bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatric Antiretroviral Therapeutic Drug Monitoring: A Five and a Half Year Experience from a South African Tertiary Hospital
Authors: Engelbrecht Anton E , Wiesner Lubbe , Norman Jennifer , Rabie Helena , Decloedt Eric H
Published: October 2019

Introduction

Antiretroviral therapeutic drug monitoring (TDM) is not routinely used in the management of human immunodeficiency virus, but may be useful in pediatric patients who are prone to altered pharmacokinetics. Data on the routine use of antiretroviral TDM in pediatrics are sparse especially data from sub-Saharan Africa.

Methods

We retrospectively reviewed the antiretroviral TDM indications at Tygerberg Children’s Hospital, identified pediatric patients who had antiretroviral TDM requests from January 2012 until June 2017 and reviewed their clinical records.

Results

Fifty-nine patients were identified who presented with 64 clinical problems for which TDM was requested. TDM was requested for lopinavir, efavirenz and nevirapine in 83% (53/64), 14% (9/64) and 3% (2/64) of clinical problems, respectively. Lopinavir was mostly requested in patients when adherence measures did not correlate with the clinical picture, suspected non-adherence, lopinavir–rifampicin interactions and for neonatal safety monitoring. Efavirenz was requested when toxicity was suspected and nevirapine in patients receiving rifampicin. Lopinavir TDM confirmed non-adherence in 25% (4/16) of cases when adherence measures did not correlate with the clinical picture and in 43% (3/7) of cases when non-adherence was suspected by the clinician. Efavirenz TDM confirmed toxicity in 100% (6/6) of patients.

Conclusions

Lopinavir TDM was mostly requested when adherence measures did not correlate with the clinical picture, when rifampicin was co-administered and for perinatal safety monitoring. Lopinavir TDM excluded pharmacokinetic reasons for failure in patients failing treatment when lopinavir dosing was supervised. Efavirenz TDM was requested for suspected toxicity with a 100% positive predictive value.
Mycovirus-Induced Hypervirulence of Leptosphaeria biglobosa Enhances Systemic Acquired Resistance to Leptosphaeria maculans in Brassica napus
Authors: Shah Unnati A. , Kotta-Loizou Ioly , Fitt Bruce D. L. , Coutts Robert H. A.
Published: October 2019

Phoma stem canker (blackleg) is one of the most important diseases of winter oilseed rape (Brassica napus) worldwide and is caused by a complex that comprises at least two species: Leptosphaeria maculans and L. biglobosa. Screening a panel of field Leptosphaeria isolates from B. napus for the presence of mycoviruses revealed the presence of a novel double-stranded RNA quadrivirus in L. biglobosa and no viruses in L. maculans. Following elimination of the mycovirus, virus-infected and virus-free isogenic lines of L. biglobosa were created. A direct comparison of the growth and virulence of these isogenic lines illustrated that virus infection caused hypervirulence and resulted in induced systemic resistance toward L. maculans in B. napus following lower leaf preinoculation with the virus-infected isolate. Analysis of the plant transcriptome suggests that the presence of the virus leads to subtle alterations in metabolism and plant defenses. For instance, transcripts involved in carbohydrate and amino acid metabolism are enriched in plants treated with the virus-infected isolate, while pathogenesis-related proteins, chitinases and WRKY transcription factors are differentially expressed. These results illustrate the potential for deliberate inoculation of plants with hypervirulent L. biglobosa to decrease the severity of Phoma stem canker later in the growing season.

[Formula: see text] Copyright © 2020 The Author(s). This is an open access article distributed under the CC BY 4.0 International license .
Bronchopulmonary Sequestration: Spectrum of Appearance on CT
Authors: Rastegar Neda , Maldjian Pierre D.
Published: October 2019

Bronchopulmonary sequestration is an uncommon pulmonary disorder consisting of a segment of nonfunctioning lung parenchyma that lacks communication with the tracheobronchial tree.1
,
2 Bronchopulmonary sequestration receives its primary arterial blood supply from an aberrant systemic artery, usually originating from the thoracic or abdominal aorta. Venous drainage can be either to pulmonary or systemic veins.1 The prevalence of bronchopulmonary sequestration ranges from 1% to 6%. The predominant sex and age of presentation is variable depending on the type of bronchopulmonary sequestration. Despite its low prevalence, bronchopulmonary sequestration is the second most common congenital lung lesion after congenital pulmonary airway malformation.
Tofacitinib Receives New Boxed Safety Warning
Authors: Aschenbrenner Diane S.
Published: October 2019

A new boxed warning has been added to the labeling of tofacitinib (Xeljanz, Xeljanz XR) based on preliminary safety data from an ongoing postmarketing trial showing an increased risk of thrombosis and death in patients with at least one cardiovascular risk factor who were taking the 10-mg twice-daily dose.

Tofacitinib 10 mg twice daily is approved as induction treatment for ulcerative colitis; the dose is not approved to treat rheumatoid arthritis or psoriatic arthritis.

NPs should adhere to the dosing regimens listed on tofacitinib's labeling. Patients should be assessed for thrombosis and taught to seek emergency help if they develop signs or symptoms of this condition.
New Guidelines for Prevention and Treatment of Migraines in Children
Authors: Rosenberg Karen , Todd Betsy
Published: October 2019

According to this study:

Nonprescription oral analgesics are often effective in children and adolescents who have migraine headaches.

