bluuebunny/crossref_metadata_2025 huggingface dataset:
Technique Tip: Bicortical Fixation of Medial Malleolus Fractures With 2.7 mm Screws
Authors: Dimitroulias Apostolos , Harbacheuski Ryhor , Gougoulias Nikolaos , Murphy Dennis , Sen Milan K.
Published: April 2022

Bicortical fixation of medial malleolus fractures provides increased interfragmentary compression and resistance to pull out. Achieving bicortical fixation with two 3.5 mm screws can be challenging especially with smaller fractures. We present a simple technique where two 2.7 mm screws are utilized for fixation of medial malleolus fractures.

Level of Evidence: Level V—expert opinion.
Two polymorphic gene loci associated with treprostinil dose in pulmonary arterial hypertension
Authors: Thomeas-McEwing Vasiliki , Psotka Mitchell A. , Gamazon Eric R. , Friedman Paula , Konkashbaev Anuar , Kubo Michiaki , Nakamura Yusuke , Ratain Mark J. , Benza Raymond L. , Cox Nancy J. , Gomberg-Maitland Mardi I. , Maitland Michael L.
Published: April 2022

Objective

Prostacyclin infusion for pulmonary arterial hypertension (PAH) is an effective therapy with varied dosing requirements and clinical response. The major aim of this study was to determine new biologically-based predictors of prostacyclin treatment response heterogeneity.

Methods

Ninety-eight patients with hemodynamically defined PAH at two academic medical centers volunteered for registry studies. A stable dose of treprostinil was the quantitative phenotype for the genome-wide association study (GWAS). Candidate genes with the largest effect sizes and strongest statistical associations were further characterized with in silico and in-vitro assays to confirm mechanistic hypotheses. The clinical significance of these candidate predictors was assessed for mechanistically consistent physiologic effects in an independent cohort of patients.

Results

GWAS identified three loci for association with P < 10-6. All three loci had clinically significant effect sizes. Specific single-nucleotide polymorphisms (SNPs) at two of the loci: rs11078738 in phosphoribosylformylglycinamidine synthase and rs10023113 in CAMK2D encoded sequence changes with clear predicted consequences. Production of the primary mediator of prostacyclin-induced vasodilation, cyclic AMP, was reduced in human cell lines by the missense variant rs11078738 (p.L621P). Located in the promoter of CAMK2D, the allele of rs10023113 associated with a higher treprostinil dose has higher ventricular transcription of CAMK2δ. At initial diagnostic catheterization in a separate cohort of patients, the same allele of rs10023113 was associated with elevated right mean atrial and ventricular diastolic pressures.

Conclusions

The quantitative phenotype of stable treprostinil dose identified two gene loci associated with pharmacodynamic response and right ventricular function in PAH worth further investigation.
An Audit to Evaluate Vancomycin Therapeutic Drug Monitoring in a Neonatal Intensive Care Unit
Authors: Alrahahleh Dua'a , Xu Sophia , Zhu Zhaowen , Toufaili Hassan , Luig Melissa , Kim Hannah Yejin , Alffenaar Jan-Willem
Published: April 2022

Background:

Therapeutic drug monitoring (TDM) is routinely used for optimization of vancomycin therapy, because of exposure-related efficacy and toxicity, in addition to significant variability in pharmacokinetics, which leads to unpredictable drug exposure.

Objective:

The aim of this study was to evaluate target attainment and TDM of vancomycin in neonates.

Methods:

The authors conducted a retrospective study and collected data from medical records of all neonates who received vancomycin therapy in the neonatal intensive care unit between January 2019 and December 2019. The primary outcome was the proportion of vancomycin courses that reached target trough concentrations of 10–20 mg/L based on appropriate TDM samples collection. Secondary outcomes included proportion of courses with appropriate dose and dose frequency, and proportion of patients who achieved target concentrations after the first dose adjustment.

Results:

In total, 69 patients were included, with 129 vancomycin courses. The median initial vancomycin trough concentration was 12 (range: 4–36) mg/L. The target trough concentration was achieved in 75% of courses after the initial dose with appropriate TDM, and 84% of courses after TDM-guided dose adjustments. Patients were dosed appropriately in 121/129 courses and TDM was performed correctly according to protocol in 51/93 courses. A dose adjustment was performed in 18/29 courses, to increase target attainment.

Conclusions:

This study showed that there is a need for an increase in dose to improve target attainment. There is also a need to explore more effective TDM strategies to increase the proportion of neonatal patients attaining vancomycin target trough concentrations.
Heart Rate Response to Exercise and Recovery
Authors: Tabachnikov Vsevolod , Saliba Walid , Aker Amir , Zafrir Barak
Published: April 2022

Purpose:

Heart rate response during exercise testing (ET) provides valuable prognostic information. Limited data are available regarding the prognostic interplay of heart rate (HR) measured at rest, exercise and recovery phases of ET, and its ability to predict risk beyond exercise capacity.

Methods:

Retrospective analysis of treadmill ETs was performed by the Bruce protocol in patients aged 35-75 yr without known cardiovascular disease (CVD; n = 13 887; 47% women). Heart rate recovery at 2 min (HRR2; defined abnormal <42 beats) and chronotropic index (CI; defined abnormal <80%, determined as age-predicted HR reserve) were analyzed in association with the risk of developing myocardial infarction, stroke, or death (major adverse cardiovascular event [MACE]) during median follow-up of 6.5 yr.

