bluuebunny/crossref_metadata_2025 huggingface dataset:
A retrospective study of patients with blood culture-confirmed typhoid fever in Fiji during 2014–2015: epidemiology, clinical features, treatment and outcome
Authors: S Aneley Getahun , Parry Christopher M , Crump John A , Rosa Varanisese , Jenney Adam , Naidu Ravi , Mulholland Kim , Strugnell Richard A
Published: July 2019

Background

Typhoid fever is endemic in Fiji. We sought to describe the epidemiology, clinical features and case fatality risk of blood culture-confirmed typhoid fever from January 2014 through December 2015.

Methods

Blood culture-positive patients were identified from a typhoid surveillance line list. A standardised case investigation form was used to record data from patients’ medical records.

Results

Of 542 patients, 518 (95.6%) were indigenous Fijians (iTaukei) and 285 (52.6%) were male. The median (IQR) age was 25 (16–38) y. Mean (SD) time from the onset of illness to admission was 11.1 (6.9) d. Of 365 patients with clinical information, 346 (96.9%) had fever, 239 (66.9%) diarrhoea, 113 (33.5%) vomiting, and 72 (30.2%) abdominal pain. There were 40 (11.0%) patients with complications, including 17 (4.7%) with shock, and 11 (3.0%) with hepatitis. Nine patients died for a case fatality risk of 1.7%. Of the 544 Salmonella Typhi isolates tested, none were resistant to first line antimicrobials; 3(0.8%) were resistant to ciprofloxacin and 5(1.4%) to nalidixic acid.

Conclusions

In Fiji, most blood culture-confirmed typhoid fever cases were in young adults. Common clinical manifestations were fever and gastrointestinal symptoms. Further studies are required to elucidate the factors associated with complications and death.
Exploring Online RN-to-BSN Student Perceptions of Learner Presence
Authors: Olson Christina , Benham-Hutchins Marge
Published: July 2019

AIM

The aim of this study was to describe how RN-to-BSN student and program-specific characteristics influence student perceptions of learner presence (LP) in the online learning environment.

BACKGROUND

Online RN-to-BSN students represent a diverse group of practicing nurses who must balance multiple obligations and challenging learner requirements. LP represents the student’s perceptions of being close to and interacting with faculty and peers within the online learning environment.

METHOD

A descriptive, exploratory design was used to examine the relationship between participant perceptions of LP and student and program characteristics.

RESULTS

Findings describe student and program characteristics and perceptions of LP. Significant findings revealed that more collaborative assignments were associated with higher perceptions of LP; individual assignments resulted in lower perceptions.

CONCLUSION

This study may enhance faculty understanding of this population of students and the extent to which course activities impact students’ communication and collaboration to meet online learner requirements.
A Creative Teaching Method for Research and Evidence-Based Practice
Authors: Weathers Elizabeth
Published: July 2019

With nursing students placed in busy clinical environments where evidence-based practice (EBP) and research are often not considered a priority, teaching EBP to nursing students can be challenging. Innovation is required to ensure that nursing students not only recognize the importance of EBP but are also equipped with the knowledge, skills, and attitudes required to promote and implement EBP. This article describes the implementation of a video project as part of the EBP and research module. Feedback from students was positive, and the project has now been formally introduced into the curriculum.
Nursing Student Perceptions of Faculty Advising
Authors: Snyder Brenda , Quinn Griffin Mary
Published: July 2019

AIM

The aim of the study was to determine student perceptions of faculty advising and the most effective method of faculty advising.

BACKGROUND

The nursing faculty advisor is important in facilitating the timely completion of the program. Faculty members have initiated synchronous electronic methods of advising to facilitate advising.

METHOD

A descriptive study was conducted with a convenience sample of members of a student nurses’ association. The Faculty Advisor Evaluation Questionnaire was used for data collection via online survey.

RESULTS

With 106 respondents, results demonstrated high levels of student-perceived effectiveness of the advising session, advocacy/accountability, faculty advisor knowledge, and availability. The majority of nursing students reported that face-to-face advising (58.5 percent, n = 62) was the most helpful method.