Lifestyle modification and acute pharmacological treatment are mainstays of migraine management.
The Effects of Private Rooms on Hospital-Associated Infections
Authors: Rosenberg Karen , Todd Betsy
Published: October 2019

According to this study:

Switching to single-patient rooms led to a notable and sustained decrease in the rates of new methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) colonization and VRE infection, but not of Clostridioides difficile or MRSA infections.
Preventing Self-Harm in the Nonpsychiatric Health Care Setting
Authors: Liberatore Kim
Published: October 2019

The Pennsylvania Patient Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events.

Safety Monitor is a column from Pennsylvania's Patient Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafety.pa.gov. For the original article discussed in this column or for other articles on patient safety, click on “Journal and Resources” and then “Advisory Archive” in the navigation menu.
Pelvic Organ Prolapse as a Function of Levator Ani Avulsion, Hiatus Size, and Strength
Authors: Handa Victoria L. , Roem Jennifer , Blomquist Joan L. , Dietz Hans Peter , Muñoz Alvaro
Published: October 2019

(Abstracted from Am J Obstet Gynecol 2019;221:41.e1–41.e7)

Vaginal childbirth significantly increases the likelihood that a parous woman will develop pelvic organ prolapse (POP). Reasons for the association between vaginal childbirth and POP are unclear, but one postulated mechanism is injury to the obstetrical injury to the levator ani muscles.
Hydrocortisone Compared with Placebo in Patients with Septic Shock Satisfying the Sepsis-3 Diagnostic Criteria and APROCCHSS Study Inclusion Criteria
Authors: Venkatesh Balasubramanian , Finfer Simon , Cohen Jeremy , Rajbhandari Dorrilyn , Arabi Yaseen , Bellomo Rinaldo , Billot Laurent , Glass Parisa , Joyce Christopher , Li Qiang , McArthur Colin , Perner Anders , Rhodes Andrew , Thompson Kelly , Webb Steve , Myburgh John
Published: October 2019

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Two recent randomized controlled trials (Adjunctive Glucocorticoid Therapy in Patients with Septic Shock [ADRENAL] and Activated Protein C and Corticosteroids for Human Septic Shock [APROCCHSS]) of corticosteroids in patients with septic shock reported different treatment effects on 90-day mortality. Both trials enrolled patients who met the criteria for septic shock using the second international consensus definitions for sepsis and septic shock (Sepsis-2), but the APROCCHSS trial mandated a greater severity of shock as an inclusion criterion.

Methods

The authors conducted post hoc sensitivity analyses of the ADRENAL trial to determine the effects of hydrocortisone versus placebo in subgroups selected using third international consensus definitions for sepsis and septic shock (Sepsis-3) diagnostic criteria or APROCCHSS inclusion criteria.

Results

There were 1,950 subjects (973 hydrocortisone and 977 placebo) who met the Sepsis-3 criteria (ADRENAL–Sepsis-3 cohort) and 905 patients (455 hydrocortisone and 450 placebo) who met the APROCCHSS criteria (ADRENAL–APROCCHSS cohort). At 90 days after randomization, in the ADRENAL–Sepsis-3 cohort, 312 of 963 (32.4%) and 337 of 958 (35.2%) patients assigned to hydrocortisone and placebo, respectively, had died (odds ratio, 0.86; 95% CI, 0.70 to 1.06; P = 0.166). The corresponding figures for the ADRENAL–APROCCHSS cohorts were 187 of 453 (41.3%) and 200 of 445 (44.9%), respectively (odds ratio, 0.84; 95% CI, 0.60 to 1.17; P = 0.303). There was no statistically significant difference in the time to death between the groups during the 90 days after randomization (hazard ratio = 0.87; 95% CI, 0.75 to 1.02; P = 0.082 for ADRENAL–Sepsis-3; and hazard ratio = 0.86; 95% CI, 0.71 to 1.06; P = 0.156 for ADRENAL–APROCCHSS cohorts). In both cohorts, patients assigned to hydrocortisone had faster resolution of shock. In the ADRENAL–Sepsis-3 cohort, patients assigned to hydrocortisone had an increase in the number of days alive and free of mechanical ventilation (57.0 ± 37.2 vs. 53.7 ± 38.2 days; 95% CI, 0.40 to 7.04; P = 0.028) and the number of days alive and free of the intensive care unit (54.3 ± 36.0 vs. 51.0 ± 37.1; 95% CI, 0.82 to 7.24; P = 0.014).

Conclusions

In a post hoc analysis of the ADRENAL trial participants who fulfilled either the Sepsis-3 or the APROCCHSS inclusion criteria, a continuous infusion of hydrocortisone did not result in a lower 90-day mortality than placebo in septic shock.
Recent Preoperative Concussion and Postoperative Complications: A Retrospective Matched-cohort Study
Authors: D’Souza Ryan S. , Sexton Matthew A. , Schulte Phillip J. , Pasternak Jeffrey J. , Abcejo Arnoley S.
Published: October 2019

Background:

Physiological alterations during the perianesthetic period may contribute to secondary neurocognitive injury after a concussion.

Methods:

Patients exposed to concussion and who received an anesthetic within 90 days were matched to unexposed patients without concussion. Intraoperative and postoperative events were compared. Subgroup analyses assessed relationships among patients with a concussion in the prior 30, 31 to 60, and 61 to 90 days and their respective unexposed matches. To facilitate identification of potential targets for further investigation, statistical comparisons are reported before, as well as after, correction for multiple comparisons.

