jaw lift/chin tilt, nasal/oral airway, and naloxone administration. Associations were assessed via logistic regression. Least absolute shrinkage and selection operator was used for multivariable model variable selection.

Results:

The 223 participants—mean age 61.1±15.5 years, body mass index 25.4kg/m2 (interquartile range: 22.4 to 30.7), 50.7% female, and 45.3% inpatient—had a high rate of respiratory complications (37.7%). There were no associations between STOP-BANG score and respiratory complications [odds ratio (OR)=1.07, 95% confidence interval (CI): 0.92-1.25]. Asthma was protective in univariable models (OR=0.26, 95% CI: 0.04-0.98), whereas endobronchial ultrasound (OR=2.34, 95% CI: 1.35-4.10) and the number of procedure types (OR=1.24, 95% CI: 1.01-1.51) was associated with increased complications. The following factors were associated with respiratory complications in both multivariable and univariate analyses: increasing age (OR=1.28/decade, 95% CI: 1.03-1.61), baseline oxygen use per each liters per minute (OR=1.57, 95% CI: 1.21-2.09), and bronchoscopy duration (OR=1.20/10 min, 95% CI: 1.08-1.33).

Conclusion:

Bronchoscopy respiratory complications are common. STOP-BANG was not associated with increased immediate bronchoscopy complication risk. Increasing age, oxygen use, and bronchoscopy duration were associated with respiratory complications; increased vigilance in these circumstances may prevent complications.
Nursing Disruption for Achieving Sustainable Development Goals by 2030
Authors: Porta Carolyn M. , Disch Joanne , Grumdahl Nathan
Published: September 2019

Sixteen million nurses, the largest global health care workforce, contribute to achievement of 17 United Nations Sustainable Development Goals through strategic and disruptive research, education, practice, and policy. Responsible for advancing the well-being of individuals, families, communities, and society, nurses are positioned to influence and impact health across the life span. They do this from promoting prenatal health and early childhood success to encouraging healthy aging and end-of-life transitions. They utilize both predictive analytics that prevent rehospitalization and evidence-based practices, such as rocking and kangaroo care, that encourage survival and thriving of preterm newborns. Nurses have a scope of practice that necessitates their presence essentially everywhere. Direct nursing care is delivered in homes, schools, correctional settings, districts, hospitals, helicopters, combat zones, refugee camps, and postnatural disaster or homeless shelters. Nurses advancing system-level health are positioned in health care administration, higher education, international nongovernmental organizations, and governmental offices. Nurse educators and researchers shape tomorrow's practitioners and practice. In general, nurses innovate and generate solutions to improve global health. Shared in this article are strategies for nurses to employ to disrupt the status quo and aggressively contribute to achieving the 2030 Sustainable Development Goals.
The Langston Center for Innovation in Quality and Safety
Authors: Bleich Michael R.
Published: September 2019

Disruptive innovations may serve both good and ill causes. This means that disruption can stimulate positive outcomes or tip people and organizations into chaos. The Langston Center for Innovation in Quality and Safety plays a moderating role by ensuring that innovations consider the upstream and downstream consequences potentiated by change initiatives characterized by a rapid implementation cycle. Drawing on change management and implementation science approaches, human factor variables are intentionally considered to generate acceptance of substantive disruptions.
Disrupting Policy and Practice
Authors: Shaffer Franklin A. , Sciasci Nicholas Gennaro , Álvarez Thomas D.
Published: September 2019

For decades, refugee policies on local, national, regional, and international levels have set the narrative surrounding refugees' identities and roles in society. Often, these policies negatively affect refugees and can hinder any effort for successful integration (ie, employment). The focus of this article is to identity how refugees, specifically refugee nurses, are reshaping standard policy practices when it comes to integration and inclusion, as well as economic and social well-being. With an estimated 68.5 million forcibly displaced persons worldwide (25.4 million of which are refugees), it is important to shed light on the importance of including their voices in the dialogue during all stages of the policy development process. They should be included in the dialogue, from agenda setting to evaluation, in order to challenge current beliefs and attitudes. It is critical for societies to recognize refugee nurses' professional qualifications, skills, and abilities in order to address the ongoing shortages of health professionals that many nations are facing today.
Safety of Early Repeated Thrombolysis
Authors: Caruso Paola , Furlanis Giovanni , Ridolfi Mariana , Ajcevic Milos , Naccarato Marcello , Manganotti Paolo
Published: September 2019

Introduction:

Intravenous thrombolysis within 4.5 hours from symptom onset improves functional outcome in acute ischemic stroke patients. Repeated intravenous tissue plasminogen activator (IVtPA) is contraindicated in patients presenting with early recurrent stroke (ERS) within 3 months from the initial stroke because of a greater risk of intracranial hemorrhage.

