bluuebunny/crossref_metadata_2025 huggingface dataset:
IMPACT OF MACULAR INTRARETINAL HEMORRHAGE AND MACULAR HOLE ON THE VISUAL PROGNOSIS OF SUBMACULAR HEMORRHAGE DUE TO RETINAL ARTERIAL MACROANEURYSM RUPTURE
Authors: Doi Shinichiro , Kimura Shuhei , Saito Shoko , Inoue Makoto , Sakurai Toshiya , Kobori Akira , Hisatomi Toshio , Imai Hisanori , Kuriyama Shoji , Takasu Ippei , Hosokawa Mio Morizane , Shiode Yusuke , Matoba Ryo , Suzuki Etsuji , Morizane Yuki
Published: February 2023

Purpose:

To compare the effects of macular intraretinal hemorrhage (IRH) and macular hole (MH) on best-corrected visual acuity (BCVA) after displacement of submacular hemorrhage (SMH) due to retinal arterial macroaneurysm (RAM) rupture.

Methods:

This multicenter retrospective study included 48 eyes with SMH due to RAM rupture. Cases underwent vitrectomy to displace SMH and were followed up for 6 months. We classified cases according to the presence of IRH and MH and compared the postoperative BCVA among the groups.

Results:

We classified the eyes into IRH(+)MH(+) group (10 eyes), IRH(+)MH(−) group (23 eyes), and IRH(−)MH(−) group (15 eyes). The postoperative BCVA was significantly worse in the IRH(+)MH(+) and IRH(+)MH(−) groups than in the IRH(−)MH(−) group (0.91 ± 0.41 in logarithm of the minimal angle of resolution units, Snellen equivalent 20/163, 0.87 ± 0.45, 20/148, and 0.18 ± 0.21, 20/30, respectively; P < 0.001). The postoperative central retinal thickness was significantly lower in the IRH(+) group (IRH(+)MH(+) and IRH(+)MH(−) groups combined) than in the IRH(−) group (IRH(−)MH(−) group) (121.4 ± 70.1 µm and 174.3 ± 32.9 µm, respectively, P = 0.008). The postoperative external limiting membrane and ellipsoid zone continuities were significantly discontinuous in the IRH(+) group (P < 0.001, P = 0.001, respectively). The multiple linear regression analysis showed that both IRH(+)MH(+) and IRH(+)MH(−) were associated with the postoperative BCVA (regression coefficient, 0.799 and 0.711, respectively; P < 0.001 for both).

Conclusion:

Both IRH and MH were poor prognostic indicators in cases with SMH due to RAM rupture.
HISTOPLASMA CAPSULATUM PACEMAKER–RELATED ENDOCARDITIS PRESENTING AS ENDOGENOUS ENDOPHTHALMITIS
Authors: Chen Cindy , Morillas Jose A. , Rehm Susan J. , Taege Alan J. , Tan Carmela , Popovic Zoran , Baynes Kimberly , Srivastava Sunil K.
Published: February 2023

Background/Purpose:

To report a unique case of pacemaker-related infective endocarditis manifesting as endogenous endophthalmitis with chorioretinitis secondary to Histoplasma capsulatum.

Methods:

Case report.

Results:

A 75-year-old man was diagnosed with blood culture-negative infective endocarditis and was admitted with deteriorating vision and ocular inflammation. Examination of the eye indicated significant vitreous inflammation and retinitis. Vitreous cultures were negative, but universal fungal polymerase chain reaction of the vitreous fluid was positive for H. capsulatum. Histopathology of the fibrous cuff around the extracted right atrial lead demonstrated hyphal and yeast forms and polymerase chain reaction of this material identified H. capsulatum. Despite aggressive antifungal and surgical treatment, the eye became phthisical.

Conclusion:

We highlight the importance of considering H. capsulatum in the differential diagnosis of endogenous endophthalmitis, particularly among patients from endemic areas who present with possible endovascular infection.
Principles behind SLE treatment with N-acetylcysteine
Authors: Nasr Sandy , Perl Andras
Published: February 2023

Systemic lupus erythematous (SLE) is a multisystem chronic autoimmune disease in which disrupted molecular pathways lead to multiple clinical manifestations. Currently approved treatments include hydroxychloroquine, some immunosuppressive medications, and some biologics. They all come with a range of side effects. N-acetylcysteine (NAC) is an antioxidant that has shown potential benefits in SLE patients without having major side effects. The following review highlights the molecular mechanisms behind the therapeutic effect of NAC in SLE patients. A higher-than normal mitochondrial transmembrane potential or mitochondrial hyperpolarization (MHP) was found in lymphocytes from SLE patients. MHP is attributed the blocked electron transport, and it is associated with the depletion of ATP and glutathione and the accumulation of oxidative stress-generating mitochondria due to diminished mitophagy. Comprehensive metabolome analyses identified the accumulation of kynurenine as the most predictive metabolic biomarker of lupus over matched healthy subjects. Cysteine is the rate-limiting constituent in the production of reduced glutathione, and it can be replaced by its precursor NAC. Kynurenine accumulation has been reversed by treatment with NAC but not placebo in the setting of a double-blind placebo-controlled clinical trial of 3-month duration. Mitochondrial oxidative stress and its responsiveness to NAC have been linked to systemic inflammation, gut microbiome changes, and organ damage in lupus-prone mice. Given the unique safety of NAC and chronicity of SLE, the clinical trial of longer duration is being pursued.
Cytokine and metabolic regulation of adipose tissue Tregs
Authors: Elkins Cody , Li Chaoran
Published: February 2023