Results:

Sixty concussion patients were matched to 176 unexposed patients. Before correction, 28.3% postconcussion versus 14.8% unexposed patients reported postanesthesia care unit pain score≥7 (P=0.02); 16.7% concussion versus 6.5% unexposed patients reported headache within 90 days of anesthesia (P=0.02) and 23.5% of patients who received surgery and anesthesia within 30 days of concussion experienced headache within 90 days of anesthesia compared with 7.1% in the unexposed group (P=0.01). Patients who experienced concussion and had anesthesia between 31 and 60 days after injury had a postanesthesia care unit Richmond Agitation and Sedation Scale score of −1.61±1.29 versus a score of −0.2±0.45 in unexposed patients (P=0.002). After adjusting the P-value threshold for multiple comparisons, the P-value for significance was instead 0.0016 for the overall cohort. Our study revealed no significant associations with application of adjusted significance thresholds.

Conclusions:

There were no differences in intraoperative and postoperative outcomes in patients with recent concussion compared with unexposed patients. Before correction for multiple comparisons, several potential targets for further investigation are identified. Well-powered studies are warranted.
Readmissions Are Not What They Seem: Incidence and Classification of 30-Day Readmissions After Orthopedic Trauma Surgery
Authors: Kelly Erin A. , Gonzalez Leah J. , Hutzler Lorraine , Konda Sanjit R. , Leucht Philipp , Egol Kenneth A.
Published: October 2019

Objectives:

To evaluate the causes of 30-day readmissions after orthopedic trauma surgery and classify them based on their relation to the index admission.

Design:

Retrospective chart review.

Setting:

One large, academic, medical center.

Participants:

Patients admitted to a large, academic, medical center for a traumatic fracture injury over a 9-year period.

Intervention:

Assignment of readmission classification.

Main Outcome Measures:

Readmissions within 30 days of discharge were identified and classified into orthopedic complications, medical complications, and noncomplications. A χ2test was performed to assess any difference in the proportion of readmissions between the hospital-reported readmission rate and the orthopedic complication readmission rate.

Results:

One thousand nine hundred fifty-five patients who were admitted between 2011 and 2018 for an acute orthopedic trauma fracture injury were identified. Eighty-nine patients were readmitted within 30 days of discharge with an overall readmission rate of 4.55%. Within the 30-day readmission cohort, 30 (33.7%) were the direct result of orthopedic treatment complications, 36 (40.4%) were unrelated medical conditions, and 23 (25.8%) were noncomplications. Thus, the readmission rate directly due to orthopedic treatment complications was 1.53%. A χ2test of homogeneity revealed a statistically significant difference between the hospital-reported readmission rate and the orthopedic-treatment complication readmission rate (P< 0.0005).

Conclusion:

The use of 30-day readmissions as a measure of hospital quality of care overreports the number of preventable readmissions and penalizes surgeons and hospitals for caring for patients with less optimal health.

Level of Evidence:

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Fracture Patterns and Comminution Zones in OTA/AO 34C Type Patellar Fractures
Authors: Misir Abdulhamit , Kizkapan Turan Bilge , Uzun Erdal , Oguzkaya Sinan , Cukurlu Mustafa , Golgelioglu Fatih
Published: October 2019

Objectives:

To characterize the fracture patterns and comminution zones for complete articular (OTA/AO 34C type) patellar fractures, using a computed tomography mapping technique.

Methods:

Eighty-three OTA/AO 34C type patellar fractures were included. Images of patellar fractures were superimposed on a coronal template of the patella, created from a healthy right knee, to identify fracture patterns and comminution zones.

Results:

Our analysis was based on 83 computed tomography images of patellar fractures, contributed by 69 male and 14 female patients (mean age, 52 years; range, 18–79 years), and included 13 type C1, 26 type C2 and 44 type C3 fractures. A transverse fracture, including both the medial and lateral facets, was the most common fracture pattern, identified in 92.8% of cases. In the C1 and C2 types, the fracture line affecting the medial and lateral joint surface was either transverse or oblique. In the C3 type, the transverse and vertical fracture line of the medial articular surface extended to the inferior pole of the patella, with transverse and oblique fractures lines on the lateral joint surface. In addition, a concentration of the fracture lines around the vertical ridge was observed.

Conclusions:

The patterns of fracture lines and comminution zones OTA/AO 34C type fractures were repeatable on the constructed maps. A transverse fracture line on the inferior pole which was observed in the C2 and C3 type fractures may be used for the modification of current classification systems to direct treatment.
Flexible intramedullary nailing of femoral shaft fractures: closed versus open reduction
Authors: Richardson Spencer M. , Dove J. Houston , Beaty James H. , Sheffer Benjamin W. , Spence David D. , Warner William C. , Sawyer Jeffrey R. , Kelly Derek M.
Published: October 2019