Case Presentation:

A 59-year-old man presented with ERS, National Institute of Health Stroke Scale of 16, 10 days after a previous stroke. Brain computed tomography (CT) showed a previous hypodensity with 4 cm3 volume. Angio-CT highlighted the left middle cerebral artery and left internal carotid occlusion. Perfusion CT showed small deep core and large penumbra. The patient underwent IVtPA. After 24 hours, the National Institute of Health Stroke Scale was 7, and CT scan showed an acute ischemic lesion in the left basal ganglia area and frontal lobe without hemorrhagic transformation.

Conclusion:

This case report suggests that further randomized studies may evaluate whether repeated IVtPA may be safe and effective in ERS occurring shortly after a previous stroke when patients experience a period of complete neurological regression, minor disability, and a small infarct volume. Should the hypothesis be confirmed, small volume core and wide volume penumbra at perfusion CT may support the decision of adopting IVtPA repetition.
Intravenous Thrombolysis For Acute Ischemic Stroke in Fabry Disease
Authors: Kargiotis Odysseas , Psychogios Klearchos , Safouris Apostolos , Kalyvas Pericles , Magoufis Georgios , Stamboulis Eleftherios , Tsivgoulis Georgios
Published: September 2019

Introduction:

Fabry is a rare X-linked recessive genetic disease caused by α-galactosidase A deficiency. Cerebrovascular events occur in ∼13% of patients, whereas stroke may be the presenting clinical manifestation. There are very limited case reports of tissue plasminogen activator administration for acute ischemic stroke in patients with Fabry disease.

Case report:

A 46-year-old man presented with right-sided hemiparesis with a National Institutes of Health Stroke Scale score of 3. Brain computed tomography showed a hyperdense lesion resembling carvenous angioma. The patient received intravenous thrombolysis 265 minutes after symptom onset, with clinical improvement (discharge National Institutes of Health Stroke Scale score of 1). Brain magnetic resonance imaging disclosed acute thalamic infarction, cavernous angioma, and multiple cerebral microbleeds. The presence of skin angiokeratomas and cardiac hypertrophy prompted further positive investigation for Fabry disease (nondetectable α-galactosidase activity, excessively elevated lyso-Gb3, and pathogenic deletion in the GLA gene).

Conclusion:

The present case supports the scarce data underscoring the safety of intravenous thrombolysis for acute ischemic stroke in Fabry disease patients even when cerebral microbleeds are present.
Cause or Consequence
Authors: Türay Sevim , Kabakuş Nimet , Hanci Fatma , Tunçlar Aslihan , Hizal Mustafa
Published: September 2019

Aim:

The aims of our study were to refer to the complex relationship between idiopathic intracranial hypertension (IIHT) and cerebral sinovenous thrombosis (CSVT), and to determine the differences and commonalities between the patients with and without CSVT in their etiology, along with documenting the uncertainties in concluding on the diagnosis and treatment of these patients.

Material and Methods:

IIHT was diagnosed according to Dandy criteria, while CSVT was screened for by way of a cranial magnetic resonance imaging for all patients and cranial magnetic resonance venography only if the magnetic resonance imaging was nebulous or there was a family history.

Results:

We retrospectively evaluated a total of 26 patients (9 of whom had CSVT) diagnosed with IIHT between 2014 and 2018. A total of 9 patients with concurrent CSVT were described as suffering from vascular IIHT, while the remaining 17 were described as suffering from other IIHT. Demographic characteristics were similar in both groups (mean age: 12 vs. 11; male/female ratio: 2/7 vs. 5/12 in vascular IIHT and other IIHT, respectively). Clinical findings, cerebrospinal fluid-opening pressure values, and pathologies of etiology were also similar (vitamin D deficiency: 66% vs. 52%; vitamin B12 deficiency: 11% vs. none; iron deficiency: 22% vs. 11%; obesity: 22% vs. 23%). A mixture of acetazolamide, topiramate, anticoagulant therapy, and acetylsalicylic acid were given according to the diagnoses.