Results:

The HRR2 <42 beats and CI <80% were each associated with increased risk of MACE: adjusted hazard ratios with 95% confidence interval 1.47: 1.27-1.72 and 1.66: 1.42-1.93, P < .001, respectively, evident also when analyzed as continuous variables. Strength of association of HRR2 and CI with outcome was attenuated but remained significant with further adjustment for exercise duration and metabolic equivalents. Having both HRR2 and CI abnormal compared with only one measure abnormal was associated with hazard ratios with 95% confidence interval of 1.66: 1.38-2.00 and 1.48: 1.22-1.79 for MACE, before and after adjustment for cardiorespiratory fitness (CRF). The degree of CRF (low vs mid/high) did not modify the prognostic effect of HRR2 and CI (P-for-interaction nonsignificant).

Conclusions:

Both HRR2 and CI provide independent prognostic information beyond CRF in patients without CVD referred for ET. The predictive ability is more pronounced when both abnormal HR measures coexist.
Early Cardiac Rehabilitation to Reduce Heart Failure Readmissions
Authors: Gerow Renee , Altice Nancy , Wu Yingxing , Muthukattil Ronex , Carter Kimberly F.
Published: April 2022

Purpose:

This research was conducted to determine whether early participation in cardiac rehabilitation (CR) reduces readmissions following heart failure (HF) hospitalization.

Methods:

A retrospective quasiexperimental comparison group design was used. Electronic medical records were abstracted for HF patients discharged between March 2013 and December 2017. The treatment group was defined as patients with HF who attended ≥1 CR session within 6 wk following discharge. The comparison group was defined as patients with HF without additional HF hospitalizations during the previous year, discharged to home/self-care, and did not attend CR within 6 wk. Readmission rates at 30 d and 6 wk were compared between groups using χ2 analysis and logistic regression.

Results:

Out of 8613 patients with HF, 205 (2.4%) attended ≥1 CR within 6 wk post-discharge. The treatment group had lower, but not statistically significant, readmission rates than the comparison group for 30-d readmissions for HF (P = .13), and 6-wk readmission rates for HF (P = .05). The treatment group had lower all-cause readmissions at 30 d (P < .01) and 6 wk (P < .01) than the comparison group. Multivariable logistic regression revealed that early CR attendance was associated with reduced 30-d all-cause readmissions (adjusted OR = 0.4: 95% CI, 0.2-0.7) and 6-wk all-cause readmissions (adjusted OR = 0.5: 95% CI, 0.3-0.8).

Conclusions:

This study contributes to the existing evidence for allowing early unrestricted CR participation with the aim of improving the health of patients with HF and reducing rehospitalization rates.
Oxalic acid in ginger specifically denatures the acrid raphides in the unprocessed dried tuber of Pinellia ternata
Authors: Fueki Tsukasa , Nose Itsuki , Liu Yan , Tanaka Koichiro , Namiki Takao , Makino Toshiaki
Published: April 2022

Objective:

Pinellia Tuber, the dried tuber of Pinellia ternata, is widely used in Japanese Kampo medicines and traditional Chinese medicines. The unprocessed Pinellia Tuber is known to cause very strong acrid irritation at oral and laryngopharynx mucosa. Recent studies have shown that the sharp needle-like crystals called raphides, that are composed of calcium oxalate and proteins, are the main causative substances of the irritation. Ginger, the rhizome of Zingiber officinale, has been used in the processing to reduce the acridity of Pinellia Tuber since before the sixth century, however, the mechanisms of reducing acridity have not been scientifically proved yet.

Methods:

We developed the raphides denaturation assay (RDA) to quantify the degree of denaturation in the raphides to cause irritation. By their lipophilic characters, the raphides could be extracted in petroleum ether (PE) layer from powdered Pinellia Tuber suspended in water, and the contents of the raphides in PE layer were measured by the absorbance. By this assay, we conducted the activity-guided fractionation from the boiling water extract of ginger to find the ingredients to denature the raphides. We also conducted the gustatory tests to detect the change of the irritation of the denatured raphides.

Results:

The treatment of powdered Pinellia Tuber suspension with ginger extract reduced the distribution of raphides in PE layer in RDA in a concentration-dependent manner. The activity-guided fractionation using RDA revealed that oxalic acid was the main active ingredient in ginger extract to denature the raphides of Pinellia Tuber. Oxalic acid reduced the lipophilicity of the raphides in the thermo-, time-, and concentration-dependent manners, and its activity was affected by pH. The treatment of powdered Pinellia Tuber suspension with oxalic acid significantly reduced its acrid irritation in gustatory test in human.

Conclusions:

We found that oxalic acid is the main active ingredient in ginger to reduce the acrid irritation of Pinellia Tuber.
Managing community engagement initiatives in health and social care: lessons learned from Italy and the United Kingdom
Authors: Longo Francesco , Barsanti Sara , Bonciani Manila , Bunea Anita , Zazzera Angelica
Published: April 2022

Background

Determining the different features and potential impacts of community initiatives aimed at health-related outcomes poses challenges for both researchers and policy makers.

Purpose

This article explores the nature of heterogeneous “community engagement initiatives” (CEIs) considering both their social and organizational features in order to understand the managerial and policy implications to maximize their potential local health and social care-related impacts.