Since their discovery over a decade ago, much has been learned regarding the importance and function of visceral adipose tissue (VAT)-resident regulatory T cells (Tregs). VAT Tregs play a critical role in controlling VAT inflammation and alleviating metabolic disease. However, this population is disrupted in obesity which exacerbates VAT inflammation and metabolic abnormalities. Therefore, understanding the factors governing the accumulation and maintenance of VAT Tregs, both at steady state and under disease conditions, is crucial for identifying the mechanisms underlying obesity-associated metabolic disease and developing novel therapies. Expansion and maintenance of the VAT Treg compartment is strongly influenced by factors in the local tissue microenvironment, including cytokines, T-cell receptor ligands, hormones, and various metabolites. This mini-review will primarily focus on recent advances in our understandings regarding the regulation of mouse epididymal VAT (eVAT) Tregs, which are the most thoroughly characterized VAT Treg population, by tissue microenvironmental factors and cellular metabolic processes. We will also briefly discuss the limited knowledge available regarding the regulation of mouse ovarian VAT (oVAT) Tregs and human omental VAT Tregs, highlight some lingering questions, and provide a prospective view on where the field is heading.
Cryptococcoma Presenting as a Central Nervous System Mass in an Immunocompetent Patient
Authors: Vasiloudes Kritos , Trivedi Shivani , Brown Alyssa , Garcia Cristina
Published: February 2023

Cryptococcus neoformans and Cryptococcus gattii are rare fungal pathogens that typically present in immunocompromised patients making it a rare differential diagnosis in an immunocompetent patient. We present a case of an immunocompetent 39-year-old patient who was diagnosed with a central nervous system cryptococcoma from a biopsy pathology report that was originally evaluated for high-grade glioma. Subsequently, the patient underwent lumbar puncture with cerebrospinal fluid analysis that indicated an active central nervous system infection. Although this patient's diagnosis and management of cryptococcosis did not unfold in a traditional manner, combination of surgical resection and antifungal therapy completely resolved his neurological symptoms.
Panophthalmitis in Patient With Dengue Hemorrhagic Fever
Authors: Mathur Mohit , Shukla Ashutosh , Khurana Saurbhi , Gera Ravinder Kumar , Garg Vivek
Published: February 2023

Dengue fever can lead to serious complications of severe bleeding, massive capillary leakage causing dengue shock syndrome and vital organ involvement. Ocular manifestations in dengue fever are rare but may sometimes lead to permanent disability. Here we report a case of rare complication of dengue fever in a 35-year-old man presenting with panophthalmitis, leading to rapidly progressive and painful visual loss. With this case, it can be emphasized that early identification and management of dengue complication may prevent vision loss.
Clozapine
Authors: Flanagan Robert James , Hunter Samora , Obee Stephen John , Reeves Suzanne
Published: February 2023

Background

Guidance on clozapine dosing in treatment refractory schizophrenia is based largely on data from young adult male White patients.

Aim

This study aimed to audit the plasma clozapine and N-desmethylclozapine (norclozapine) concentrations attained in male and female patients of different ethnicity and smoking habit.

Method

The effect of dose, sex, ethnicity, age, body weight, and smoking habit on plasma clozapine and norclozapine concentrations were studied using data from a therapeutic drug monitoring service, 1993 to 2017.

Results

There were 371,610 samples (48,098 patients, 32,855 male). Ethnicity was recorded for 763 Afro-Caribbean, 536 Asian, and 7940 White patients. Males were prescribed significantly higher median doses than females but attained significantly lower median plasma clozapine and norclozapine concentrations. Asian and Afro-Caribbean males were prescribed significantly lower and higher median doses, respectively, than White males but attained significantly higher and lower median plasma clozapine and norclozapine concentrations, respectively. Data from 78,431 samples (23,516 patients) were analyzed using a linear mixed model. The predicted dose to attain a predose plasma clozapine concentration of 0.35 mg/L in a nonsmoking White male aged 40 years, with weight of 70 kg, and plasma clozapine-norclozapine ratio of 1.32 was 344 mg/d (95% confidence interval, 227–526 mg/d). The predicted dose was 33% higher and 20% lower in otherwise analogous Afro-Caribbean and Asian patients, respectively. In all cases, the predicted dose was increased by 36% in smokers and decreased by 22% in females.

Conclusions

Research is needed to further investigate the complex relationships between dose, sex, ethnicity, plasma clozapine and norclozapine concentrations, and clinical outcome such as weight gain.
Improving glucose control in patients with type 2 diabetes using retrospective continuous glucose monitoring
Authors: Diamond Katlyn
Published: February 2023

Background:

The prevalence and cost of type 2 diabetes mellitus (T2DM) is rising. Diabetes care should be individualized based on patient risk factors and goals. Professional continuous glucose monitoring (CGM) is a tool for primary care providers to assist patients with diabetes management.

Local Problem:

Nurse practitioners at an outpatient primary care practice began using CGM in patients with T2DM in 2019 to guide treatment due to the high number of patients not reaching glucose targets. There was no policy in place to guide patient selection for CGM.

Methods:

This quality improvement (QI) project, conducted in an outpatient primary care clinic, evaluated the effect of retrospective CGM use in patients with T2DM through a retrospective chart review to create a policy for use.

