bluuebunny/crossref_metadata_2025 huggingface dataset:
Noninvasive prenatal testing in women undergoing in vitro fertilization with preimplantation genetic testing
Authors: Klimczak Amber M. , Seli Emre , Scott Richard T.
Published: April 2021

Purpose of review

To discuss the utilization, performance, and interpretation of noninvasive prenatal testing (NIPT) results in women achieving pregnancy through in vitro fertilization (IVF) and preimplantation genetic testing for aneuploidy (PGT-A).

Recent findings

Although PGT-A is a highly accurate method for the selection of euploid embryos the possibility for error still exists. Many women pursue NIPT after conception via IVF with or without PGT-A, whereas some forgo prenatal screening all together. Recent evidence suggests that the prevalence of a positive NIPT following PGT-A is low, and the positive predictive value is altered in this population.

NIPT is a valuable prenatal screening tool that should be offered to pregnant women regardless of prior PGT. In women who conceive following IVF and PGT-A through the transfer of euploid embryos, positive test results should be interpreted with caution.
Triglycerides and cardiovascular disease
Authors: Esan Oluwayemisi , Wierzbicki Anthony S.
Published: April 2021

Purpose of review

Triglycerides (TGs) are measured as part of routine lipid profiles but their relationship to cardiovascular disease (CVD) risk has been controversial and overshadowed by high-density lipoprotein cholesterol (HDL-C).

Recent findings

Epidemiological studies show a clear relationship of TG-containing lipoproteins including remnant particles with CVD risk with the effect being most clearly demonstrated through the excess risk captured by non-HDL-C compared with low-density lipoprotein-cholesterol (LDL-C). Mendelian randomisation studies show a consistent relationship of gene variants linked to TG metabolism with rates of CVD. Furthermore, meta-analyses of intervention trials with statins and other nonstatin drugs also suggest that reducing TGs is associated with benefits on rates of CVD events. Historical subgroup data from fibrate trials suggest benefits in patients with high TG:HDL ratios but seem to add little to optimized statin therapy. Recent trials with omega-3 fatty acids (specifically eicosapentaenoic acid) have suggested that high-dose formulations in contrast to low dose formulations have benefits on CVD outcomes.

Further studies with newer agents are required to determine the place of TG-lowering drugs in therapeutic pathways. Trials with agents such as pemafibrate and vupanorsen may finally answer these questions.
Identifying Reasons for Nonattendance and Noncompletion of Cardiac Rehabilitation
Authors: Vonk Thijs , Nuijten Malou A. H. , Maessen Martijn F. H. , Meindersma Esther P. , Koornstra-Wortel Hetty J. J. , Waskowsky Marc M. , Snoek Johan A. , Eijsvogels Thijs M. H. , Hopman Maria. T. E.
Published: April 2021

Purpose:

Despite strong recommendations and beneficial health effects of cardiac rehabilitation (CR), participation rates remain low. Little data are available on reasons beyond quantitative factors in the underutilization of CR. The aim of this study was to identify personal reasons for nonattenders and noncompletions of CR among Dutch and German patients with cardiovascular diseases (CVD) eligible for CR.

Methods:

Between December 2017 and January 2019, a total of 4265 questionnaires were distributed among eligible patients for CR in the bordering area of the eastern Netherlands and western Germany. Patients were eligible if they had an indication for CR according to national guidelines. Questionnaires were used to assess reasons of nonattendance and noncompletion of CR, when applicable.

Results:

A total of 1829 patients with CVD completed the questionnaire. Of these, 1278 indicated that they received referral to CR. Despite referral, 192 patients decided not to participate in CR and 88 patients with CVD withdrew from the CR program. The three most reported reasons for nonattendance were as follows: (1) did not need the supervision (56%, n = 108), (2) did not need the CR trajectory (55%, n = 105), and (3) already exercised regularly (39%, n = 74). The most reported reasons for noncompletion were as follows: (1) could no longer participate because of other physical problems (30%, n = 26), (2) did not need the CR trajectory (26%, n = 23), and (3) the CR program was not personal enough (23%, n = 20).

Conclusions:

Most patients had motivational or perceptive reasons for nonattendance or noncompletion to CR. These possible misconceptions as well as perceived shortcomings of traditional CR underline the need for adequate motivation, information, and more personalized solutions (eg, eHealth, home-based CR) to increase the uptake and completion of CR.
Assessment of the Early Disabling Effects of Coronary Artery Bypass Graft Surgery Using Direct Measures of Physical Function
Authors: Rengo Jason L. , Savage Patrick D. , Hirashima Fuyuki , Leavitt Bruce J. , Ades Philip A. , Toth Michael J.
Published: April 2021

Purpose:

Coronary artery bypass graft (CABG) surgery is an important treatment option in patients with coronary artery disease. Despite its beneficial effects, CABG surgery and its subsequent hospitalization may reduce physical functional capacity in patients, contributing to physical disability. Our objective was to assess the early disabling effects of CABG surgery and its subsequent hospitalization using direct measurements of physical function.

Methods:

Patients (n = 44) were assessed pre-surgery and at hospital discharge for physical function using the Short Physical Performance Battery (SPPB) and self-reported physical and mental health by questionnaire.

Results:

The total SPPB score (P < .001) and all of its components (P < .01-.001) decreased markedly following CABG surgery and hospitalization, with greater reductions in total SPPB score (P < .05) and gait speed (P < .01) in patients with higher body mass index. While CABG surgery and hospitalization reduced patient-reported physical function, changes in these indices largely did not correlate with changes in SPPB outcomes.