Methodology

A threefold qualitative analysis was conducted: (a) Three frameworks were developed to classify and analyze different CEIs features, building upon the current literature debate; (b) primary data were collected from Italian CEIs; and (c) a comparative cross-case analysis of a total of 79 CEIs in Italy and the United Kingdom was implemented.

Findings

The results show two types of strategic policy and management implications: (a) CEI portfolios are very broad and differentiated; (b) different social networks have diversified social constructs, internal cultures, and organizational features; and (c) there is a consequent need to contextualize relational and steering approaches in order to maximize their potential community added value.

Conclusion

CEIs are fundamental pillars of contemporary welfare systems because of both the changing demography and epidemiology and the disruptive impact of platform economy models. This challenging scenario and the related CEIs involve a complex social mechanism, which requires a new awareness and strengthened competences for public administrations’ steering.

Practice Implications

It is crucial for policy makers and managers to become familiar with all the different CEIs available in order to choose which solution to implement, depending on their potential impacts related to local public health and social care priorities. They also need to select the related effective steering logic.
Rethinking how health care professionals cope with stress: A process model for COVID-19 and beyond
Authors: Harley Jason M. , Montreuil Tina C. , Lou Nigel Mantou , Feldman Liane S. , Fried Gerald M. , Lavoie-Tremblay Mélanie , Bhanji Farhan , Kennedy Heather
Published: April 2022

Issue

Prior to the COVID-19 pandemic, there was evidence of challenges surrounding the psychological well-being of health care professionals (HCPs). HCPs already frayed psychological ability to cope risks being further compromised by COVID-19-related stresses.

Critical Theoretical Analysis

Most research on stress, psychological distress, and coping among HCPs is done in a piecemeal manner without a theoretical model connecting these different but related phenomena. This critical advancement article aims to apply and extend Wheaton and Montazer’s model of stressors, stress, and distress to the literature on HCPs, generally, and COVID-19, specifically, to summarize past and guide future research on HCPs’ mental health, resilience, and coping. Our model describes how different sources of support buffer the effect of stressors on stress and how coping strategies moderate the effect of stress on psychological distress.

Advance

We extended the model by (a) distinguishing context from the support in HCPs’ environment; (b) distinguishing adaptive from maladaptive coping strategies and their relationships with antecedents and outcomes; (c) describing the adverse impacts that psychological distress has on patients, HCPs, and health services; and (d) describing how such outcomes can become stressors, in turn, further contributing to HCPs’ stress in a vicious cycle.

Practice Implications

Our model provides a broader perspective of HCPs’ work-related mental health and helps guide the creation, implementation, and evaluation of different sources of support and promote adaptive coping strategies. This model helps HCPs, researchers, and health services managers better understand and respond to the well-being crisis HCPs are facing, especially during the pandemic.
Hybrid 23/25-Gauge Direct Perfluorocarbon Liquid—Silicone Oil Exchange
Authors: Elhusseiny Abdelrahman M. , Sanders Riley N. , Ellabban Abdallah A. , Sallam Ahmed B.
Published: April 2022

Purpose:

To describe a novel technique for direct perfluorocarbon liquid (PFCL)-silicone oil exchange that aims to reduce the inherent risk of intraoperative intraocular pressure spike.

Methods:

We use the conventional setup for passive PFCL–silicone exchange, but intentionally create a mismatch between the passive PFCL aspiration and the active silicone injection that favors the PFCL extrusion. This is achieved by converting one port to a large gauge one—23 or 20-gauge.

Results:

We did not note the occurrence of high intraocular pressure spikes with this technique as noted by disk pallor or attenuated vessels.

Conclusion:

A hybrid 23/25-gauge technique for direct PFCL–silicone oil exchange is safe and reduces the risk of intraoperative intraocular pressure spike.
Squamoid Eccrine Ductal Carcinoma of the Eyelid: Clinicopathologic Correlation of a Case
Authors: Patel Nish , Alabiad Chrisfouad R. , Wick Mark R. , Elgart George W. , Tang Vincent D. , Abou Khzam Rayan A. , Dubovy Sander R.
Published: April 2022

Squamoid eccrine ductal carcinoma (SEDC) is a rare cutaneous neoplasm that often manifests as a plaque or nodule in sun-exposed areas of older patients. Herein, the authors report the first case of SEDC in the eyelid. A 76-year-old man presented with a 2.5 × 1.5 mm area of left upper eyelid erythema, thickening, ulceration, and scaling with madarosis superotemporally just above the lash line. Full-thickness wedge biopsy demonstrated irregular epithelial tubules with nuclear atypia and focal squamous differentiation, consistent with SEDC. The patient underwent Mohs resection and has had no recurrence approximately 27 months after surgical removal. The authors present this case to raise awareness of SEDC to ophthalmologists as all previous cases have been described in the nonophthalmic literature. A full-thickness biopsy is recommended to avoid misdiagnosing SEDC as squamous cell carcinoma (SCC), a less aggressive tumor. With greater awareness, there may be increased recognition of this likely underreported, more malignant entity.
Oxygen-supplemented transepithelial-accelerated corneal crosslinking with pulsed irradiation for progressive keratoconus: 1 year outcomes
Authors: Cronin Brendan , Ghosh Atanu , Chang Clark Y.
Published: April 2022

Purpose:

To investigate the effects of combining oxygen supplementation with enhanced UV-A light and increased riboflavin permeability in improving the efficacy of epithelium-on crosslinking (epi-on CXL).