Interventions:

Hemoglobin A1c (HbA1c) measurements pre-CGM and post-CGM use were compared. CGM reports were evaluated for the presence of hypoglycemia. Additionally, number of times a patient used CGM between HbA1c laboratory examinations as well as insulin status were determined by reviewing the electronic health record.

Results:

Patients using CGM for HbA1c higher than goal (n = 60) noted a 1.01% decrease in HbA1c (p < .01). The decrease was similar regardless of exogenous insulin status. Hypoglycemia was detected in 54.3% of patients (n = 44), including 45% (n = 27) of those with elevated HbA1c levels.

Conclusions:

Retrospective CGM is a cost-effective tool to individualize management of patients with T2DM in primary care. A policy was created to guide CGM use in patients not reaching glucose goals and those with concern for hypoglycemia.
Nursing care of a patient with rupture and bleeding of cystic artery pseudoaneurysm
Authors: Wang Changshuai , Yi Dan , Jiang Yu , Zhang Shuang , Gao Yan , Fu Xiaochen , Zhao Lijing
Published: February 2023

Rationale:

Biliary bleeding, a rare cause of upper gastrointestinal bleeding, is rarely caused by cystic artery pseudoaneurysms. In this article, a case of abdominal hemorrhage caused by a ruptured cystic artery pseudoaneurysm is reported and its main nursing measures are outlined.

Patient concerns:

A 50-year-old man was admitted to the emergency room with intermittent pain in the right upper abdomen lasting for a month that had become worse for 1 day.

Diagnosis:

The main manifestations included pain in the right upper abdomen, rebound pain, and muscle tension. Celiac angiography revealed an aneurysm of the cystic artery. Imaging revealed a hematoma in and around the duodenum. Nursing evaluation revealed a painful face, elevated body temperature, and moist skin with a potential risk of shock. The diagnosis was ruptured and bleeding of a cystic artery pseudoaneurysm.

Interventions:

The patient underwent cholecystic artery embolization under local anesthesia, followed by ultrasound-guided gallbladder puncture, drainage, and cholecystectomy carried out successively. Accurate nursing care was provided to the patient for delirium, paralytic intestinal obstruction, septic shock, and thrombus during hospitalization.

Outcomes:

The patient was hospitalized for a total of 20 days, discharged after careful treatment and care, and followed-up by nurses by telephone once a month for half a year.

Lessons:

Although rupture and bleeding of cystic artery pseudoaneurysms are rare, they can cause complications that may occur quickly and even threaten life. Therefore, it is necessary to carefully observe changes in the patient condition during the nursing process and provide comprehensive and high-quality care to promote patient recovery.
Isolated right oculomotor nerve palsy as the first presenting manifestation of metastatic renal Ewing’s sarcoma
Authors: Al-Mashdali Abdulrahman F. , Naser Mohammad S. , Murshed Khaled , Aakel Hassan , Shablak Alaaeldin
Published: February 2023

Introduction:

Extraskeletal Ewing’s sarcoma is a rare malignancy in the adult population, and its primary renal involvement is even rarer. Renal Ewing’s sarcoma is often metastatic at the initial presentation and has a poor prognosis.

Patient concern:

We present the case of a 53-year-old Filipino woman who presented to our emergency department with acute right oculomotor nerve palsy.

Diagnosis:

Imaging revealed metastatic lesions involving the skull and vertebra as well as the presence of a left kidney mass. Renal biopsy result of the kidney confirmed the diagnosis of renal Ewing's sarcoma.

Intervention:

The patient was started on doxorubicin, vincristine, and cyclophosphamide, alternating with ifosfamide and etoposide.

Outcomes:

The patient developed severe adverse effects from chemotherapy and died 4 months after diagnosis.

Conclusion:

To our knowledge, this is the first case of renal Ewing’s sarcoma that initially presented with neurological manifestations secondary to bone metastasis in the absence of any urological manifestations, such as flank pain or hematuria.
A case report of multiple Mycobacterium Kansasii bone infection with pathological fracture of T11 vertebral body and thoracic spinal cord injury
Authors: Sun Kui , Wang Weiqun , Chen Deyuan , Xu Yaoning , Chi Weidong , Huang Fuli , Zhou Xingmao
Published: February 2023

Rationale:

Cases of vertebral infection with bone destruction and spinal cord injury caused by Mycobacterium kansasii infection are rarely reported, and the infection is usually associated with severe immunosuppression.

Patient concerns:

A 62-year-old male patient was hospitalized for 10 days due to recurrent low back pain with diminished skin sensation below the umbilical level.

Diagnosis:

The patient had no underlying disease. MRI showed multiple bone destruction lesions throughout the body, pathological fractures of the T11 vertebral body, and compression and degeneration of the thoracic spinal cord. Complete back abscess puncture examination, CT-guided vertebral puncture examination, metagenomic next-generation sequencing and bone marrow puncture and other examinations to confirm the diagnosis of Mycobacterium kansasii infection.

Intervention:

According to the drug susceptibility test of pathogenic bacteria, combined antiinfective treatment was given. After 3 weeks of drug treatment, the patient underwent thoracic posterior debridement, spinal canal decompression, and pedicle screw internal fixation.

Outcome:

The skin sensation of the patient’s lower limbs was improved 1 month after the operation compared with that before the operation. After adhering to oral drug treatment, the inflammatory index decreased steadily. Four months after the operation, the skin sensation of the patient’s lower extremities returned to normal.