Conclusion:

Our results show the early disabling effects of CABG surgery and hospitalization on directly measured physical function, and that patients with higher body mass index had greater reductions. In addition, our results underscore the need to perform direct measurements of physical function to describe reductions in physiological functional capacity. These findings suggest the need for inpatient rehabilitation or early mobility programs to address this decline in physical function.
Health Literacy Among Patients With Chronic Lung Disease Entering Pulmonary Rehabilitation and Their Resident Loved Ones
Authors: Coenjaerds Miranda M. J. , Spruit Martijn A. , Cleutjens Fiona A. H. M. , Ponds Rudolph W. H. M. , Franssen Frits M. E. , Wouters Emiel F. M. , Janssen Daisy J. A.
Published: April 2021

Purpose:

The objective of this study was determine the prevalence of low health literacy (HL) and low reading ability among patients with chronic lung disease referred for pulmonary rehabilitation (PR) in the Netherlands and their loved ones; and to understand whether low HL or low reading ability influence PR outcomes.

Methods:

Health literacy was measured using the Health Literacy Survey-Europe Q16 (HLS-EU-Q16). Reading ability and cognitive functioning were measured using the Rapid Estimate of Adult Literacy in Medicine-Dutch (REALM-D) and the Montreal Cognitive Assessment. Exercise capacity, health status, and symptoms of anxiety and depression were assessed.

Results:

Patients (n = 120) entering PR and loved ones (n = 41) participated. Of all patients, 51% had low HL and 29% had low reading ability. Also, 39% of all loved ones had low HL. PR outcomes were comparable between patients with low or adequate HL. Patients with adequate reading ability showed greater improvement in symptoms of depression than patients with low reading ability (P = .047).

Conclusion:

Low HL and low reading ability are common among patients entering PR and their loved ones. For patients with low or adequate HL, PR is an effective treatment. Whether considering low HL and low reading ability by offering tailored education during treatment could augment the benefits of PR warrants further study.
Corneal Densitometry Assessed With Scheimpflug Camera in Healthy Corneas and Correlation With Specular Microscopy Values and Age
Authors: Karmiris Efthymios , Soulantzou Konstantina , Machairoudia Genovefa , Ntravalias Thomas , Tsiogka Anastasia , Chalkiadaki Evangelia
Published: April 2021

Purpose:

To investigate correlations between specular microscopy endothelial parameters and age with corneal densitometry values, as they are presented from a Scheimpflug device, in different levels of the cornea.

Methods:

Two hundred eighty-four eyes of 142 healthy subjects were included in this observational, prospective study. Corneal densitometry was evaluated with Scheimpflug imaging system in the central 0- to 2-mm annular zone of the cornea, whereas the endothelial cell properties were assessed with the use of a noncontact specular microscope.

Results:

Corneal densitometry values of all corneal layers were statistically significant and positively correlated with age. In univariate linear regression analysis among corneal densitometry values and the endothelial parameters, only endothelial cell density (CD) was statistically significant and inversely correlated with densitometry values in all corneal layers. In stepwise multivariate linear regression analysis, after adjustment for age, hexagonality was statistically significant and inversely correlated with posterior densitometry values, whereas coefficient of variation was positively and significantly correlated with the anterior densitometry values. When repeating stepwise multivariate linear regression analysis without adjusting for age, CD was negatively and significantly correlated with corneal densitometry values of all layers, whereas coefficient of variation was positively and significantly correlated with anterior and total corneal densitometry values.

Conclusions:

Corneal densitometry increases with age. It is also inversely correlated with CD, and this might be used as an indirect way to assess the status of the corneal endothelium.
Aspiration as a Novel Technique to Address Facial and Periocular Myiasis
Authors: Lu Jonathan E. , Mohan Sukriti , Pfeiffer Margaret L. , Clark Bhavishya S. , Chang Jessica R.
Published: April 2021

Suction aspiration, which has not yet been described in the treatment for myiasis in the periorbital and facial regions, was used to achieve rapid resolution of maggot burden in a 78-year-old patient who presented with a large ulcerated squamous cell carcinoma of the face. This technique also facilitates submission of parasite samples for further analysis. Suction aspiration had no complications, such as significant residual ruptured maggots in the wound or eye injury. Suction aspiration is a safe and efficient technique to reduce maggot burden that has advantages over classic myiasis treatments, especially near the eyes and airway.
Disseminated Coccidioidomycosis With Orbital Osteomyelitis and Periorbital Abscess
Authors: Reed Donovan S. , Kostosky Nicole , Epstein Aliza , Blaydon Sean , Durairaj Vikram , Somogyi Marie
Published: April 2021

Coccidioidomycosis osteomyelitis involving the orbital bones is exceedingly rare and is often misdiagnosed initially as other inflammatory or infectious conditions. No clear guidelines currently exist regarding appropriate management. The authors present an atypical presentation of disseminated coccidioidomycosis in an immunocompetent child with frontal bone superotemporal orbital rim osteomyelitis and associated periorbital abscess, successfully managed with surgical debridement through an upper eyelid crease incision.
Extraocular Muscle Enlargement and Proptosis Associated with Chronic Inflammatory Demyelinating Polyradiculoneuropathy
Authors: Barkley Michael R. , Ben Artsi Elad , McNab Alan A. , Hardy Thomas G.
Published: April 2021