Setting:

Private eye clinic in Brisbane, Queensland, Australia.

Design:

Retrospective single-center nonrandomized uncontrolled longitudinal cohort case series.

Methods:

Transepithelial CXL was performed on keratoconic eyes. Applications of an oxygen goggle and pulsed UV-A irradiation (1 second on, 1 second off) were used to enhance oxygen kinetics during epi-on CXL. Additional procedural modifications included the use of benzalkonium chloride and high UV-A irradiance level (30 mW/cm2) to improve the stromal bioavailability of riboflavin and UV-A. The main efficacy outcomes were the changes in mean corrected distance visual acuity (CDVA) and safety over 12 months. Additional refractive and keratometry (K) outcomes were also observed.

Results:

53 eyes (38 patients) were included in this study. 12 months postoperatively, mean CDVA improved from a mean of 0.18 ± 0.2 at baseline to 0.07 ± 0.1 logMAR (P < .0001). No statistically significant change was observed in maximum K (Kmax) and mean K, which were respectively 51.7 ± 5.8 diopters (D) and 46.4 ± 3.85 D at baseline and 51.2 ± 5.7 D (P = .152) and 46.0 ± 3.84 D (P = .06) 12 months postoperatively. Only 3 eyes experienced an increase of more than 2 D in Kmax; however, none of these eyes experienced a CDVA loss. There were no reported infections, corneal scarring, or other severe adverse effects.

Conclusions:

Performing supplemental oxygen epi-on CXL with accelerated, pulsed UV-A irradiation in conjunction with riboflavin permeability enhancers resulted in improved CDVA (P < .0001) and stable keratometry up to 12 months postoperatively with a good safety profile.
Mechanisms of an App-Based Physical Activity Intervention and Maintenance in Community-Dwelling Women
Authors: Fukuoka Yoshimi , Haskell William , Vittinghoff Eric
Published: April 2022

Background

Understanding the mechanism of interventions that increase physical activity (PA) is critical to developing robust intervention strategies.

Aims

This study aims to examine the mediation effects of hypothesized changes in self-efficacy, social support, and barriers on daily changes in accelerometer-measured steps and the duration of moderate to vigorous PA over 3-month intervention and 6-month maintenance periods with a mobile phone–based PA education program.

Methods

Data were analyzed for a total of 210 physically inactive women who were randomized. The mean (SD) age was 52.4 (11.0) years. The framework of Baron and Kenny and the Sobel test were used to evaluate the proportion of the treatment effect explained by mediation factors.

Results

Postintervention PA changes were mediated by a reduction in self-efficacy and barriers and an increase in social support from friends during the intervention and maintenance periods (P ≤ .05). However, social support from family was significant only during the intervention, but not the maintenance (P = .90). Barriers to PA had the largest mediation effect on the intervention, explaining 13% to 16% of the 3-month intervention effect and 14% to 19% of the 6-month maintenance effect on daily steps and duration of moderate to vigorous PA minutes (P ≤ .05).

Conclusions

Incorporating strategies for overcoming PA barriers and promoting social support for PA is important for the design of interventions for physically inactive women. However, a reduction in self-efficacy was observed in the intervention group at 3 and 9 months as compared with the control group. This unexpected finding requires further investigation.
Responding to the Challenges and Barriers Unique to Rural Appalachian Sexual Assault Nurse Examiner Programs
Authors: Treat Sarah , Vanhook Patricia , Hendrix Lenee’ , Wallace Kelsey , McCook Judy G.
Published: April 2022

The purpose of this article is to explore the opportunities and barriers challenging sexual assault nurse examiners (SANEs) operating in rural and underserved areas. These challenges include the absence of established SANE programs, patient isolation and poverty, inadequate community support, and ensuring program sustainability. While not specific to rural communities, these challenges and barriers are further exacerbated by long-held beliefs and misconceptions that exist in small, close-knit communities. To mitigate these challenges, SANE programs in rural communities are asked to respond with creative and unique solutions. Through strong community partnerships and carefully coordinated efforts, SANE programs can thrive in even the most isolated and economically depressed rural communities.
Physiologic and compositional coronary artery disease extension in patients with takotsubo syndrome assessed using artificial intelligence: an optical coherence tomography study
Authors: Kumar Sant , Chu Miao , Tu Shengxian , Kuku Kayode O. , Kahsay Yirga , Gonzalo Nieves , Salazar Carlos Hernando , Alfonso Fernando , Garcia-Garcia Hector M.
Published: April 2022

Background

Takotsubo syndrome (TTS) is an acute and reversible ventricular motion abnormality without epicardial coronary obstruction. Optical flow ratio (OFR) is an approach to evaluate the coronary stenosis significance based on three-dimensional optical coherence tomography (3D-OCT). The aim of this study is to utilize OCT and an artificial intelligence plaque characterization model to show the prevalence and composition of atherosclerotic disease in coronary vessels of patients with TTS.

Methods

This is a retrospective and observational study which enrolled patients with TTS who underwent coronary angiography and OCT examination. OCT images were analyzed for tissue characterization and OFR computation using a novel artificial intelligence algorithm.

Results

A total of 37 patients and 49 vessels were studied. All patients were imaged in the left anterior descending coronary artery (LAD) and about two-thirds were also imaged in the left circumflex coronary artery (LCX). Most patients were women (n = 35), and apical was the most common takotsubo type. Tissue composition analysis yielded the following overall plaque types: fibrous (67.1%), lipid (15.5%), and calcium (3.77%). The mean OFR for LAD and LCX was 0.97 ± 0.04 and 0.98 ± 0.02, respectively.