Children's femoral shaft fractures are commonly treated with flexible intramedullary nailing after closed or open reduction, but there is little information concerning indications for open reduction. The purpose of this study was to determine radiographic and clinical features likely to lead to open reduction before flexible intramedullary nailing. Record review identified 158 femoral shaft fractures treated with flexible intramedullary nailing. In addition to patient demographics and mechanism of injury, data obtained included surgeon name, estimated blood loss, type of reduction, type and diameter of nail, type of operating table, the use of percutaneous reduction techniques or supplemental casting, time to and duration of surgery, total time in operating room, and time to union. Fracture ratios were calculated based on established radiographic protocol. Of 158 fractures, 141 were treated with closed reduction and 17 with open reduction. The anteroposterior fracture index (1.3 ± 0.4, P = 0.0007), surgeon (P = 0.002), and flattop operating table (0.05) were associated with open reduction. Smaller lateral diameter of bone at the fracture site, transverse fracture, and surgeon were all found to be independent risk factors for open reduction; patient characteristics, including age, sex, and BMI, did not seem to influence the choice of open reduction. Fractures with a lower fracture index or pattern resembling a transverse fracture rather than oblique or spiral had an increased risk of converting to an open reduction. Surgeon preference and use of flattop tables also had a significant influence on how the fracture was treated.
Hereditary spherocytosis: a risk factor for thigh pressure myonecrosis in posterior spine surgery
Authors: Marasigan Joanne Abby M. , Solano Mitchell A. , Wicklund Brian M. , Schwend Richard M.
Published: October 2019

The objective of this study was to make surgeons aware of a potential pressure complication in posterior spine surgery for patients with hereditary spherocytosis (HS) and to present a plausible hypothesis for injury. Posterior spine surgery is common practice for adolescent idiopathic scoliosis (AIS). Common, less severe surgical risks include pressure ulcers; while rare, more severe pressure complications include rhabdomyolysis and compartment syndrome. In patients with HS, a familial hemolytic disorder with altered red cell deformability, it is unknown if their red cell disorder is an additional risk factor for pressure-related surgical injuries. Two patients with HS, an 18-year-old male and a 17-year-old female, were both post-splenectomy and underwent revision posterior spinal fusion and instrumentation for progressive AIS. Surgery lasted 9 hours and 7 hours respectively, with no intraoperative complications other than prolonged surgical time due to revision nature of the deformities. Thigh redness and swelling was noted in both patients directly deep to the thigh pads. Thigh myonecrosis was diagnosed with eventual recovery in both cases. Patients with HS may be at inherent more risk of pressure complications during posterior spine surgery. We propose that thigh myonecrosis occurs with decreased perfusion and hemolysis from HS erythrocytes’ inherent fragility, decreased deformability within capillaries, and prolonged microvasculature compression from positioning, causing poor microvascular perfusion, tissue ischemia, and reperfusion injury. Level of veidence: IV.
Supplementation with phytoestrogens and insoluble fibers reduces intestinal carcinogenesis and restores ER-β expression in Apc-driven colorectal carcinogenesis
Authors: Luceri Cristina , Femia Angelo Pietro , Tortora Katia , D’Ambrosio Mario , Fabbri Sergio , Fazi Marilena , Caderni Giovanna
Published: October 2019

Supplementation with phytoestrogens and insoluble fibers has been reported to reduce duodenal polyps in colectomized familial adenomatous polyposis patients, with a mechanism involving, at least in part, upregulation of estrogen receptor-β subtype, whose expression is lowered during intestinal tumorigenesis. These data suggest a protective effect also in the colon, the main target organ for tumorigenesis in familial adenomatous polyposis and a major cancer type in non-familial (sporadic) cancers. Therefore, we tested whether a similar preparation might reduce tumorigenesis in the colon of Pirc rats (F344/NTac-Apcam1137) mutated in the Apc gene and thus, like familial adenomatous polyposis patients, spontaneously developing multiple tumors in the colon. We first demonstrate that estrogen receptor-β expression in Pirc rat colon is significantly down-regulated compared to age-matched wt rats. Then, Pirc rats aged 1 month were treated for 3 months with Adipol (Adi), a patented preparation containing phytoestrogens and insoluble fibers. Colon tumorigenesis was significantly reduced by Adi treatment (colon tumors/rat were 5.3 ± 0.8 and 2.9 ± 0.3, Mucin Depleted Foci/rat 127 ± 6.6 and 97.1 ± 8.6 in Controls and Adi-treated rats, respectively, means ± SE, P < 0.01). The treatment also normalized colon proliferation pattern along the crypt and significantly increased apoptosis in colon tumors. Estrogen receptor-β expression was increased by Adi treatment, especially in the tumors. These positive effects suggest that Adipol may be exploited as a chemopreventive agent to reduce cancer risk in familial adenomatous polyposis patients and to postpone prophylactic colectomy. Moreover, given the similarities between familial adenomatous polyposis and sporadic colorectal cancer, it might also be used as chemopreventive agent in colorectal cancer patients at risk.
Superficial Basal Cell Cancers Demonstrate Higher Rates of Mixed Histology on High-Risk Anatomical Sites
Authors: Petersen Erik T. , Ahmed Saqib R. , Pradhan Dinesh , MacFarlane Deborah F.
Published: October 2019

BACKGROUND

The Mohs Appropriate Use Criteria (MAUC) have come into question recently regarding the most appropriate treatment for superficial basal cell carcinoma (sBCC). At the heart of this debate is the limited body of evidence describing tumor behavior of sBCC based on clinical factors relevant to the MAUC.

OBJECTIVE

To determine whether sBCC is more likely to harbor aggressive subtypes in high-risk anatomical locations and in immunocompromised patients.

MATERIALS AND METHODS

A single institution retrospective review produced 133 evaluable Mohs cases performed on sBCC over a 10-year period. All slides from the respective cases were reviewed for the presence of histologic patterns other than known sBCC. Cases were then grouped by both MAUC anatomical zone (H, M, and L) and patient immune status for statistical analysis.