Lessons:

Regular, adequate, and full course of drug treatment is the key to the treatment of Mycobacterium kansasii infection. Next-generation metagenomic sequencing can improve the efficiency and accuracy of the detection of Mycobacterium kansasii. For patients with abscesses and spinal nerve compression, surgical decompression and abscess removal are effective treatment options.
Usefulness of inhaled iloprost in managing exercise-induced pulmonary hypertension in a patient with systemic sclerosis-associated interstitial lung disease
Authors: Kinoshita Natsu , Nawata Takashi , Mochizuki Mamoru , Asami-Noyama Maki , Wada Yasuaki , Yano Masafumi
Published: February 2023

Rationale:

Inhaled iloprost has been used as a selective pulmonary vasodilator in the treatment of pulmonary arterial hypertension; however, it is unclear whether it is an effective treatment for exercise-induced pulmonary hypertension (PH).

Patient concerns:

A 66-year-old Japanese woman with systemic sclerosis-associated interstitial lung disease presented with dyspnea, worsening during exertion.

Diagnosis:

Overlap of exercise-induced PH and group 3 PH.

Interventions:

Inhaled iloprost was administrated.

Outcomes:

Exercise echocardiography revealed that inhaled iloprost therapy improved her exercise-induced PH.

Conclusion:

Exercise echocardiography and inhaled iloprost revealed that the patient’s PH included both group 3 and group 1 PH. This case suggests that a combination of exercise echocardiography and inhaled iloprost may be useful in distinguishing patients with systemic sclerosis-associated interstitial lung disease in whom group 1 and group 3 PH overlap. In addition, this method might also be useful for determining the therapeutic effects of iloprost.
Synchronous tongue squamous cell carcinoma and papillary thyroid carcinoma with Collision metastasis to a single cervical lymph node
Authors: Fareed Ahmed M. , Awny Shady , Ali Khadiga M. , Atallah Khalid , Sallam Abdel Aziz A. , Abdellattif Ahmed M. , Zaid Amir M. , Hegazy Mohamed A.F.
Published: February 2023

Introduction:

The frequency of synchronous malignant tumors in patients with squamous cell carcinoma (SCC) of the oral tongue is relatively low (2%), with the oral cavity being the most frequent secondary site, followed by the pharynx.[1] Collision tumors are defined as 2 histologically distinct neoplasms that originate from topographically separate primaries, and abut and intermix with 1 another. The main site for intermixing of 2 tumors is the lymph node. There are no areas of transition between the 2 tumors. However, collision tumors can be summarized as tumor-to-tumor metastasis with exceedingly rare incidence.[1] Proper treatment of the thyroid gland is debatable when metastatic papillary thyroid carcinoma is incidentally encountered during neck dissection for the index treatment of primary SCC of the oral tongue, considering the good prognosis for thyroid cancer and the difficulty to find the primary tumor.[2]

Case report:

We report a 28 years old woman with synchronous tongue squamous cell carcinoma and papillary thyroid carcinoma, with a lymph node containing metastasis from both tumors (collision node).

Conclusion:

Although the extreme rarity of this synchronous tumor may make it impossible to draw a significant conclusion regarding proper treatment of thyroid disease, it is important to be aware that even when primary head and neck SCC is at an advanced stage, a cure is possible. Active management of the thyroid carcinoma should be considered because it may affect prognosis, as in the present case.
Does prophylactic local tobramycin injection lower open fracture infection rates?
Authors: Aneja Arun , Kavolus Matthew W. , Teasdall Robert J. , Sneed Chandler R. , Pectol Richard W. , Isla Alexander E. , Stromberg Arnold J. , Obremskey William
Published: February 2023

Objective: To determine whether local aqueous tobramycin injection in combination with systemic perioperative IV antibiotic prophylaxis will reduce the rate of fracture-related infection (FRI) after open fracture fixation.

Other Outcomes of Interest: (1) To compare fracture nonunion rates and report differences between treatment and control groups and (2) compare bacterial speciation and antibiotic sensitivity among groups that develop FRI.

Design: Phase 3 prospective, randomized clinical trial.

Setting: Two level 1 trauma centers.

Participants: Six hundred subjects (300 in study/tobramycin group and 300 in control/standard practice group) will be enrolled and assigned to the study group or control group using a randomization table. Patients with open extremity fractures that receive definitive internal surgical fixation will be considered.

Intervention: Aqueous local tobramycin will be injected into the wound cavity (down to bone) after debridement, irrigation, and fixation, following closure.

Main Outcome Measurements: Outcomes will look at the presence or absence of FRI, the rate of fracture nonunion, and determine speciation of gram-negative and Staph bacteria in each group with a FRI.

Results: Not applicable.

Conclusion: The proposed work will determine whether local tobramycin delivery plus perioperative standard antibiotic synergism will minimize the occurrence of open extremity FRI.

Level of Evidence: Level 1.
Usage of orthopaedic trauma registries among members of the International Orthopaedic Trauma Association: How are we doing?
Authors: Nguyen Mai P. , Paull Thomas Z. , Miclau Theodore , Marmor Meir T. ,   on behalf of the International Orthopaedic Trauma Association
Published: February 2023

Introduction: The use of national databases for orthopaedic research has increased significantly in the past decade. The purpose of this study was to report on the current state of orthopaedic trauma registries in 21 countries represented by 20 member societies of the International Orthopaedic Trauma Association (IOTA).