Conclusion

Utilizing automatic plaque characterization on OCT images by artificial intelligence, we found that TTS patients have coronary artery disease (i.e. presence of lipid, calcified, or fibrous tissue). The advent of artificial intelligence methods may allow for large-scale studies of patients with TTS.
Fluvoxamine in Nonhospitalized Patients With Acute COVID-19 Infection and the Lack of Efficacy in Reducing Rates of Hospitalization, Mechanical Ventilation, and Mortality in Placebo-Controlled Trials: A Systematic Review and Meta-Analysis
Authors: Bhuta Sapan , Khokher Waleed , Kesireddy Nithin , Iftikhar Saffa , Beran Azizullah , Mhanna Mohammed , Patel Neha J. , Patel Mitra , Burmeister Cameron , Assaly Ragheb
Published: April 2022

Background:

Recent clinical trials have investigated the use of fluvoxamine in preventing clinical deterioration in nonhospitalized patients with acute COVID-19 infection via stimulation of sigma-1 receptors, which regulates cytokine production and functional inhibition of acid sphingomyelinase activity, which may prevent infection of epithelial cells with SARS-CoV-2. However, the role of fluvoxamine is currently unclear because of a paucity of studies, particularly because the drug is being repurposed as an immunomodulatory and antiviral agent.

Study Question:

Aim of our meta-analysis was to investigate the efficacy of fluvoxamine in nonhospitalized patients with acute COVID-19 infection.

Data Source:

Comprehensive literature search of PubMed, Embase, Cochrane Library databases, and Web of Science was performed from inception to February 10, 2022, for studies comparing fluvoxamine versus placebo for outpatient management of COVID-19.

Study Design:

The primary outcome of interest was rate of hospitalization. The secondary outcomes were rates of patients requiring mechanical ventilation and mortality. The random-effects model was used to calculate the risk ratios (RR) and confidence intervals (CI). A P value <0.05 was considered statistically significant. Heterogeneity was assessed using the Higgins I2 index.

Results:

Three studies (2 randomized controlled trials and one prospective cohort trial) involving 1762 patients were included in the meta-analysis. In patients who received fluvoxamine compared with placebo, there was no significant difference in rates of hospitalization (RR 0.26, 95% CI, 0.04–1.73, P = 0.16, I2 = 62%), mechanical ventilation (RR 0.73, 95% CI, 0.45–1.19, P = 0.21, I2 = 0%), and mortality (RR 0.67, 95% CI, 0.37–1.22, P = 0.19, I2 = 0%).

Conclusion:

Current evidence does not indicate a significant effect of fluvoxamine on the rates of hospitalization, mechanical ventilation, and mortality of patients with COVID-19 infection.
Fetal and Neonatal Reticulocyte Count Response to Intrauterine Transfusion for the Treatment of Red Blood Cell Alloimmunization
Authors: Lee Alan J. , Leonard Anthony , Markham Kara B.
Published: April 2022

Management of hemolytic disease of the fetus and newborn relies on monitoring of maternal antibody titers, fetal ultrasound, and fetal middle cerebral artery peak systolic velocity studies and is generally treated by intrauterine transfusion (IUT). Few studies have explored fetal and neonate physiological responses to IUT. Our objective was to examine fetal erythropoietic response and to examine neonatal erythropoietic effects after treatment. Thirty-six patients treated from 2005 to 2015 were identified retroactively. The time course of treatment, including gestational age and number of IUT, and timing of delivery were reviewed. Fetal reticulocyte count and neonatal hemoglobin and reticulocyte counts were analyzed for each IUT. For each gestational week, reticulocyte count decreased by ∼8.6% (95% confidence interval [CI]: 5.3-12.0). In the neonatal period, there was significant correlation between hemoglobin at birth and number of transfusions (Spearman correlation 0.473, 95% CI: 0.113-0.715, P=0.01) as well as reticulocyte count at birth and number of transfusions (Spearman correlation: 0.393, 95% CI: 0.058-0.642, P=0.02). IUT appears to have a direct and measurable effect on fetal reticulocyte production which persists in neonates.
Symptoms of Paranoia Experienced by Students of Pakistani Heritage in England
Authors: Elahi Anam , McIntyre Jason C. , Thomas Justin , Abernethy Louise , Bentall Richard P. , White Ross G.
Published: April 2022

Individuals belonging to ethnic minority groups are less likely to experience symptoms of psychosis, such as paranoia, if they live in areas with high proportions of people from the same ethnic background. This effect may be due to processes associated with group belonging (social identification). We examined whether the relationship between perceived discrimination and paranoia was moderated by explicit and implicit Pakistani/English identification among students of Pakistani heritage (N = 119). Participants completed measures of explicit and implicit Pakistani and English identity, a measure of perceived discrimination, and a measure of paranoia. Perceived discrimination was the strongest predictor of paranoia (0.31). Implicit identities moderated the relationship between perceived discrimination and paranoia (−0.17). The findings suggest that higher levels of implicit Pakistani identity were most protective against high levels of paranoia (0.26, with low implicit English identity; 0.78, with medium English identity; 1.46, with high English identity). Overall, a complex relationship between identity and paranoia was apparent.
Developing New Clinical Nurse Specialist Educational Opportunities in Ambulatory Care Settings
Authors: Urton Michael S. , Reis Pamela , Cowin Pamela Bailey , Linder Julie Michelle
Published: April 2022

Purpose

The purpose of this project was to develop an ambulatory clinical practicum for clinical nurse specialist (CNS) students in rural and underserved Eastern North Carolina.