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory neuropathy, which commonly causes peripheral neuropathy. It has rarely been associated with cranial nerve hypertrophy and neuro-ophthalmic manifestations. Proptosis secondary to cranial nerve hypertrophy has been reported in association with CIDP. The authors present a case of a 67-year-old man with CIDP who presented with bilateral proptosis, strabismus, and episodes of globe subluxation. The proptosis was mainly attributed to significant enlargement of the extraocular muscles, in addition to bilateral enlargement of the trigeminal nerves. There has been no published case of CIDP with associated enlargement of extraocular muscles without a history of underlying hyperthyroidism, inflammation, or malignancy. This may represent a new clinical finding in CIDP and adds to the limited literature on the neuro-ophthalmic and orbital associations of CIDP. The proptosis was managed with an uncomplicated bilateral orbital decompression.
Associations of Preoperative Self-rated Symptoms of Anxiety and Depression on Length of Hospital Stay and Long-term Quality of Life in Patients Undergoing Cardiac Surgery
Authors: Gorini Alessandra , Giuliani Mattia , L'Acqua Camilla , Barbieri Simone , Sisillo Erminio , Veglia Fabrizio , Tremoli Elena
Published: April 2021

Background

Anxiety and depression are often associated with cardiovascular diseases. Nevertheless, few study authors have investigated psychological effects on immediate and long-term cardiac surgery–related outcomes, such as surgical complications, length of hospital stay (LOS), and long-term health-related quality of life (HRQoL).

Objectives

The aims of this study were to (a) investigate the role of preoperative symptoms of anxiety and depression in predicting LOS in a sample of surgical patients and (b) evaluate the impact of preoperative symptoms of anxiety and depression on the patients' HRQoL 3 months after surgery.

Methods

One hundred fifty-one patients waiting for surgery were included. To evaluate symptoms of anxiety and depression, the Hospital Anxiety and Depression Scale was used. Multiple regression analyses were conducted to evaluate the impact of both clinical and psychological factors on LOS, whereas quantile regression was performed to assess their effect on the patients' HRQoL 3 months after surgery.

Results

The multiple regression shows that EuroSCORE, length of endotracheal intubation, and anxiety symptoms predict LOS. The multiple quantile regression analyses also show that both symptoms of anxiety and depression predict a negative HRQoL up to 3 months after surgery.

Conclusion

Preoperative symptoms of anxiety predict the patients' LOS, and both symptoms of anxiety and depression predict a scarce HRQoL 3 months after cardiac surgery. These results suggest the need for implementing presurgical in-hospital screening procedures for both symptoms of anxiety and depression. Finally, focused psychological interventions should be implemented for reducing inpatients' hospital LOS and improving their future quality of life.
Exercise Interventions to Improve Pelvic Floor Muscle Functioning in Older Women With Urinary Incontinence: A Systematic Review
Authors: Fricke Anja , Lark Sally D. , Fink Philip W. , Mundel Toby , Shultz Sarah P.
Published: April 2021

Background:

An estimated 200 million people worldwide live with urinary incontinence, and women are more affected than men. The World Health Organization and the International Continence Society recommend pelvic floor muscle training to treat urinary incontinence in women.

Objective:

The purpose of this systematic review was to examine pelvic floor muscle function and understand its impact on urinary incontinence in women older than 50 years.

Methods:

Medline, PsycINFO, Webscience, CINAHL, and Scopus were searched for articles from 1988 to May 2019. Included studies had a comparison or control group, exercise intervention aimed to train the pelvic floor musculature, women 50 years and older, and had been published in peer-reviewed journals.

Results:

Eight studies were included in this review. Exercise interventions included home-based as well as supervised pelvic floor muscle-strengthening, and indirect pelvic floor muscle-strengthening exercises via co-contraction of surrounding muscles. All interventions were able to improve pelvic floor muscle strength as well as urinary incontinence symptoms, with bigger improvements found in supervised interventions.

Conclusion:

This review has shown that exercise interventions targeting the pelvic floor muscles may be effective in improving pelvic floor muscle strength, urinary incontinence symptoms, and even quality of life measures. Exercise interventions that were supervised or included some type of biofeedback device showed greater and faster improvements than interventions without additional assistance.
The medical treatment of cardiogenic shock: cardiovascular drugs
Authors: De Backer Daniel , Arias Ortiz Julian , Levy Bruno
Published: April 2021

Purpose of review

To discuss the use of vasopressors and inotropes in cardiogenic shock.

Recent findings

The classic form or cardiogenic shock requires administration of inotropic and/or vasopressor agents to try to improve the impaired tissue perfusion. Among vasopressors various alpha-adrenergic agents, vasopressin derivatives and angiotensin can be used. The first-line therapy remains norepinephrine as it is associated with minimal adverse effects and appears to be associated by the best outcome in network meta-analyses. On the contrary, epinephrine is associated with an increased incidence of refractory shock and observational studies suggest an increased risk of death. Vasopressin may be an excellent alternative in tachycardiac patients or in the presence of pulmonary hypertension. Concerning inotropic agents, dobutamine is the first-line agent but levosimendan is an excellent alternative or additional agent in cases not responding to dobutamine. The impact on outcome of inotropic agents remains controversial.

Recent studies have refined the position of the various vasopressor and inotropic agents. Norepinephrine is recommended as first-line vasopressor agent by various guidelines. Among inotropic agents, selection between the agents should be individualized and based on the hemodynamic response.
Maryland’s Global Budget Revenue Program
Authors: Xie Liyang , Boudreaux Michel , Franzini Luisa
Published: April 2021

Background:

In 2014, Maryland implemented the Global Budget Revenue (GBR) program to reduce unnecessary hospital utilization and contain spending. Little is known about its impact on pediatric health outcomes and high-cost services that are primarily financed by payers other than Medicare.