Methods: A web-based survey was circulated to all IOTA member societies. The survey consisted of 10 questions (five open-ended and five multiple-choice).

Results: Representatives from all 21 countries replied. Five countries (24%) do not currently have or plan to start a registry. One country (5%) had a registry that is now closed. Two countries (10%) are building a registry. Thirteen countries (62%) reported at least one active registry, including four countries with more than one registry. Of the 14 countries that reported the existence of a registry, there were 17 registries noted that included patients with fracture. There were seven registries dedicated to high-energy trauma and four registries that included elderly hip fractures. In addition, 9/17 representatives reported the utilization of a fracture classification and 9/17 noted some level of mandate from medical providers. All responders but one reported that data were manually entered into their registries.

Conclusions: Despite the shared vision of quality control and outcome optimization, IOTA society representatives reported significant variability in the depth and format of the orthopaedic trauma registry among IOTA members. These findings represent an opportunity for collaboration across organizations in creating fracture registries.

Level of Evidence: Level IV.
Change in Gustilo-Anderson classification at time of surgery does not increase risk for surgical site infection in patients with open fractures: A secondary analysis of a multicenter, prospective randomized controlled trial
Authors: Axelrod Daniel , Comeau-Gauthier Marianne , Prada Carlos , Bzovsky Sofia , Heels-Ansdell Diane , Petrisor Brad , Jeray Kyle , Bhandari Mohit , Schemitsch Emil , Sprague Sheila ,   on behalf of the FLOW Investigators
Published: February 2023

Introduction:

Open fractures represent a major source of morbidity. Surgical site infections (SSIs) after open fractures are associated with a high rate of reoperations and hospitalizations, which are associated with a lower health-related quality of life. Early antibiotic delivery, typically chosen through an assessment of the size and contamination of the wound, has been shown to be an effective technique to reduce the risk of SSI in open fractures. The Gustilo-Anderson classification (GAC) was devised as a grading system of open fractures after a complete operative debridement of the wound had been undertaken but is commonly used preoperatively to help with the choice of initial antibiotics. Incorrect preoperative GAC, leading to less aggressive initial management, may influence the risk of SSI after open fracture. The objectives of this study were to determine (1) how often the GAC changed from the initial to definitive grading, (2) the injury and patient characteristics associated with increases and decreases of the GAC, and (3) whether a change in GAC was associated with an increased risk of SSI.

Methods:

Using data from the FLOW trial, a large multicenter randomized study, we used descriptive statistics to quantify how frequently the GAC changed from the initial to definitive grading. We used regression models to determine which injury and patient characteristics were associated with increases and decreases in GAC and whether a change in GAC was associated with SSI.

Results:

Of the 2420 participants included, 305 participants had their preoperative GAC change (12.6%). The factors associated with upgrading the GAC (from preoperative score to the definitive assessment) included fracture sites other than the tibia, bone loss at presentation, width of wound, length of wound, and skin loss at presentation. However, initial misclassification of type III fractures as type II fractures was not associated with an increased risk of SSI (P = 0.14).

Conclusions:

When treating patients with open fracture wounds, surgeons should consider that 12% of all injuries may initially be misclassified when using the GAC, particularly fractures that have bone loss at presentation or those located in sites different than the tibia. However, even in misclassified fractures, it did not seem to increase the risk of SSI.
The Deterioration Risk Index: Developing and Piloting a Machine Learning Algorithm to Reduce Pediatric Inpatient Deterioration*
Authors: Rust Laura O. H. , Gorham Tyler J. , Bambach Sven , Bode Ryan S. , Maa Tensing , Hoffman Jeffrey M. , Rust Steven W.
Published: February 2023

OBJECTIVES:

Develop and deploy a disease cohort-based machine learning algorithm for timely identification of hospitalized pediatric patients at risk for clinical deterioration that outperforms our existing situational awareness program.

DESIGN:

Retrospective cohort study.

SETTING:

Nationwide Children’s Hospital, a freestanding, quaternary-care, academic children’s hospital in Columbus, OH.

PATIENTS:

All patients admitted to inpatient units participating in the preexisting situational awareness program from October 20, 2015, to December 31, 2019, excluding patients over 18 years old at admission and those with a neonatal ICU stay during their hospitalization.

INTERVENTIONS:

We developed separate algorithms for cardiac, malignancy, and general cohorts via lasso-regularized logistic regression. Candidate model predictors included vital signs, supplemental oxygen, nursing assessments, early warning scores, diagnoses, lab results, and situational awareness criteria. Model performance was characterized in clinical terms and compared with our previous situational awareness program based on a novel retrospective validation approach. Simulations with frontline staff, prior to clinical implementation, informed user experience and refined interdisciplinary workflows. Model implementation was piloted on cardiology and hospital medicine units in early 2021.

MEASUREMENTS AND MAIN RESULTS:

The Deterioration Risk Index (DRI) was 2.4 times as sensitive as our existing situational awareness program (sensitivities of 53% and 22%, respectively; p < 0.001) and required 2.3 times fewer alarms per detected event (121 DRI alarms per detected event vs 276 for existing program). Notable improvements were a four-fold sensitivity gain for the cardiac diagnostic cohort (73% vs 18%; p < 0.001) and a three-fold gain (81% vs 27%; p < 0.001) for the malignancy diagnostic cohort. Postimplementation pilot results over 18 months revealed a 77% reduction in deterioration events (three events observed vs 13.1 expected, p = 0.001).