Description of the Program

A 14-week clinical practicum was designed for CNS students who participated in a Health Resources and Services Administration Advanced Nursing Education Workforce grant–sponsored program entitled “Advanced Practice Registered Nurse RURAL Scholars Program.” The objectives of the clinical practicum were to increase student competence in ambulatory care, identify critical knowledge and competencies in CNS ambulatory care, and determine potential opportunities for CNS practice in ambulatory settings.

Outcome

Students demonstrated increased awareness and interest in specific health challenges faced by rural and underserved communities and became aware of services available for individuals with complex healthcare needs. Deficiencies in the CNS curricula regarding ambulatory care were identified by students. Although the value of the CNS in ambulatory practice was appreciated by students, staff, and preceptors alike, opportunities for employment in ambulatory settings in rural and underserved communities continue to remain a challenge.

Conclusion

Student experiences in an ambulatory care CNS clinical practicum support the need for the development of knowledge and competencies in ambulatory care that will allow for the expansion of CNS practice in rural and underserved communities.
The Implementation of the Graduate Nurse Role to Support Nursing Staff During the COVID-19 Pandemic
Authors: Plamondon Cassandra , Peterson Kym , Baker Kathy M. , Barsamian Jenny , Grillo Darcy Ann Marie , Mackinson Lynn , Milano Andrea , Mills Lauren B.
Published: April 2022

Purpose/Objectives

The purpose is to describe the development and implementation of an onboarding program that successfully oriented and supported graduate nurses (GNs) in their transition to practice during the first COVID-19 pandemic surge.

Description of the Program

The program was developed utilizing Benner's novice-to-expert model with consideration of the Institute of Medicine's report: The Future of Nursing: Leading Change, Advancing Health as an evidence-based theoretical framework and structure. The GN orientation consisted of 3 phases that began upon initial hire into the role and ended after they transitioned into the entry-level registered nurse (RN) role.

Outcomes

Fifteen of the 16 GNs hired passed the NCLEX-RN examination and transitioned to the entry-level RN. After transitioning, GNs were surveyed to assess comfort levels with professional nursing roles and to identify knowledge gaps and areas for improvement. Six categories emerged for discussion: (1) work experience, (2) communication and feedback, (3) support, (4) clinical confidence, (5) workload, and (6) transition challenges. Implications to consider for future programs are to improve communication surrounding the GN role and limiting the number of preceptors during orientation.

Conclusions

A 3-phased approach to orientation was successful in onboarding and supporting GNs in their transition to practice.
PEComa-like Neoplasms Characterized by ASPSCR1-TFE3 Fusion
Authors: Argani Pedram , Wobker Sara E. , Gross John M. , Matoso Andres , Fletcher Christopher D.M. , Antonescu Cristina R.
Published: April 2022

Identical TFE3-related gene fusions may be found in renal cell carcinoma and mesenchymal neoplasms such as alveolar soft part sarcoma and TFE3-rearranged perivascular epithelioid cell tumor (PEComa). Among mesenchymal neoplasms, the ASPSCR1-TFE3 gene fusion has previously been described only in alveolar soft part sarcoma. We report 3 unusual mesenchymal neoplasms harboring the ASPSCR1-TFE3 gene fusion, the morphologic phenotype of which more closely matches PEComa rather than alveolar soft part sarcoma. All 3 neoplasms occurred in females ranging in age from 18 to 34 years and were located in the viscera (kidney, bladder, and uterus). All 3 contained nests of epithelioid cells bounded by fibrovascular septa. However, all were associated with hyalinized stroma, tight nested architecture, mixed spindle cell and epithelioid pattern, clear cytoplasm, and lacked significant discohesion. Overall, morphologic features closely resembled PEComa, being distinct from the typical alveolar soft part sarcoma phenotype. While none of the neoplasms labeled for HMB45, cytokeratin, or PAX8 all showed positivity for TFE3 and cathepsin K, and all except 1 were positive for smooth muscle actin. One patient developed a liver metastasis 7 years after nephrectomy. These cases bridge the gap between 2 TFE3-rearranged neoplasms, specifically alveolar soft part sarcoma and Xp11 translocation PEComa, highlighting the relatedness and overlap among Xp11 translocation neoplasms. While most TFE3-rearranged neoplasms can be confidently placed into a specific diagnostic category such as alveolar soft part sarcoma, PEComa, or Xp11 translocation renal cell carcinoma, occasional cases have overlapping features, highlighting the potential role that the cell of origin and the specific gene fusion play in the phenotype of these neoplasms.
Association Between Continuous Kidney Replacement Therapy Clearance and Outcome in Pediatric Patients With Hyperammonemia Not Due to Inborn Error of Metabolism
Authors: Starr Michelle C. , Cater Daniel T. , Wilson Amy C. , Wallace Samantha , Bennett William E. , Hains David S.
Published: April 2022

OBJECTIVES:

To describe a single-center experience of pediatric patients with hyperammonemia not due to inborn errors of metabolism and determine the association between use of continuous kidney replacement therapy (CKRT) treatment and outcomes.