Objective:

The aim was to examine the impact of the GBR program on neonatal intensive care unit (NICU) admission and infant mortality.

Research Design:

We conducted a difference-in-differences analysis comparing changes of NICU admissions and infant mortality in Maryland with changes in 20 comparison states (including DC), before and after implementation of the GBR program. Effects were estimated for all infants and for risk groups defined by birthweight and gestation.

Subjects:

A total of 11,965,997 newborns in Maryland and the comparison states was identified using US birth certificate data from 2011 to 2017.

Measures:

NICU admissions, the infant mortality rate, and the neonatal mortality rate.

Results:

The GBR program was associated with a 1.26 percentage points (−16.8%, P=0.03) decline in NICU admissions over three full years of implementation. Reductions were driven by fewer admissions among moderately low to normal birthweight (1500–3999 g) and moderately preterm to term (32–41 wk) infants. The effects for very-low birthweight and very preterm infants were small and not statistically precise. There was no significant change in infant or neonatal mortality rates.

Conclusions:

Maryland’s hospitals reacted to the GBR program by reducing NICU services for infants that did not have clear observed clinical need. Our results suggest that GBR constrained high-cost services, without adversely affecting infant mortality.
Electronic Health Record Usability
Authors: Kutney-Lee Ann , Brooks Carthon Margo , Sloane Douglas M. , Bowles Kathryn H. , McHugh Matthew D. , Aiken Linda H.
Published: April 2021

Background:

Electronic health record (EHR) usability issues represent an emerging threat to the wellbeing of nurses and patients; however, few large studies have examined these relationships.

Objective:

To examine associations between EHR usability and nurse job (burnout, job dissatisfaction, and intention to leave) and surgical patient (inpatient mortality and 30-day readmission) outcomes.

Methods:

A cross-sectional analysis of linked American Hospital Association, state patient discharge, and nurse survey data was conducted. The sample included 343 hospitals, 1,281,848 surgical patients, and 12,004 nurses. Logistic regression models were used to assess relationships between EHR usability and outcomes, before and after accounting for EHR adoption level (comprehensive vs. basic or less) and other confounders.

Results:

In fully adjusted models, nurses who worked in hospitals with poorer EHR usability had significantly higher odds of burnout [odds ratio (OR), 1.41; 95% confidence interval (CI), 1.21–1.64], job dissatisfaction (OR, 1.61; 95% CI, 1.37–1.90) and intention to leave (OR, 1.31; 95% CI, 1.09–1.58) compared with nurses working in hospitals with better usability. Surgical patients treated in hospitals with poorer EHR usability had significantly higher odds of inpatient mortality (OR, 1.21; 95% CI, 1.09–1.35) and 30-day readmission (OR, 1.06; 95% CI, 1.01–1.12) compared with patients in hospitals with better usability. Comprehensive EHR adoption was associated with higher odds of nurse burnout (OR, 1.14; 95% CI, 1.01–1.28).

Conclusion:

Employing EHR systems with suboptimal usability was associated with higher odds of adverse nurse job outcomes and surgical patient mortality and readmission. EHR usability may be more important to nurse job and patient outcomes than comprehensive EHR adoption.
Determination of tumour dose response threshold and implication on survival in patients with HCC treated with Y90 radiation segmentectomy: a simple semi-quantitative analysis
Authors: Cheng Bernard , Sethi Ila , Villalobos Alex , Wagstaff William , Schuster David M. , Bercu Zachary , Brandon David , Kokabi Nima
Published: April 2021

Purpose

To evaluate the relationship between Yttrium-90 (Y90) tumour dose and response rate in patients with hepatocellular carcinoma (HCC) who undergo Y90 radiation segmentectomy (Y90-RS) and to determine implication on overall survival (OS).

Materials and methods

Post Y90-RS Bremsstrahlung single-photon emission computed tomography/CT of 105 HCC patients with 110 treatments performed with glass microspheres was retrospectively analysed. The dose-volume histogram of the targeted tumour was determined with commercially available dosimetry software. Tumour response at 3 months was evaluated using modified Response Evaluation Criteria in Solid Tumours. Tumour dose thresholds associated with the objective response with 80% specificity were then used to evaluate implication on OS using Kaplan–Meier estimation and log-rank analysis.

Results

Tumour dose thresholds to predict objective response with 80% specificity were the following: maximum tumour dose (748 Gy), mean tumour dose (568 Gy), minimum tumour dose of 30% tumour volume (608 Gy), minimum tumour dose of 50% tumour volume (565 Gy), minimum tumour dose of 70% tumour volume (464 Gy) and minimum tumour dose of 100% tumour volume (213 Gy). These parameters all significantly predicted tumour response with areas under the ROC curve of >0.6. Mean tumour dose of ≥250 Gy predicted median OS of 43.67 vs. 17.87 months for others (P = 0.026). Minimum dose ≥180 Gy to 100% of tumour volume predicted median OS of 44.93 vs. 35.87 months for others (P = 0.043).

Conclusion

In patients with HCC undergoing Y90-RS, mean tumour dose ≥250 Gy and minimum tumour dose of ≥180 Gy to 100% of tumour volume are both significantly correlated with higher objective tumour response and prolonged survival.
Thickened liquids: do they still have a place in the paediatric dysphagia toolkit?
Authors: Stewart Alexandra , Burr Samantha
Published: April 2021

Purpose of review

Use of thickened fluids has long been a cornerstone of dysphagia management. However, clinicians and researchers are increasingly questioning their effectiveness and highlighting potential harms. This review aims to present the current state of the evidence for use of thickened fluids in children.