RESULTS

A significantly higher rate of mixed histology (MH) was observed when comparing Zone H with Zone L across all patients, healthy patients, and immunocompromised patients. The same was true when comparing Zone M with Zone L for all patients and healthy patients (immunocompromised did not reach significance).

CONCLUSION

The authors' data very clearly demonstrate a higher rate of MH in sBCC of the head and neck which provides strong support to the current MAUC scoring.
MicroRNA-200a-3p Is a Positive Regulator in Cardiac Hypertrophy Through Directly Targeting WDR1 as Well as Modulating PTEN/PI3K/AKT/CREB/WDR1 Signaling
Authors: Yang Xiaomei , Chen Gang , Chen Zhengxu
Published: October 2019

Cardiac hypertrophy is an adaptive expansion of the myocardium due to the overloaded stress of heart. Recently, emerging studies have drawn a conclusion that microRNAs (miRNAs) are involved in myocardial hypertrophy and even heart failure. To figure out the role of microRNA-200a-3p (miR-200a-3p) in cardiac hypertrophy, the in vitro cardiac hypertrophy model was established in H9c2 cells using angiotensin II (Ang-II) as previously described. First of all, we observed a significant increase of miR-200a-3p expression in Ang-II–induced hypertrophic H9c2 cells. Moreover, inhibition of miR-200a-3p dramatically reversed the Ang-II–upregulated expression of hypertrophic markers (atrial natriuretic peptide, brain natriuretic peptide, and β-MHC) and the expanded cell surface area in H9c2 cells. In addition, our results indicated that miR-200a-3p directly targeted both WDR1 and phosphatase and tensin homolog (PTEN). In this regard, miR-200a-3p further activated PI3K/AKT/CREB pathway so as to intensify its negative regulation on WDR1. At length, WDR1 silence, PTEN inhibitor, and PI3K activator recovered the repressive effect of miR-200a-3p suppression on the development of cardiac hypertrophy. Jointly, our study suggested that miR-200a-3p facilitated cardiac hypertrophy by not only directly targeting WDR1 but also through modulating PTEN/PI3K/AKT/CREB/WDR1 signaling, therefore proving novel downstream molecular pathway of miR-200a-3p in cardiac hypertrophy.
Utilizing a Physician Scribe in a Pediatric Plastic Surgical Practice: A Time-driven Activity-based Costing Study
Authors: Cho Jonathan , Sanchez Karl , Ganor Oren , Afshar Salim , Ruditsky Alex , Bierman Alex , Taghinia Amir H.
Published: October 2019

Background:

To use time-driven activity-based costing methodology to compare the costs of routine pediatric plastic surgical patient visits with and without a physician scribe.

Methods:

Pediatric plastic surgical clinic visits at a tertiary care facility with the following diagnoses were studied: skin lacerations, skin lesions, and plagiocephaly. Two plastic surgeons saw patients individually either with or without a scribe over a 10-month period. The time that the scribe and physician spent on the patient was recorded, including the duration of the clinic visit and time spent creating, dictating, reviewing, and signing the note. An average appointment activity time for each measurement component was produced, and a capacity cost rate was introduced to derive the cost per minute for a scribe and physician. Sensitivity analysis and paired t-test were conducted to analyze the results.

Results:

A total of 45 cases with a physician scribe were observed with an average appointment activity time of 12.83 minutes (4.97 min for the scribe, 0.92 min for the physician, and 6.95 min combined). A total of 72 cases without a physician scribe were observed with an average appointment activity time of 12.01 minutes. The total attributable cost saving per appointment was $13.82 when a physician scribe was utilized.

Conclusion:

Time-driven activity-based costing methodology showed that the use of a physician scribe reduced cost per office visit by substituting physician time for a less expensive resource.
Interaction Between Ethnicity and Helicobacter pylori Infection in the Occurrence of Reflux Disease
Authors: Sonnenberg Amnon , Turner Kevin O. , Genta Robert M.
Published: October 2019

Background and Aims:

Few reports are available to reliably assess the ethnic distribution of Barrett metaplasia and reflux esophagitis. The present study served to analyze the joint influence of Helicobacter pylori infection and patient demographics on the diagnoses of Barrett metaplasia and reflux esophagitis.

Methods:

The Inform Diagnostics database is a national electronic repository of histopathologic records of patients distributed throughout the United States. In a case-control study of 52,096 cases with Barrett metaplasia, 189,235 cases with reflux esophagitis, and 152,322 controls without any signs or symptoms suggestive of gastroesophageal reflux disease, we assessed the influence of age, gender, ethnicity, and H. pylori status on occurrence of Barrett metaplasia or reflux esophagitis.

Results:

Barrett metaplasia was less common among East Asians (with odds ratio, 0.48; 95% confidence interval, 0.44-0.53) and Hispanics (0.60, 0.57-0.63) than other ethnic groups living in the United States. Reflux esophagitis was also less common among East Asians (0.86, 0.82-0.90), but more common among Hispanics (1.18, 1.14-1.21). Both types of esophageal disease were associated with a lower prevalence rates of gastric H. pylori infection than controls, with 0.48, 0.44-0.53 for Barrett metaplasia and 0.60, 0.57-0.63 for reflux esophagitis. The prevalence rates of gastric H. pylori and both esophageal diseases were greater in older than younger and male than female patients in all ethnic groups alike.