DESIGN:

Retrospective cohort study.

SETTING:

Tertiary-care children's hospital.

PATIENTS:

All children less than 21 years old admitted to the hospital with hyperammonemia defined as an elevated ammonia levels (>100 µmol/L) not due to inborn error of metabolism.

INTERVENTIONS:

None.

MEASURES AND MAIN RESULTS:

Of 135 children with hyperammonemia, the most common reason for admission was infection in 57 of 135 (42%), congenital heart disease in 20 of 135 (14%), and bone marrow transplantation in 10 of 135 (7%). The overall mortality was 61% (82 of 135), which increased with degree of hyperammonemia (17 of 23 [74%] in those with ammonia >250 µmol/L). After multivariable regression, hyperammonemia severity was not associated with mortality (aOR, 1.4; 95% CI, 0.92–2.1; p = 0.11). Of the 43 patients (32%) receiving CKRT, 21 were prescribed standard clearance and 22 high clearance. The most common indications for CKRT were fluid overload in 17 of 43 (42%) and acute kidney injury or uremia in 16 of 43 (37%). Mean CKRT duration was 13 days. There was no difference between standard and high clearance groups in risk of death (76% vs 86%; p = 0.39), cerebral edema on CT scan (19% vs 27%; p = 0.52), nor decrease in ammonia levels after 24 or 48 hours of CKRT (p = 0.20, p = 0.94). Among those receiving CKRT, we failed to find an association between high clearance and decreased risk of death in multivariable analysis (aOR, 1.2; 95% CI, 0.64–2.3; p = 0.55).

CONCLUSIONS:

In our single-center retrospective study, we failed to find an association between clearance on CKRT and improved survival nor decreased cerebral edema on head imaging. In fact, we failed to find an association between ammonia level and mortality, after controlling for illness severity.
Face Lift Practice Patterns: An American Society of Plastic Surgeons Member Survey, 2000 and 2020. How Much Have We Changed?
Authors: Sinclair Nicholas R. , Kochuba Andrew , Coombs Demetrius M. , Couto Rafael A. , Charafeddine Ali H. , Grow Jacob , Matarasso Alan , Zins James E.
Published: April 2022

Background:

In 2000, Matarasso et al. performed a survey of American Society of Plastic Surgeons members’ face lift practice patterns. Since that publication, the aesthetic marketplace has changed dramatically, as have ancillary face lift techniques. In an attempt to detail these changes, we repeated that original survey, adding questions to address more recent technical issues and advances. The goal of this report was to define current face lift practice patterns, compare current patterns to the previous ones, and define recent advances.

Methods:

A 38-question survey assessing face lift techniques, perioperative management, complications, and concomitant procedures was electronically distributed to a random cohort of American Society of Plastic Surgeons members. Data were recorded and statistically analyzed utilizing the Pearson chi-square test.

Results:

A total of 251 forms were returned and analyzed. Details of demographics, face lift techniques, ancillary procedures, perioperative care, and complications are presented. Current results were compared to the previously published society member practice patterns delineated in the 2000 Plastic and Reconstructive Surgery publication.

Conclusions:

The basic approach of American Society of Plastic Surgeons members to the face lift operation has not changed dramatically over the past 20 years. The development of operative adjuncts, however, has been positive, including fat grafting techniques, concomitant use of skin resurfacing, and means of minimizing blood loss with tranexamic acid. In certain instances, respondents do not follow evidence-based guidelines for perioperative care. Finally, common complications of practicing members appear to coincide with published retrospective reviews.
The Impact of Electronic Communication of Medication Discontinuation (CancelRx) on Medication Safety: A Pilot Study
Authors: Pitts Samantha I. , Yang Yushi , Woodroof Taylor , Mollenkopf Nicole L. , Wang Nae-Yuh , Thomas Bridgette A. , Chen Allen R.
Published: April 2022

Objectives

This study aimed to evaluate the impact of electronic communication of medication discontinuation from prescribers to pharmacies (CancelRx) on medication safety.

Methods

We used electronic health record (EHR) data to identify medications that were e-prescribed from a pilot practice to a health system pharmacy and subsequently discontinued before or after CancelRx implementation (January 16–April 15, 2018 versus 2019). We matched these EHR data to pharmacy management software data to identify medications that were sold to patients in the 6 months after discontinuation. As a surrogate for unintended cancellation, we also identified medications refilled within 120 days of discontinuation. We conducted a medical record review to identify documentation of prescriber intent to discontinue these medications.

Results

CancelRx implementation prevented prescriptions from being sold after discontinuation in the EHR (42 of 392 [10.7%] versus 0 of 387 [0.0%], P < 0.0001), but only 15 of 42 (35.7%) had documented intent to discontinue the medication (15 of 392, or 3.8% overall). There was a nonsignificant increase in the proportion of discontinued medications reordered within 120 days (10.0% versus 12.7%, P = 0.23). Medical record review of reordered prescriptions after CancelRx implementation found that 10 of 49 (10 of 387, or 2.6% overall) might have been unintentionally canceled.