Recent findings

The relationship between aspiration and respiratory infection is complex. The role of thickened fluids in improving respiratory health is limited and contradictory. A high level of variability exists in all aspects of thickened fluid use. Little is known about patient and family perspectives on meaningful endpoints for intervention.

Clinicians should be open and transparent in their decision making with patients and families, acknowledging the limited evidence and the need for individualised care. Further research is needed to establish the efficacy of thickened fluid use in children with regard to improvements in respiratory health, fluid intake and child and family wellbeing.
Maternal postpartum depression: risk factors, impacts, and interventions for the NICU and beyond
Authors: Shovers Samuel M. , Bachman Sara S. , Popek Leah , Turchi Renee M.
Published: April 2021

Purpose of review

Postpartum depression (PPD) negatively impacts caregivers, infants, siblings, and entire families. Mothers with infants admitted to the neonatal intensive care unit (NICU) face additional risk for PPD, coupled with risk factors extending beyond a NICU admision. The novelty of this review is the focus on maternal PPD for mothers with infants admitted to the NICU. Interventions aimed at limiting and preventing PPD in this population include: prenatal and postpartum depression screening, PPD symptom awareness and monitoring, and trauma-informed care.

Recent findings

PPD, the most frequent complication of childbirth, affects approximately 10–15% of mothers worldwide. Prevalence rates increase to 40% for mothers whose infant is admitted to the NICU. PPD can affect maternal and child health across the life course and predispose future generations to a myriad of developmental, psychosocial, and physical challenges. Prevalence rates are higher for racial and ethnic minorities, immigrant and refugee populations, and mothers in rural locations. Trauma-informed care is suggested at individual and organizational levels, leading to better care for those with and without previous trauma exposure.

Increasing PPD symptom awareness, screening for PPD, and connecting to resources should begin during prenatal visits. Care teams should discuss barriers to obtaining resources for mothers, children, and families to improve access and support.
Intracranial Hemorrhage Associated With T-Cell Acute Lymphoblastic Leukemia With Hyperleukocytosis: A Case Report
Authors: Ağrali Eröz Nesli , Derviş Melda F. , Tuna Deveci Rumeysa , Sencer Serra , Peker Bariş , Demirkol Demet
Published: April 2021

Acute leukemia in children may present with hyperleukocytosis. Symptomatic hyperleukocytosis is a medical emergency that necessitates rapid stabilization of the patient and prompt lowering of the leukocyte count. We report on a patient with intracranial hemorrhage associated with T-cell acute lymphoblastic leukemia with hyperleukocytosis, which is a rare occurrence. A 16-year-old boy with hyperleukocytosis (total white cell count; 398×103/µL) underwent repeated leukapheresis and received supportive treatment until a definite diagnosis of T-cell acute lymphoblastic leukemia was made and chemotherapy was started at 10% of the usual dose. On day 2 of treatment, he had headache, vomiting, and was agitated. Brain magnetic resonance imaging showed bilateral extensive hemispheric and cerebellar punctate areas of hemorrhage and perilesional edema. Chemotherapy intensified to a maximum dose on day 3. If supportive care for tumor lysis syndrome can be promptly provided, initial chemotherapy regimen can immediately be begun at an optimal dose.
Promoting Evidence-Based Practice in Clinical Education at a Hospice Designated Education Unit
Authors: Mann Catherine M. , Sullivan Suzanne S.
Published: April 2021

Integration of palliative care principles into undergraduate nursing curriculum is essential to prepare students to provide supportive care services across the continuum of care for individuals with serious illness. Baccalaureate nursing curricula emphasize development and application of evidence-based practice (EBP); however, development of nursing skills often overshadows teaching students how to deliver care or facilitate practice changes based on evidence in clinical education. Problems revealed in clinical practice are a valuable tool for improving student use and appreciation of EBP in clinical settings. The EBP project presented in this article provides a process to promote palliative and end-of-life EBP in clinical education. This project highlights the proposed American Association of Colleges of Nursing hospice/palliative/supportive care sphere of care in a hospice dedicated education unit following The Seven Steps of EBP. Students participating in the project developed core skills to search, appraise, and translate evidence and the ability to lead EBP projects guided by the dedicated education unit model. Dedicated education units serve as ideal clinical education sites to develop student EBP competencies and support transition to practice through collaboration with practice partner stakeholders.
Mast Cells and Proteins Related to Myofibroblast Differentiation (PAR-2, IL-6, and TGFβ1) in Salivary Cancers: A Preliminary Study
Authors: Ismerim Adna B. , de Oliveira Araújo Iguaracyra B. , de Aquino Xavier Flávia C. , Rocha Clarissa A.G. , Macedo Cláudia L. , Cangussu Maria C.T. , Freitas Valéria S. , Della Coletta Ricardo , Cury Patrícia R. , Santos Jean N.
Published: April 2021