Conclusions:

Gastric H. pylori infection, ethnicity, gender, and age all influence the occurrence of Barrett metaplasia, and reflux esophagitis.
How harmless are E-cigarettes? Effects in the pulmonary system
Authors: Bozier Jack , Zakarya Razia , Chapman David Geoffrey , Oliver Brian Gregory George
Published: October 2019

Purpose of review

Electronic cigarettes have quickly risen to be the leading alternative nicotine source to tobacco. E-cigarette use is hard to research and regulate because of the novelty and rapid evolution of the devices and E-liquids. Epidemiological data on long-term usage is currently lacking, but in smaller cohort studies we are starting to understand the usage patterns and demographics of users, which differ depending on where the study takes place and the regulatory environment. The present review describes the current knowledge of the effects of E-cigarettes on the pulmonary system and knowledge of their usage patterns worldwide.

Recent findings

E-cigarette use is continuing to rise in young adults in United States and Canada, but not in United Kingdom. These suggest that regulation is influencing uptake in young adults. If E-cigarettes are to be considered as a harm minimisation smoking cessation product, use in young never smokers must be factored into the risk assessment. A recent surge in cases of lung injury associated with vaping in America has resulted in the definition of vaping associated pulmonary injury, although the exact cause remains unknown.

It is our opinion that E-cigarettes can no longer be defined as harmless. Further studies are needed to determine the risks for all populations as it is evident that a large proportion of E-cigarette users are never-smokers, meaning they cannot only be considered from a harm reduction perspective.
IV Ibuprofen for Prevention of Post‐ERCP Pancreatitis in Children
Authors: Troendle David M. , Gurram Bhaskar , Huang Rong , Barth Bradley A.
Published: October 2019

Background:

Post‐endoscopic retrograde cholangiopancreatography (post‐ERCP) pancreatitis (PEP) is reported to occur in up to 11% of pediatric patients. To date, no study has prospectively evaluated an intervention to prevent PEP in children. It is unclear if such a study is even feasible.

Objective:

The aim of the study was to evaluate the feasibility of studying IV ibuprofen for PEP prevention in the pediatric population.

Methods:

This was a prospective randomized double‐blind placebo‐controlled feasibility study. Patients younger than 19 years of age undergoing ERCP were randomized to receive 10 mg/kg IV ibuprofen (max of 800 mg) or placebo (saline) at the time of ERCP. The primary outcome was PEP. Secondary outcomes included post‐ERCP–related bleeding, rates of other procedural and medication‐related adverse events.

Results:

Fifty‐eight patients were randomized and received either IV ibuprofen or placebo. Preprocedure‐ and procedure‐related factors were not significantly different between the groups except that patients in the placebo group tended to weigh less (48.7 vs 63.7 kg, P = 0.03). There were 7 episodes of PEP (12%). PEP was less frequently identified in the Ibuprofen group than in the control group (7% vs 17%), but this was not statistically significant (P = 0.42). Mean postprocedural abdominal pain scores were significantly lower in the IV Ibuprofen group than in the control group (1.1 vs 3.1, P = 0.01) and the number of patients who had increased abdominal pain after the procedure was significantly lower in ibuprofen group than in the control group (3% vs 38%, P = 0.002). There were no significant differences in procedure‐related or drug‐related adverse events.

Conclusions:

Postprocedural pain scores and the number of patients who had increased abdominal pain after the procedure were significantly lower in the IV ibuprofen group. The current study provides encouraging, but only very weak evidence that IV ibuprofen decreases PEP in children. Power analysis suggests that a small handful of high‐volume pediatric centers would be able to perform an adequate clinical trial in a reasonable time frame. Focusing on all cause postprocedural pain (PEP and non‐PEP) may allow for a more efficiency study design and be just as clinically relevant.
Changing New Graduate Nurse Profiles and Retention Recommendations for Nurse Leaders
Authors: Tyndall Deborah E. , Scott Elaine S. , Jones Lenna R. , Cook Kristy J.
Published: October 2019

OBJECTIVE

This study compares and contrasts new graduate nurse attributes and perceptions using findings from a 2010 study and a recent analysis of new graduate nurses participating in the same residency program.

BACKGROUND

As millennials saturate the healthcare work environment, their unique views and needs will influence the evolution of new graduate nurse residencies.

METHODS

This study used previously reported data on new graduate nurses between 1999 and 2009 and compared it with a secondary analysis of data collected on new graduate nurses between 2011 and 2016.

Results

This study provides evidence that millennial new graduate nurses' levels of commitment and satisfaction do not moderate turnover intentions in the 1st 2 years of practice as they did in the previous group of new graduate nurses.

Conclusions

Job embeddedness, a construct that measures the likelihood of whether a person is going to stay, may be a better measurement among new graduate nurses than commitment or satisfaction because millennials, a generation that is predominant in current new graduate nurses, are more engaged than loyal.
The Role of Nurse Managers in the Adoption of Health Information Technology
Authors: Strudwick Gillian , Booth Richard G. , Bjarnadottir Ragnhildur I. , Rossetti Sarah (Collins) , Friesen Madison , Sequeira Lydia , Munnery Mikayla , Srivastava Rani
Published: October 2019

OBJECTIVE

This study aims to investigate the role of nurse managers in supporting point-of-care nurses' health information technology (IT) use and identify strategies employed by nurse managers to improve adoption, while also gathering point-of-care nurses' perceptions of these strategies.