CONCLUSIONS:

The etiology of pediatric inpatient deterioration requires acknowledgement of the unique pathophysiology among cardiology and oncology patients. Selection and weighting of diverse candidate risk factors via machine learning can produce a more sensitive early warning system for clinical deterioration. Leveraging preexisting situational awareness platforms and accounting for operational impacts of model implementation are key aspects to successful bedside translation.
Optimizing Resident Education during Family-centered Rounds: An Educational Improvement Initiative
Authors: Calardo Sarah J. , Tomlinson Lesya , Bhatia Darshita , Weis Amy , Port Courtney
Published: February 2023

Introduction:

Family-centered rounding (FCR) allows the medical team to partner with patients in medical decision-making, improving communication, and enhancing safety. However, FCR may compromise aspects of the resident education experience. In a survey of pediatric residents at our children’s hospital, only 20% felt FCR provided the best educational experience. We designed this project to increase the percentage of residents with a positive perception of the educational experience on FCR from 20% to 80% in 6 months.

Methods:

This project utilized The Model for Improvement and sequential plan-do-study-act cycles. A needs assessment identified educational activities negatively impacted by FCR. We then designed a hybrid FCR process with formal presentations outside patient rooms followed by traditional bedside FCR. Our primary measure was the percentage of residents positively perceiving the FCR educational experience. Our balancing measures included rounding duration and family satisfaction and comprehension.

Results:

Residents who perceive FCR to be the best educational experience improved from a baseline of 21% to 76%, with a calculated response rate of 79%. Patients receiving FCR remained above 80%. All surveyed families understood their care plans and remained satisfied with the information provided, although 21% were concerned about the number of people present on rounds during the COVID-19 pandemic. Forty-three percent of hospitalist rounds exceeded the allotted time.

Conclusions:

The hybridization of FCR to include formal presentations may improve the resident learning experience while preserving family satisfaction and comprehension.
Endotracheal Tube Cuff Pressures in the Operating Room of a Pediatric Hospital: A Quality Improvement Initiative
Authors: Moon Kelly M. , Donaworth Sherry , Hagele Molly S. , Kim Stephani S. , Willer Brittany L. , Tobias Joseph D.
Published: February 2023

Introduction:

Endotracheal tube (ETT) cuff pressures are frequently out of the recommended range of 20–30 cm H2O. This can lead to multiple iatrogenic complications ranging from cough, sore throat, and tracheal edema to more serious medical issues such as tracheal stenosis, aspiration, nerve injuries, and tracheal rupture. Additionally, current methods to inflate ETT cuffs vary between anesthesia providers and are not consistent in the recommended range. The objective of this quality improvement project was to increase the percentage of cuff pressures between 20 and 30 cm H2O.

Methods:

Four plan-do-study-act (PDSA) cycles were completed in the operating rooms at Nationwide Children’s Hospital over 9 months to assess ways to improve the accuracy of obtaining recommended ETT cuff pressures. Control charts were used to evaluate the primary outcome measure.

Results:

Preimplementation, ETT cuff pressures were out of the recommended range 76% of the time. Cuff pressures were out of the recommended range 64% of the time with the addition of the air method, 84% of the time in the tidal volume ratio cycle, and 50% of the time using the removal of air technique. The removal of air method was the most effective in achieving cuff pressures within the recommended pressure range (P < 0.001).

Conclusions:

Using quality improvement methodology, the percentage of ETT cuff pressures falling within the recommended pressure range increased using the removal of air technique. This approach is a simple and practical method that can be easily implemented in the clinical setting and would provide additional safety in the anesthetic management of pediatric patients.
A Quality Improvement Initiative to Improve After-visit Summary Distribution in Orthopedic Outpatient Clinics
Authors: Williamson Jayme , Holstine Jessica , Balch Samora Julie
Published: February 2023

Introduction:

Communication and patient education are key to effective healthcare encounters and improved health outcomes. The after-visit summary (AVS) is an integral communication and education tool for patients and families. Without effective communication, gaps in comprehension may result in decreased satisfaction with medical encounters, lack of adherence to recommended treatment plans, missed appointments, and increased malpractice claims.

Methods:

We initiated a quality improvement (QI) initiative implementing concepts derived from the Institute for Healthcare Improvement (IHI) model, including plan-do-study-act cycles, to increase AVS distribution rates in a high-volume, fast-paced ambulatory pediatric orthopedic clinic. Interventions included staff education and training, trainee instruction, enlistment of electronic medical record superusers to enhance the distribution process, and provision of regular, transparent communication of individual and team performance. The impact of interventions was measured using a p-chart.

Results:

There was a consistent improvement in the rate of AVS distribution with each intervention implemented. The distribution rate on project initiation was 81.9%, with a final rate of 95.7%. The most statistically significant shift occurred following the final intervention, which included sharing unblinded individual performance data.

Conclusion:

Our data demonstrate that a dedicated QI program using IHI methodology improved AVS distribution rates in a pediatric orthopedic clinic. Consistently distributing the AVS affords our patients and families a better opportunity to review pertinent visit information, education, medication changes, and upcoming appointments.
Arriving Safely: Decreasing Rapid Escalations in Care for Incoming Transported Pediatric Patients
Authors: Zheng Christie , Gibson Cynthia , Jeong Hyungjoo , Port Courtney
Published: February 2023

Introduction:

Accurate inpatient placement at the level of care needed for incoming transported patients can present challenges that may result in a rapid escalation in care following admission to the general inpatient unit. The Pediatric Early Warning System (PEWS) score is useful for early recognition of clinical deterioration. Therefore, we aimed to reduce rapid escalations in care for incoming transported patients via the implementation of an escalation algorithm with a goal of 80% PEWS score completion rate during transport within 6 months.