Salivary gland neoplasms represent an important group of cancers in the head and neck and myoepithelial cells play a key role on the development these tumors. This study evaluated the distribution of mast cells and related proteins (PAR-2, TGFβ1, IL-6) to the myofibroblastic differentiation in malignant tumors of salivary glands with and without myoepithelial differentiation. Immunohistochemical assessement for tryptase mast cells, SMA, PAR-2, TGFβ1, IL-6 was performed in 10 cases of polymorphous low-grade adenocarcinoma, 14 cases of mucoepidermoid carcinoma (MEC) and 10 cases of adenoid cystic carcinoma. When the density of mast cells were compared between tumors, their density was significantly higher in MEC (P=0.08). Tumors with high expression of PAR-2 (79.4%) exhibited a high density of mast cells. Myofibroblasts were more frequent in malignant tumors with low expression (<50%) of cell masts. Individual analysis of the tumors showed no significant difference between the expression of PAR-2, IL-6, TGFβ1, and myofibroblasts. When the density of mast cells, myofibroblasts and the expression of PAR-2 protein, IL-6, and TGFβ1 were compared, it was no statistically significant difference between tumors with and without myoepithelial differentiation. The results of present study suggest a possible participation of mast cells and especially of PAR-2 in the development and progression of malignant salivary cancers, regardless of myoepithelial content.
Gastrointestinal Stromal Tumors (GISTs) as Incidental Findings in Gynecological Surgery
Authors: Boyle William , Phillips Andrew , Vella Josefa , Williams Anthony , Ganesan Raji
Published: April 2021

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the gastrointestinal tract that may be diagnosed incidentally as a part of intra-abdominal surgery for other diseases. This is a single center review to document the incidental finding of GIST at surgery for gynecological malignancies during a 10-yr period. Sixteen cases of incidental GISTs were identified in women ranging in age from 39 to 82 yr. GISTs presented as incidental secondary lesions in women undergoing surgery for other indications, typically primary debulking surgery for tubo-ovarian high-grade serous carcinoma. The GIST was located in the stomach wall in 9 cases. Other sites were cecum, omentum, and mesentery. Diagnosis of GIST was supported by immunohistochemistry in all cases and by molecular studies in 3 cases. Seventy-five percent of cases were micro-GISTs, measuring <2 cm in diameter and, where Miettinen and Lasota criteria could be applied, fitted into “no risk,” “very low risk” or “low risk” prognostic groups. Seventy-five percent of women for whom survival data was available, showed disease-free survival at follow-up. The 2 women who died had concurrent high stage or high-grade gynecological malignancy at initial diagnosis.
Longitudinal Association of a Medication Risk Score With Mortality Among Ambulatory Patients Acquired Through Electronic Health Record Data
Authors: Ratigan Amanda Rondinelli , Michaud Veronique , Turgeon Jacques , Bikmetov Ravil , Gaona Villarreal Gabriela , Anderson Heather D. , Pulver Gerald , Pace Wilson D.
Published: April 2021

The use of electronic health records allows for the application of a novel medication risk score for the rapid identification of ambulatory patients at risk of adverse drug events. We sought to examine the longitudinal association of medication risk score with mortality. This retrospective cohort study included patients whose data were available through electronic health records from multiple health care organizations in the United States that provided data as part of a Patient Safety Organization. Patients were included if they had ≥1 visit and ≥1 medication in their record between January 1, 2011, to June 30, 2017. Cox proportional hazards regression was used to examine the association between continuous and categorized medication risk score with all-cause mortality. Among 427,103 patients, the median age was 50 years (interquartile range, 29–64 years); 61% were female; 50% were White, 11% were Black, and 38% were Hispanic; and 6873 had a death date recorded. Patients 30 to 49 years old had the highest hazard ratios (HRs), followed by the 50- to 64-year-olds and lastly those 65 years or older. Controlling for all covariates, 30- to 49-year-olds with a score of 20 to 30 (versus <10) had a 604% increase in the hazard of death (HR, 7.04; 95% confidence interval [CI], 3.86–12.85), 50- to 64-year-olds had a 254% increase (HR, 3.54; 95% CI, 2.71–4.63), and ≥65-year-olds had an 87% increase (HR, 1.87; 95% CI, 1.67–2.09). The medication risk score was independently associated with death, adjusting for multimorbidities and other conditions. Risk was found to vary by age group and score. Results suggest that pharmaceutical interventions among those with elevated scores could improve medication safety for patients taking multiple medications.
Solitary Adult Rib Langerhans Cell Histiocytosis Evaluated by 18F-FDG PET/CT
Authors: Wang Qixin , Yang Songsong , Tang Wenxin , Liu Hanxiang , Chen Yue
Published: April 2021

Langerhans cell histiocytosis (LCH) is a rare proliferative histiocytic disorder. It mainly occurs in the pediatric population, whereas it is rarely reported in adults. Herein, we reported a case of a patient with isolated rib LCH, which showed elevated 18F-FDG uptake. Our case showed that 18F-FDG PET/CT can be a potential tool in the evaluation of LCH.
Multiple Primary Osseous B-Lymphoblastic Lymphoma/Leukemia Shown on Bone Scintigraphy
Authors: Wen Ming , Peng Xiao-Juan , Huang Jian-Min , Wei Ling-Ge , Xie Peng
Published: April 2021

Primary osseous B-lymphoblastic lymphoma/leukemia is very rare, especially multiple bones involved. Herein, we reported the bone scintigraphy findings in a 16-year-old adolescent boy with a 20-day history of right thigh pain caused by B-lymphoblastic lymphoma/leukemia. Multiple abnormal MDP-avid foci were noted on 99mTc-MDP bone scintigraphy. Interestingly, the CT images of corresponding lesions were unrevealing. Finally, the B-lymphoblastic lymphoma/leukemia was confirmed by pathology and immunohistochemistry.
The Challenge of Staging Breast Cancer With PET/CT in the Era of COVID Vaccination
Authors: Brown Adam Harry , Shah Sweni , Groves Ashley M. , Wan Simon , Malhotra Anmol
Published: April 2021