Conclusion:

CSVT is a common clinical entity among the causes of IIHT, and it should be taken into consideration in this patient group. However, there is a need for a common guideline for laboratory and imaging methods to understand the etiopathogenesis of childhood IIHT and determine the patients at risk.
Histologic Appearance and Immunohistochemistry of DNA Mismatch Repair Protein and p53 in Endometrial Carcinosarcoma
Authors: Saijo Masayuki , Nakamura Keiichiro , Ida Naoyuki , Nasu Atsuko , Yoshino Tadashi , Masuyama Hisashi , Yanai Hiroyuki
Published: September 2019

Endometrial carcinosarcoma (ECS) is a rare and aggressive mixed-type epithelial and mesenchymal tumor. This study focused on the histologic appearance, loss of DNA mismatch repair (MMR) protein expression, and aberrant p53 expression in the epithelial component, and overall prognosis of 57 cases with ECS. Histologically, 21 and 36 cases exhibited low-grade (endometrioid grade 1 and 2) and high-grade (others) epithelial components, respectively. In a Kaplan-Meier analysis, patients with a high-grade epithelial component exhibited worse progression-free survival (PFS), compared with those with a low-grade component. Although the former group also exhibited worse overall survival, the difference was not significant. Thirty-six cases exhibited aberrant p53 expression. Of these, 5 cases exhibited focally aberrant p53 expression in carcinomatous components with diffuse aberrant p53 expression in mesenchymal components. Aberrant expression of p53 did not show significant association with prognosis. Six patients with MMR deficiency exhibited relatively better PFS. In conclusion, a low-grade epithelial component is a superior predictor of the PFS of ECS, compared with MMR protein and p53 expression status. In some cases of ECS, TP53 mutation may be a late event associated with histogenesis of the sarcomatous component.
Fluorescent In Situ Hybridization Analysis for 12p Alterations in Sarcomatoid Yolk Sac Tumors
Authors: Idrees Muhammad T. , Ulbright Thomas M. , Epstein Jonathan I.
Published: September 2019

“Sarcomas” in patients with testicular germ cell tumors (GCTs) are a common form of “somatic-type malignancy.” There is support, based on morphology and immunohistochemistry, that many such sarcomatous tumors represent an unusual form of yolk sac tumor (YST). A virtually universal chromosomal anomaly in GCTs is increase in 12p copy number, often in the form of isochromosome 12p [i(12p)], but this aspect of sarcomatoid YSTs has not hitherto been studied. We performed interphase fluorescent in situ hybridization assay for detection of increased 12p copy number in sarcomatoid YSTs using a bacterial artificial chromosome–derived probe localized to 12p12.1 and a commercially available centromeric probe. Sixteen formalin-fixed, paraffin-embedded specimens from 11 patients, along with normal controls, were studied. Overrepresentation of 12p was expressed as a ratio between the number of signals for 12p and the number of signals for centromere 12. A ratio ≥1.3 was considered overrepresentation. All cases were postchemotherapy recurrences or metastases. Ages ranged 22 to 38 years (mean: 36). Most tumors (12/16) showed myxoid or fibromyxoid stroma and 15 of 16 were high grade. Thirteen of 16 specimens (81%) showed overrepresentation of 12p by the above criteria. Two cases exhibited loss of 12p and 1 case had gain of a whole chromosome 12 (trisomy 12). We conclude that, as in other GCTs, sarcomatous differentiation of YST demonstrates 12p alterations that can be identified by interphase fluorescent in situ hybridization. Apart from 12p overrepresentation, these tumors may exhibit loss of 12p or even gain of an entire chromosome 12 (trisomy 12). Increase in 12p copy number of a sarcomatous neoplasm provides support for sarcomatoid YST in clinically ambiguous settings.
Impact of Positive Feedback on Antimicrobial Stewardship in a Pediatric Intensive Care Unit: A Quality Improvement Project
Authors: Jones Alison S. , Isaac Rhian E. , Price Katie L. , Plunkett Adrian C.
Published: September 2019

Introduction:

We hypothesized that antimicrobial stewardship (AMS) could be enhanced through positive feedback for the behaviors of healthcare professionals. This project aimed to reduce antimicrobial consumption in a Pediatric Intensive Care Unit (PICU) by >5%, with secondary aims to reduce broad-spectrum antimicrobial consumption, and processes related to AMS. Learning from Excellence is a positive feedback initiative conceptualized at our institution.