Methods:

We created an escalation algorithm utilizing PEWS scores and direct lines of communication between emergency medical technicians and receiving physicians. Audit and feedback increased the adoption of the process. We defined rapid escalations as transfer to a higher level of care within 6 hours of admission.

Results:

PEWS score completion increased from a mean of 48% to 70%. This result varied by emergency medical technician crew level of care. Eleven percent (n = 114) of PEWS scores required physician notification, 20% (n = 23) of which resulted in interventions en route. There were no differences in rapid escalation rates over time, but it remained low at <2% of all incoming transported patients. Some crew members report improved communication with hospital providers and feel more empowered to speak up when a patient’s assessment is not as expected following algorithm implementation.

Conclusions:

This project improved PEWS score completion and maintained a low rate of rapid escalations of care among incoming transfers.
Key Drivers Associated with Effective Sepsis Care on a Surgical Unit
Authors: Koehler Richele , Burke Meghan , Rolison Elise , Newman Jennifer , Lockwood Justin M
Published: February 2023

Background:

In 2020, we observed an increase in inpatient postoperative patient deteriorations. Preliminary case reviews suggested gaps in sepsis care.

Objectives:

To identify key drivers associated with effective care escalation and sepsis care in the inpatient surgical setting as part of the initial planning phase of a large improvement initiative.

Methods:

Our multidisciplinary team included surgical nurses, surgical providers, medical providers, patient safety experts, subject matter experts in pediatric sepsis, and subject matter experts in escalation of care. This team formally reviewed cases involving postoperative deterioration to identify causes of gaps in sepsis care and applied its learnings to the development of a key driver diagram. Themes from the key driver diagram included (1) Enhance recognition of deterioration and subsequent escalation of care and (2) Optimize postoperative patient placement. The team hosted a mini-Kaizen event with frontline team members focused on the first theme, the output of which included consensus agreement on two focus areas (Escalation Chain of Command & Shared Situation Awareness) and a fishbone diagram to identify/prioritize opportunities in postoperative care escalation.

Results:

Causes of gaps in sepsis care included barriers to care escalation that could limit generalizability of sepsis resources to the inpatient surgical setting. Figure 1 shows the key driver diagram.

Conclusion:

We aim to highlight challenges associated with postoperative sepsis care in an inpatient pediatric surgical setting.
Value Added from Same-day Discharge after Appendectomy for Children with Simple Appendicitis
Authors: Juviler Peter , Wilson Nicole A. , Livingston Michael H. , Levatino Elizabeth , Bowden Acacia , Meyers Jeffrey M. , Tesini Brenda , Gleason Cassandra , Pegoli Walter , Arca Marjorie J. , Wakeman Derek
Published: February 2023

Introduction:

Same-day discharge of children after appendectomy for simple appendicitis is safe and associated with enhanced parent satisfaction. Our general pediatric surgeons aimed to improve the rate of same-day discharge after appendectomy for simple appendicitis.

Methods:

We implemented a clinical practice guideline in September 2019. A surgeon-of-the-week service model and the urgent operating room started in November 2019 and January 2020, respectively. Data for children with simple appendicitis from our academic medical center were gathered prospectively using National Surgical Quality Improvement Program-Pediatric. Patient outcomes before intervention implementation (n = 278) were compared with patients following implementation (n = 264).

Results:

The average monthly percentage of patients discharged on the day of surgery increased in the postimplementation group (32% versus 75%). Median postoperative length of stay decreased [16.5 hours (interquartile range, 15.9) versus 4.4 hours (interquartile range, 11.7), P < 0.001], and the proportion of patients discharged directly from the postoperative anesthesia care unit increased (22.8% versus 43.6%; P < 0.001). There were no differences in balancing measures, including the return to the emergency department and readmission. Fewer children were discharged home on oral antibiotics after implementation (6.8% versus 1.5%, P = 0.002), and opioid prescribing at discharge remained low (2.5% versus 1.1%, P = 0.385).

Conclusions:

Using quality improvement methodology and care standardization, we significantly improved the rate of same-day discharge after appendectomy for simple appendicitis without impacting emergency department visits or readmissions. As a result, our health care system saved 140 hospital days over the first 21 months.
Electroencephalographic characteristics of children and adolescents with chronic musculoskeletal pain
Authors: Ocay Don Daniel , Teel Elizabeth F. , Luo Owen D. , Savignac Chloé , Mahdid Yacine , Blain-Moraes Stefanie , Ferland Catherine E.
Published: February 2023

Introduction:

The pathophysiology of pediatric musculoskeletal (MSK) pain is unclear, contributing to persistent challenges to its management.

Objectives:

This study hypothesizes that children and adolescents with chronic MSK pain (CPs) will show differences in electroencephalography (EEG) features at rest and during thermal pain modalities when compared with age-matched controls.