BACKGROUND

Nurse managers are essential in facilitating point-of-care nurses' use of health IT; however, the underlying phenomenon for this facilitation remains unreported.

METHODS

A qualitative descriptive study was conducted with 10 nurse managers and 14 point-of-care nurses recruited from a mental health hospital environment in Ontario, Canada. Inductive and deductive content analyses were used to analyze the semistructured interviews.

RESULTS

Nurse managers adopt the role of advocate, educator, and connector, using the following strategies: communicating system updates, demonstrating use of health IT, linking staff to resources, facilitating education, and providing IT oversight.

CONCLUSIONS

Nurse managers use a variety of strategies to support nurses' use of health IT. Future research should focus on the effectiveness of these strategies.
Experiences With Managing the Workplace Social Environment
Authors: Price Sheri L. , Vine Jocelyn , Gurnham Mary Ellen , Paynter Martha , Leiter Michael
Published: October 2019

OBJECTIVE

This study aims to examine 1st-line managers' (FLMs') experiences in managing the workplace social environment (WSE).

BACKGROUND

FLMs are responsible for the establishment and maintenance of supportive WSE essential for effective teamwork. Poorly managed WSE and dysfunctional teams hold negative implications for patients, teams, and organizations.

METHODS

This was a qualitative descriptive study, using content analysis of individual and focus group interviews with FLMs and directors.

RESULTS

FLMs play a critical role in the management of the WSE; however, the task is fraught with constraints and challenges including competing demands, lack of support, and insufficient training. Findings explicate how competing demands and communication challenges impede the successful management of the WSE.

CONCLUSIONS

Given the importance of a healthy WSE to patient, professional, and organizational outcomes, FLMs need support, training, and resources to assist them in managing the social environment alongside other competing priorities.
Nurse and Patient Satisfaction
Authors: Meier Adam , Erickson Jeanette Ives , Snow Nicholas , Kline Melissa
Published: October 2019

The American Nurses Credentialing Center's Magnet Recognition Program® 2019 Magnet Application Manual “continue(s) to raise the bar as the gold standard for nursing” (p. IX). In this column, the authors, who are Magnet® commissioners, provide background and guidance on the standards for nurse satisfaction and patient satisfaction.
A Systems-Level Method for Developing Nursing Informatics Solutions
Authors: Mosier Sammie , Roberts Wm. Dan , Englebright Jane
Published: October 2019

Nursing leadership can play an essential role in the development of nursing informatics solutions by virtue of their broad understanding and oversight of nursing care. We describe a systems-level method for creating nursing informatics solutions with clearly defined structure and leadership from nursing executives. Based on the guiding principles of clear lines of responsibility, respect for expertise, and commitment to project aims, this allows nursing executive leadership to organize, set up, and own the development of nursing informatics solutions.
Dedicated Education Unit Improving Critical Thinking and Anxiety
Authors: Vnenchak Kathleen , Sperling Marnie Lynn , Kelley Kathleen , Petersen Brenda , Silverstein Wendy , Petzoldt Olivia , Cooper Lise , Kowalski Mildred Ortu
Published: October 2019

Seventeen senior bachelor of science in nursing students participated in a dedication education unit. The longitudinal study findings were statistically significant (p < .05) in all areas of measure: Health Education System Inc, critical thinking scores, decreased anxiety, self-efficacy, self-confidence in clinical decision-making, and confidence. Findings from this study were translated into the clinical institution's onboarding process, the Practice Transition Program, which was restructured and accredited by the American Nurses Credentialing Center in 2019.
Low Awareness of and Access to Pre-exposure Prophylaxis But High Interest Among Heterosexual Women in Cleveland, Ohio
Authors: Bogorodskaya Milana , Lewis Steven A. , Krakower Douglas S. , Avery Ann
Published: October 2019

Women received <5% of all US pre-exposure prophylaxis (PrEP) prescriptions in 2016. Among 351 heterosexual women surveyed in Cleveland, Ohio, 14.5% were aware of PrEP, 20.5% knew where to access PrEP, 75.9% were willing to try PrEP, and 50.9% expressed interest in more information.
Neurofilament Immunohistochemistry Followed by Luxol Fast Blue, for Staining Axons and Myelin in the Same Paraffin Section of Spinal Cord
Authors: Moszczynski Alexander J. , Volkening Kathryn , Strong Michael J.
Published: October 2019

Many disorders of the central nervous system are characterized by both axonal pathology and demyelination. In assessing this concurrent pathology, techniques for staining axons or myelin are frequently used separately. Here we report the development of a combined immunohistochemical and tinctorial staining technique in which we have modified the Luxol fast blue myelin stain to be used in conjunction with a diaminobenzidine-based immunohistochemical stain for high molecular weight neurofilament (SMI-31). This modification of staining will have utility in experimental neuropathology laboratories investigating demyelination and axonal damage in human tissue and animal models.
A Standardized Cardiac Protocol for Pediatric Drug Ingestion Hospital Admissions
Authors: Del Grippo Erica L. , Baskar Shankar , Gray Seth , Osakwe Onyekachukwu , Powell Adam W. , Anderson Jeffrey , Spar David , Madsen Nicolas
Published: October 2019

Objective:

To optimize patient resource utilization and safety, we created a standard-of-care guideline for pediatric drug ingestion hospital admissions.