Methods:

This project took place over 12 months (April 2017–March 2018) in a 31-bedded PICU. We identified and measured processes about AMS daily. Healthcare professionals, achieving success in these processes, received positive feedback via Learning from Excellence, during a 6 months intervention period. Selected reports were followed with appreciative inquiry interviews to reinforce positive feedback. We calculated antimicrobial consumption data from existing databases (antimicrobial doses dispensed divided by PICU bed-days). Health Care-Associated Infection (HCAI) rates were included as a balancing measure.

Results:

Antimicrobial consumption was 6.5% lower during the intervention period compared with the matching period from the previous year. We reduced broad-spectrum antimicrobial (meropenem) consumption by 17.6%. Improvements in processes were mixed: a daily review of antimicrobials and documentation of antimicrobial prescription and administration significantly improved. Other processes failed to improve. HCAI rates did not change.

Conclusions:

Positive feedback can be used as a QI intervention to improve processes around AMS. This intervention may contribute to a reduction in antimicrobial consumption. Not all processes are impacted equally, and there may be a “dose-response” effect. Further evaluation would benefit from a trial study design in other settings.
Reducing Healthcare Costs in the Management of Pediatric Metacarpal Neck Fractures
Authors: Beals Corey , Lin James , Holstine Jessica B. , Samora Julie Balch
Published: September 2019

Background:

We hypothesize that a quality improvement initiative utilizing a Velcro ulnar gutter brace over traditional casting will impart significant savings without compromising clinical outcomes in the management of small metacarpal neck fractures.

Methods:

Baseline data on number and treatment regimens of small metacarpal neck fractures were collected starting in October 2015. Velcro ulnar gutter braces were purchased for all orthopedic clinics in December 2016. Patients with <70 degrees of angulation and no rotational deformity of the small finger were eligible to have brace treatment without reduction of the fracture. Data were collected each month on several patients managed by Velcro ulnar gutter brace.

Results:

Three hundred twelve pediatric patients met nonoperative guidelines. Before the intervention, patients were casted and followed radiographically for a minimum of 2 orthopedic clinic visits—which total $916.25 in charges. From October 2015 to November 2016, we treated <1% (1/147) of patients with metacarpal neck fractures without casting. Following the implementation of interventions from December 2016 to January 2019, the percentage of patients treated without cast immobilization increased to 54.5% (90/165), with a process mean shift to >65%. These patients did not have a scheduled follow-up or further radiographic evaluation. In the first 26 months of implementation, this decreased healthcare expenditures by $261,846.

Conclusions:

A quality improvement initiative emphasizing Velcro ulnar gutter brace treatment for pediatric metacarpal neck fractures resulted in a shift away from cast immobilization in >65% of patients, reducing risks and expenses of cast immobilization.
The Complexity of Conducting a Multicenter Clinical Trial: Taking It to the Next Level Stipulated by the Federal Agencies
Authors: Chung Kevin C. , Malay Sunitha , Shauver Melissa J.
Published: September 2019

Randomized controlled trials are becoming increasingly difficult to organize and conduct efficiently. This, in turn, hinders the ability to derive the highest level of evidence. Often, investigators forget or remain unaware of essential practices that will help them fulfill their study goals. This article emphasizes the common issues that a study team experiences during the planning and conducting of randomized controlled trials. The authors sought to share remedies to overcome these issues with the experience garnered in conducting several multicenter clinical trials and observational studies. In addition, the authors list resources from sponsors such as the National Institutes of Health and the U.S. Food and Drug Administration that study teams can apply to undertake studies effectively.
Sonographic Evaluation of Genitourinary Inflammatory Pseudotumors and Its Mimics
Authors: Forrest Allison , Numbere Numbereye , Jean-Gilles Jerome , Dogra Vikram
Published: September 2019

Inflammatory pseudotumor is a relatively rare, nonneoplastic lesion composed of inflammatory cells and myofibroblastic spindle cells that can be identified on sonographic evaluation of the genitourinary system. These lesions are thought to be an inflammatory response to insults such as surgery, trauma, infection, or malignancy. Such lesions need to be distinguished from true neoplasms and other benign lesions, including inflammatory responses and infectious processes. Identification of inflammatory pseudotumors and its mimics is important for radiologists to guide patient treatment and follow-up. This pictorial essay presents sonographic features of inflammatory pseudotumors of the genitourinary tract and its mimics with cross-sectional imaging and histopathology, where available.