Conclusions

Implementation of CancelRx eliminated the sale of e-prescribed medications after discontinuation in the EHR but might result in the unintentional cancellation of some prescriptions. Strategies to increase situational awareness of providers and pharmacy staff, including increased visibility of CancelRx, clear distinctions between active and expired prescriptions, and transmission of the reason for discontinuation, might reduce the risk of unintentional cancellations.
Patient Safety Issues From Information Overload in Electronic Medical Records
Authors: Nijor Sohn , Rallis Gavin , Lad Nimit , Gokcen Eric
Published: April 2022

Background and Objective

Electronic health records (EHRs) have become ubiquitous in medicine and continue to grow in informational content. Little has been documented regarding patient safety from the resultant information overload. The objective of this literature review is to better understand how information overload in EHR affects patient safety.

Methods

A literature search was performed using the Transparent Reporting of Systematic Reviews and Meta-Analyses standards for literature review. PubMed and Web of Science were searched and articles selected that were relevant to EHR information overload based on keywords.

Results

The literature search yielded 28 articles meeting the criteria for the study. Information overload was found to increase physician cognitive load and error rates in clinical simulations. Overabundance of clinically irrelevant information, poor data display, and excessive alerting were consistently identified as issues that may lead to information overload.

Conclusions

Information overload in EHRs may result in higher error rates and negatively impact patient safety. Further studies are necessary to define the role of EHR in adverse patient safety events and to determine methods to mitigate these errors. Changes focused on the usability of EHR should be considered with the end user (physician) in mind. Federal agencies have a role to play in encouraging faster adoption of improved EHR interfaces.
Texas Hospitals' Perspectives About NICU Performance Measures: A Mixed-Methods Study
Authors: Doherty Julie R. , Schaefer Andrew , Goodman David C.
Published: April 2022

Background and Objectives:

This study was conducted to assess Texas hospital leaders' perspectives about neonatal intensive care (NICU) performance measures.

Methods:

We conducted an explanatory mixed-methods study. First, we sent a survey and a copy of the Dartmouth Atlas of Neonatal Intensive Care to clinical and administrative leaders of 150 NICUs in Texas. We asked respondents to review the chapter that reported Texas-specific results and respond to a variety of open and closed-ended questions about the overall usefulness of the report. Second, we conducted semistructured qualitative interviews with a subset of survey respondents to better understand their perspectives.

Results:

The survey had a 50% hospital response rate. Respondents generally found the report to be interesting and useful, and 87.7% of all respondents reported being in favor of receiving future reports with their own hospital's data benchmarked against anonymous peers. All of the specific measures in the Atlas were found to be of interest and valuable, with NICU admissions and special care days rating among the most interesting and useful. In the semistructured interviews, respondents expressed that a report with performance data would serve as a mechanism to drive change by identifying opportunities for improvement.

Conclusion:

Texas hospital NICU leaders are interested in routinely receiving more information about their own NICU's performance anonymously benchmarked against their peers. This would facilitate a greater understanding of a unit's functionality, as well as accelerate clinically appropriate quality improvement initiatives, which together have the potential to deliver better newborn care at lower costs for all Texans.
Accuracy of the Simplified HOSPITAL Score to Predict Nonelective Readmission in a Brazilian Tertiary Care Public Teaching Hospital
Authors: Pivatto Júnior Fernando , Helena Dias Pereira dos Santos Ulbrich Ana , Gheno Jociele , Antônio Fisch Marco , Cristina Petry Roberta , da Silva Nunes Thaise , Wajner André
Published: April 2022

Background and Objectives:

Predictive models to identify patients at high risk of readmission have gained the attention of health care teams, which have focused the strategies to reduce unnecessary readmissions on the “at-risk” patients. The HOSPITAL score includes 7 predictor variables with a C-statistic of 0.70 or more when applied to international datasets. Its simplified version retains a C-statistic at around the same level, but only incipient external validation has been attempted to date. The primary objective of this study was to evaluate the prognostic accuracy of the simplified HOSPITAL score to predict nonelective hospital readmissions in a tertiary care public teaching hospital in Brazil.

Methods:

We used a retrospective cohort that included all patients discharged from the internal medicine service of a Brazilian tertiary care public teaching hospital in 2018. We excluded patients who died before index discharge, were transferred to another institution, left against medical advice, or were readmitted electively. We calculated the simplified HOSPITAL score for each admission, and admissions were divided into low (0-4 points) or high risk (≥ 5 points) of nonelective 30-day readmission. We estimated accuracy, area under the receiver operating characteristic curve (AUC), and observed/expected (O/E) readmission ratio; the latter using the mid-P exact test with Miettinen's modification at a 95% confidence interval (CI). A P value < .05 was considered significant.

Results:

A total of 4472 hospital discharges were analyzed during the study period after application of the exclusion criteria. The nonelective 30-day readmission rate was 14.0% (n = 625). Of all patients discharged, 3173 (71.0%) were considered to be at low risk and 1299 (29.0%) at high risk of readmission according to the simplified HOSPITAL score. The AUC was 0.68 (95% CI: 0.66-0.71; P < .001). The nonelective 30-day readmission rate was 9.2% in the low-risk group (expected: 9.2%; O/E: 1.0 [95% CI: 0.89-1.12]) and 25.7% in the high-risk group (expected: 27.2%; O/E: 0.95 [95% CI: 0.85-1.05]) (P < .001). At a cut-off of 5 points, the score had a sensitivity of 53.4%, specificity of 74.9%, positive predictive value of 25.7%, and negative predictive value (NPV) of 90.8%.

Conclusions:

The parameters of the score were almost identical to the original study, with better applicability to exclude low-risk patients given its high NPV. Additional adjustments are still needed for better applicability in daily clinical practice.