We report a case series of biopsy-proven reactive axillary lymph nodes, which were avid on FDG PET/CT in breast cancer patients post COVID-19 vaccination. With 4 cases presenting in a consecutive 10-day period, it became apparent that metabolically active axillary lymphadenopathy is an adverse effect of COVID-19 vaccines, currently being deployed worldwide. This may lead to patients undergoing unnecessary biopsy. We have started taking a COVID-19 vaccine status history before PET/CT. If enlarged/metabolically active axillary nodes are identified in the ipsilateral vaccinated arm, then axillary ultrasound at 4 weeks is suggested.
DOTATATE -Avid Bilateral Axilla and Subpectoral Lymphadenopathy Induced From COVID-19 mRNA Vaccination Visualized on PET/CT
Authors: Lu Yang
Published: April 2021

A 64-year-old woman with malignant carcinoid tumor of the ileum received right ileocolectomy 9 years ago. Series follow-up imaging studies including most recent 68Ga-DOTATATE PET/CT scan in June 2020 have been negative for disease. Current 68Ga-DOTATATE PET/CT scan showed new cluster of bilateral axillary and subpectoral lymphadenopathy with normal CT morphology, but with avid DOTATATE uptake. There was no other abnormal DOTATATE-avid lesion or suspicious CT image findings. The medical history revealed that the patient received 2 doses of COVID-19 (coronavirus disease 2019) mRNA vaccine at bilateral upper arm deltoid muscles at 21 and 42 days prior to the PET/CT examination, respectively.
Inappropriate Prescribing of Proton Pump Inhibitors in Outpatient Clinics
Authors: Çelik Feyza , Aypak Cenk , Özdemir Ayşe , Görpelioğlu Süleyman
Published: April 2021

Proton pump inhibitors are the commonly prescribed drugs for acid-related disorders. However, many of those prescriptions are inappropriate in inpatient and outpatient settings according to the recommended guidelines. Many studies have been conducted in inpatient clinics, but data about the appropriateness of proton pump inhibitor prescribing in outpatient clinics are scarce. Therefore, the aim of this study was to determine inappropriate proton pump inhibitor prescribing rates among patients admitted to a tertiary hospital family medicine outpatient clinic. A total of 259 patients (median age = 59 years; 72.6% women) were enrolled into the study and 35.9% of them had no proper indications to utilize proton pump inhibitors. Inappropriate proton pump inhibitor usage rate was significantly higher in patients older than 60 years compared with their younger counterparts (62.4% vs. 37.6%; p = .001). The most frequent reason to use a proton pump inhibitor with nonapproved indications was polypharmacy (41.9%). Despite endoscopic evaluation, 41.9% of the patients received a proton pump inhibitor without an approved indication. A significant proportion of nonindicated prescriptions were a consequence of continued prescribing without re-evaluating patients in outpatient clinics. Consideration of proton pump inhibitor indications according to the guidelines in every admission may prevent inappropriate prescriptions.
Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative
Authors: Holmstrom Amy L. , Ott Katherine C. , Weiss Hannah K. , Ellis Ryan J. , Hungness Eric S. , Shapiro Michael B. , Yang Anthony D.
Published: April 2021

BACKGROUND

Performance of a trauma tertiary survey (TTS) reduces rates of missed injuries, but performance has been inconsistent at trauma centers. The objectives of this study were to assess whether quality improvement (QI) efforts would increase the frequency of TTS documentation and determine if TTS documentation would increase identification of traumatic injuries. Our hypothesis was that QI efforts would improve documentation of the TTS.

METHODS

Before-and-after analysis of QI interventions at a level 1 trauma center was performed. The interventions included an electronic template for TTS documentation, customized educational sessions, and emphasis from trauma leadership on TTS performance. The primary outcome was documentation of the TTS. Detection of additional injuries based on tertiary evaluation was a secondary outcome. Associations between outcomes and categorical patient and encounter characteristics were assessed using χ2 tests.

RESULTS

Overall, 592 trauma encounters were reviewed (296 preimplementation and 296 postimplementation). Trauma tertiary survey documentation was significantly higher after implementation of the interventions (30.1% preimplementation vs. 85.1% postimplementation, p < 0.001). Preimplementation documentation of the TTS was less likely earlier in the academic year (14.3% first academic quarter vs. 46.5% last academic quarter, p < 0.001), but this temporal pattern was no longer evident postimplementation (88.5% first academic quarter vs. 77.9% last academic quarter, p = 0.126). Patients were more likely to have a missed traumatic injury diagnosed on TTS postimplementation (1.7% in preimplementation vs. 5.7% postimplementation, p = 0.009).

CONCLUSION

Documentation of the TTS and missed injury detection rates were significantly increased following implementation of a bundle of QI interventions. The association between time of year and documentation of the TTS was also attenuated, likely through reduction of the resident learning curve. Targeted efforts to improve TTS performance may improve outcomes for trauma patients at teaching hospitals.