Methods:

A multidisciplinary committee developed specific telemetry guidelines for pediatric drug ingestion hospital admissions at a tertiary pediatric hospital. The guidelines stipulated inpatient admission with telemetry monitoring for the following criteria: (1) corrected QT interval (interval between the Q wave and T wave on a standard EKG)≥ 500 ms, (2) ingestion of an antiarrhythmic medication, or (3) ingestion of a tricyclic antidepressant. We created guidelines for electrocardiogram frequency for nontelemetry admissions. We implemented these guidelines in November 2015 in partnership with the Emergency Medicine Department and Poison Control Center. We reviewed medical records of all these admissions between January 1, 2015, and July 31, 2016, and divided patients into preintervention (January 1, 2015 to November 30, 2015) and postintervention (December 1, 2015 to July 31, 2016) groups. We used statistical process control charts and methodology to monitor changes over time.

Results:

There were a total of 622 drug ingestion admissions during the study period. We admitted 69 patients (11%) to the cardiac acute care unit (CACU) for telemetry monitoring. The preintervention period included 61 admissions (5.5 CACU admissions per month). The postintervention period included 8 admissions (1.1 CACU admissions per month). This difference reflects an overall absolute decrease of 87%. There was no evidence of an increase in the rate of intensive care unit utilization, rapid response events, or adverse events in the postintervention period.

Conclusions:

A standardized admission protocol for pediatric drug ingestions can safely improve resource utilization.
Next-of-Kin Involvement in Regulatory Investigations of Adverse Events That Caused Patient Death: A Process Evaluation (Part II: The Inspectors’ Perspective)
Authors: Wiig Siri , Schibevaag Lene , Tvete Zachrisen Rannveig , Hannisdal Einar , Anderson Janet E. , Haraldseid-Driftland Cecilie
Published: October 2019

Objective

The aim of the study was to explore regulatory inspectors’ experiences with a new method for next-of-kin involvement in investigation of adverse events causing patient death. A resilient healthcare perspective is used as the theoretical foundation.

Methods

The study design was a qualitative process evaluation of the new involvement method in 2 Norwegian counties. Next of kin, who had lost a close family member in an adverse event, were invited to a 2-hour face-to-face meeting with the inspectors. Data collection involved 3 focus group interviews with regulatory inspectors and observation (20 hours) of the meetings (2017–2018). Data were analyzed by a thematic content analysis.

Results

Next-of-kin involvement informed the investigations by additional and new information about the adverse events and by different versions of the investigators’ earlier obtained information, such as time sequences, what happened and how, and who were involved. Inspectors considered next of kin as a key source of information that contributed to improve the quality of the investigation. The downside was that the involvement method increased work load and could challenge the principle of equal treatment in regulatory practice.

Conclusions

Involvement of next of kin in regulatory investigation of adverse events causing patient death contributes to a better understanding of work as done in clinical practice and contributes to strengthen the learning potential in resilience.
The Great Mimicker—Tuberculosis Involving Prostate and Vertebrae Posing as Metastatic Prostate Carcinoma on FDG PET/CT
Authors: Joshi Prathamesh Vijay , Shewalkar Balaji , George Thomas , Sahasrabudhe Shrikant , Joshi Sujit , Kulkarni Mukta
Published: October 2019

A 65-year-old man underwent FDG PET/CT for evaluation of vertebral lesions, radiologically suspected to be metastases. The scan showed hypermetabolism in D8 to D9 vertebrae, retroperitoneal lymph nodes, and both the lobes of prostate. Transrectal ultrasound-guided biopsy of prostate was performed with suspicion of prostate malignancy. The biopsy revealed caseating granulomatous lesions in prostate suggestive of tuberculosis. Post antitubercular treatment patient showed excellent clinical response. Possibility of infective pathologies mimicking malignancy should be kept in mind while evaluating hypermetabolic foci seen on PET/CT. Although rare, tuberculosis of prostate needs consideration in differential diagnosis of FDG-avid foci seen in prostate.
Nasal Reconstruction With Two Stages Versus Three Stages Forehead Fap: What is Better for Patients With High Vascular Risk?
Authors: Lo Torto Federico , Redi Ugo , Cigna Emanuele , Losco Luigi , Marcasciano Marco , Casella Donato , Ciudad Pedro , Ribuffo Diego
Published: October 2019

In nasal reconstruction, it is necessary to replace all anatomic layers in order to reinstate correct aesthetics. The most apt donor site to use in order to cover the nose has been recognized as forehead skin. Traditionally 2 phases are required to reconstruct the forehead flap; however, an intermediate third phase was described by Millard which is between transfer of the flap and division of the pedicle. These methods will be compared in this study with regard to both complication rates and aesthetic results in high vascular risk patients.

46 patients were enrolled in the study, all of whom were undergoing either total or subtotal nasal reconstruction from January 2001 to March 2018. The 2-step technique (2S Group) was performed on 30 patients and the 3-step technique (3S Group) was performed on 16. Evaluation questionnaires were completed by patients and a plastic surgeon who was extraneous to the study to evaluate aesthetic satisfaction. Complications other than flap necrosis such as infection, wound dehiscence and hematoma were recorded. VAS and Likert mean values, used to evaluate aesthetic satisfaction, were examined with a Student t test and were discovered to be relevant. Complication rates studied with Fisher exact test showed no statistically significant difference between the 2 groups. The 3-phase method for nose reconstruction using a forehead flap represents a better functional and aesthetic option for patients at high vascular risk.