Methods:

One hundred forty-two CP patients and 45 age-matched healthy controls (HCs) underwent a standardized thermal tonic heat and cold stimulations, while a 21-electrode headset collected EEG data. Cohorts were compared with respect to their EEG features of spectral power, peak frequency, permutation entropy, weight phase-lag index, directed phase-lag index, and node degree at 4 frequency bands, namely, delta (1–4 Hz), theta (4–8 Hz), alpha (8–13 Hz), and beta (13–30 Hz), at rest and during the thermal conditions.

Results:

At rest, CPs showed increased global delta (P = 0.0493) and beta (P = 0.0002) power in comparison with HCs. These findings provide further impetus for the investigation and prevention of long-lasting developmental sequalae of early life chronic pain processes. Although no cohort differences in pain intensity scores were found during the thermal pain modalities, CPs and HCs showed significant difference in changes in EEG spectral power, peak frequency, permutation entropy, and network functional connectivity at specific frequency bands (P < 0.05) during the tonic heat and cold stimulations.

Conclusion:

This suggests that EEG can characterize subtle differences in heat and cold pain sensitivity in CPs. The complementation of EEG and evoked pain in the clinical assessment of pediatric chronic MSK pain can better detect underlying pain mechanisms and changes in pain sensitivity.
Real-world data and evidence in pain research: a qualitative systematic review of methods in current practice
Authors: Vollert Jan , Kleykamp Bethea A. , Farrar John T. , Gilron Ian , Hohenschurz-Schmidt David , Kerns Robert D. , Mackey Sean , Markman John D. , McDermott Michael P. , Rice Andrew S.C. , Turk Dennis C. , Wasan Ajay D. , Dworkin Robert H.
Published: February 2023

The use of routinely collected health data (real-world data, RWD) to generate real-world evidence (RWE) for research purposes is a growing field. Computerized search methods, large electronic databases, and the development of novel statistical methods allow for valid analysis of data outside its primary clinical purpose. Here, we systematically reviewed the methodology used for RWE studies in pain research. We searched 3 databases (PubMed, EMBASE, and Web of Science) for studies using retrospective data sources comparing multiple groups or treatments. The protocol was registered under the DOI:10.17605/OSF.IO/KGVRM. A total of 65 studies were included. Of those, only 4 compared pharmacological interventions, whereas 49 investigated differences in surgical procedures, with the remaining studying alternative or psychological interventions or epidemiological factors. Most 39 studies reported significant results in their primary comparison, and an additional 12 reported comparable effectiveness. Fifty-eight studies used propensity scores to account for group differences, 38 of them using 1:1 case:control matching. Only 17 of 65 studies provided sensitivity analyses to show robustness of their findings, and only 4 studies provided links to publicly accessible protocols. RWE is a relevant construct that can provide evidence complementary to randomized controlled trials (RCTs), especially in scenarios where RCTs are difficult to conduct. The high proportion of studies reporting significant differences between groups or comparable effectiveness could imply a relevant degree of publication bias. RWD provides a potentially important resource to expand high-quality evidence beyond clinical trials, but rigorous quality standards need to be set to maximize the validity of RWE studies.
A Sixteen-year Review of Clinical Practice Patterns in Liposuction Based on Continuous Certification by the American Board of Plastic Surgery
Authors: Stein Michael J. , Sasson Daniel C. , Harrast John , Alderman Amy , Matarasso Alan , Gosain Arun K.
Published: February 2023

Background:

The American Board of Plastic Surgery (ABPS) has collected data on cosmetic surgery tracers as part of the Continuous Certification (CC) process since 2005. These data offer valuable information on national trends in clinical practice. The present study was performed to analyze evolving trends in Suction-Assisted Liposuction (SAL) from the ABPS cosmetic tracer procedures.

Methods:

Tracer data was review from 2005 to 2021 and grouped into an “early cohort (EC)” from 2005-2014 and a “recent cohort (RC)” from 2015-2021. Fisher’s exact tests and two-sample t-tests compared patient demographics, surgical techniques, and complication rates.

Results:

Data from 2810 SAL cases were included (1150 EC, 1660 RC). In-office procedures have increased (36%EC vs 41%RC, p<0.01), while the use of general anesthesia has remained the same (63%EC vs. 62%RC, p=0.01). Power-assisted liposuction (PAL) has increased in popularity (24%EC vs. 40%RC, p<0.001) while ultrasound-assisted (UAL) has decreased (5% vs. 2%, p<0.0001). The volume of lipoaspirate is increasing (1150cc EC vs. 1660cc RC, p<0.0001). With respect to body areas treated, the abdomen (64% EC vs. 69% RC, p<0.01), flank (60%EC vs. 64%RC, p<0.05), and back (22%EC vs. 34%RC, p<0.0001) have increased, while thighs (36%EC vs. 23%RC, p<0.0001) and knees (8%EC vs. 5%RC, p<0.01) have decreased. Position changes from prone to supine are more common (30%EC vs. 37%RC, p<0.0001) and surgeons are reporting more SAL of multiple areas in one case (28%EC vs. 36%RC, p<0.0001). Perioperative heparin use has significantly increased (2%EC vs. 7%RC, p<0.0001) during liposuction.

Conclusions:

This study highlights evolving trends in the clinical practice of liposuction over the last 16 years. We find that liposuction is becoming increasingly common in an outpatient setting and being performed concomitantly with other procedures. Despite multiple emerging technologies, the popularity of PAL is increasing. While adverse actions have not significantly increased with these changes the authors stress careful pre-operative evaluation of patients to identify factors that increase the risk of complications, especially those associated with combined procedures and liposuctions of multiple areas.