LEVEL OF EVIDENCE

Care management, Level IV.
Cryoprecipitate attenuates the endotheliopathy of trauma in mice subjected to hemorrhagic shock and trauma
Authors: Barry Mark , Trivedi Alpa , Miyazawa Byron Y. , Vivona Lindsay R. , Khakoo Manisha , Zhang Haoqian , Pathipati Praneeti , Bagri Anil , Gatmaitan Michelle G. , Kozar Rosemary , Stein Deborah , Pati Shibani
Published: April 2021

BACKGROUND

Plasma has been shown to mitigate the endotheliopathy of trauma. Protection of the endothelium may be due in part to fibrinogen and other plasma-derived proteins found in cryoprecipitate; however, the exact mechanisms remain unknown. Clinical trials are underway investigating early cryoprecipitate administration in trauma. In this study, we hypothesize that cryoprecipitate will inhibit endothelial cell (EC) permeability in vitro and will replicate the ability of plasma to attenuate pulmonary vascular permeability and inflammation induced by hemorrhagic shock and trauma (HS/T) in mice.

METHODS

In vitro, barrier permeability of ECs subjected to thrombin challenge was measured by transendothelial electrical resistance. In vivo, using an established mouse model of HS/T, we compared pulmonary vascular permeability among mice resuscitated with (1) lactated Ringer’s solution (LR), (2) fresh frozen plasma (FFP), or (3) cryoprecipitate. Lung tissue from the mice in all groups was analyzed for markers of vascular integrity, inflammation, and inflammatory gene expression via NanoString messenger RNA quantification.

RESULTS

Cryoprecipitate attenuates EC permeability and EC junctional compromise induced by thrombin in vitro in a dose-dependent fashion. In vivo, resuscitation of HS/T mice with either FFP or cryoprecipitate attenuates pulmonary vascular permeability (sham, 297 ± 155; LR, 848 ± 331; FFP, 379 ± 275; cryoprecipitate, 405 ± 207; p < 0.01, sham vs. LR; p < 0.01, LR vs. FFP; and p < 0.05, LR vs. cryoprecipitate). Lungs from cryoprecipitate- and FFP-treated mice demonstrate decreased lung injury, decreased infiltration of neutrophils and activation of macrophages, and preserved pericyte-endothelial interaction compared with LR-treated mice. Gene analysis of lung tissue from cryoprecipitate- and FFP-treated mice demonstrates decreased inflammatory gene expression, in particular, IL-1β and NLRP3, compared with LR-treated mice.

CONCLUSION

Our data suggest that cryoprecipitate attenuates the endotheliopathy of trauma in HS/T similar to FFP. Further investigation is warranted on active components and their mechanisms of action.
Impact of US hospital center and interhospital transfer on spinal cord injury management: An analysis of the National Trauma Data Bank
Authors: Williamson Theresa , Hodges Sarah , Yang Lexie Zidanyue , Lee Hui-Jie , Gabr Mostafa , Ugiliweneza Beatrice , Boakye Maxwell , Shaffrey Christopher I. , Goodwin C. Rory , Karikari Isaac O. , Lad Shivanand , Abd-El-Barr Muhammad
Published: April 2021

BACKGROUND

Traumatic spinal cord injury (SCI) is a serious public health problem. Outcomes are determined by severity of immediate injury, mitigation of secondary downstream effects, and rehabilitation. This study aimed to understand how the center type a patient presents to and whether they are transferred influence management and outcome.

METHODS

The National Trauma Data Bank was used to identify patients with SCI. The primary objective was to determine association between center type, transfer, and surgical intervention. A secondary objective was to determine association between center type, transfer, and surgical timing. Multivariable logistic regression models were fit on surgical intervention and timing of the surgery as binary variables, adjusting for relevant clinical and demographic variables.

RESULTS

There were 11,744 incidents of SCI identified. A total of 2,883 patients were transferred to a Level I center and 4,766 presented directly to a level I center. Level I center refers to level I trauma center. Those who were admitted directly to level I centers had a higher odd of receiving a surgery (odds ratio, 1.703; 95% confidence interval, 1.47–1.97; p < 0.001), but there was no significant difference in terms of timing of surgery. Patients transferred into a level I center were also more likely to undergo surgery than those at a level II/III/IV center, although this was not significant (odds ratio, 1.213; 95% confidence interval, 0.099–1.48; p = 0.059).

CONCLUSION

Patients with traumatic SCI admitted to level I trauma centers were more likely to have surgery, particularly if they were directly admitted to a level I center. This study provides insights into a large US sample and sheds light on opportunities for improving pre hospital care pathways for patients with traumatic SCI, to provide the timely and appropriate care and achieve the best possible outcomes.

LEVEL OF EVIDENCE

Care management, Level IV.
Resuscitative endovascular balloon occlusion of the aorta in combat casualties: The past, present, and future
Authors: Stokes Sarah C. , Theodorou Christina M. , Zakaluzny Scott A. , DuBose Joseph J. , Russo Rachel M.
Published: April 2021

BACKGROUND

Noncompressible torso hemorrhage is a leading cause of preventable death on the battlefield. Intra-aortic balloon occlusion was first used in combat in the 1950s, but military use was rare before Operation Iraqi Freedom and Operation Enduring Freedom. During these wars, the combination of an increasing number of deployed vascular surgeons and a significant rise in deaths from hemorrhage resulted in novel adaptations of resuscitative endovascular balloon occlusion of the aorta (REBOA) technology, increasing its potential application in combat. We describe the background of REBOA development in response to a need for minimally invasive intervention for hemorrhage control and provide a detailed review of all published cases (n = 47) of REBOA use for combat casualties. The current limitations of REBOA are described, including distal ischemia and reperfusion injury, as well as ongoing research efforts to adapt REBOA for prolonged use in the austere setting.

LEVEL OF EVIDENCE

Level V.