CONCLUSION

This study is one of the first to examine nursing students’ perceptions of faculty advising. As nursing faculty implement online methods of advising, it is important to evaluate the evidence.
Perioperative Management of Direct Oral Anticoagulants in Intracranial Surgery
Authors: Porter John , Dinsmore Judith
Published: July 2019

The use of direct oral anticoagulants is increasing rapidly, because of perceived benefits over older agents, such as predictable pharmacokinetics and a reduced risk of bleeding. Elderly patients, who are more likely to be prescribed these drugs, are also presenting for neurosurgical procedures more often. The combination of these factors will result in neurosurgeons and neuroanesthesiologists encountering patients prescribed direct oral anticoagulants on an increasingly frequent basis. This review provides a summary of the current evidence pertaining to the perioperative management of these drugs, in the context of elective and emergency intracranial surgery. It highlights emerging therapies, including specific antidotes, as well as areas where the evidence base is likely to improve in the future.
Malassezia furfur Emergence and Candidemia Trends in a Neonatal Intensive Care Unit During 10 Years
Authors: Chen I-Ting , Chen Chih-Cheng , Huang Hsin-Chun , Kuo Kuang-Che
Published: July 2019

Background:

Because Candida spp is a major cause of mortality and morbidity in preterm infants, fluconazole prophylaxis has been suggested by some experts and hospital policy. In our hospital, fluconazole prophylaxis was used in eligible preterm infants and set as the neonatal intensive care unit (NICU) practice in 2014.

Purpose:

This study focused on fungal bloodstream infections and aimed to evaluate the benefit and harm of fluconazole prophylaxis.

Methods/Search Strategy:

This retrospective, descriptive study involved medical record reviews in our hospital from April 2005 to October 2016. NICU patients were included if Candida species, yeast-like organisms, or Malassezia species were cultured from their venous catheter tips or blood cultures.

Findings/Results:

After fluconazole prophylaxis, cases of Candida spp decreased and those of Malassezia furfur emerged. We reviewed 19 cases of catheter-related M furfur colonization and 1 case of M furfur fungemia. The gestational age was 27.3 ± 2.0 weeks and birth weight was 959.2 ± 229.8 g. Hyperalimentation with lipid infusion was used in all cases. All of the neonates survived with antifungal agent use.

Implications for Practice:

This study highlights that prophylactic fluconazole may be an associated factor of Malassezia colonization; M furfur remains a potential concern for fungemia in the care of premature infants and thus requires our attention.

Implications for Research:

Future studies should further investigate the incidence and impact of noncandidal fungal infections with fluconazole prophylaxis use in premature infants.
Urologic Injury and Fistula After Hysterectomy for Benign Indications
Authors: Dallas Kai B. , Rogo-Gupta Lisa , Elliott Christopher S.
Published: July 2019

OBJECTIVE:

To explore the rates and risk factors for sustaining a genitourinary injury during hysterectomy for benign indications.

METHODS:

In this population-based cohort study, all women who underwent hysterectomy for benign indications were identified from the Office of Statewide Health Planning and Development databases in California (2005–2011). Genitourinary injuries were further classified as identified at the time of hysterectomy, identified after the date of hysterectomy; or unidentified until a fistula developed.

RESULTS:

Of the 296,130 women undergoing hysterectomy for benign indications, there were 2,817 (1.0%) ureteral injuries, 2,058 (0.7%) bladder injuries and 834 (0.3%) genitourinary fistulas (80/834 of which developed after an injury repair). Diagnosis was delayed in 18.6% and 5.5% of ureteral and bladder injuries, respectively. Subsequent genitourinary fistula development was lower if the injury was identified immediately (compared with delayed) for both ureteral (0.7% vs 3.4% odds ratio [OR] 0.28; 95% CI 0.14–0.57) and bladder injuries (2.5% vs 6.5% OR 0.37; 95% CI 0.16–0.83). Indwelling ureteral stent placement alone was more successful in decreasing the risk of a second ureteral repair for immediately recognized ureteral injuries (99.0% vs 39.8% for delayed injuries). With multivariate adjustment, prolapse repair (OR 1.44, 95% CI 1.30–1.58), an incontinence procedure (OR 1.40, 95% CI 1.21–1.61), mesh augmented prolapse repair (OR 1.55, 95% CI 1.31–1.83), diagnosis of endometriosis (OR 1.46, 95% CI 1.36–1.56), and surgery at a facility in the bottom quartile of hysterectomy volume (OR 1.37, 95% CI 1.01–1.89) were all associated with an increased likelihood of a genitourinary injury. An exclusively vaginal (OR 0.56, 95% CI 0.53–0.64) or laparoscopic (OR 0.80, 95% CI 0.75–0.86) approach was associated with lower risk of a genitourinary injury as compared with an abdominal approach.

CONCLUSION:

Genitourinary injury occurs in 1.8% of hysterectomies for benign indications; immediate identification and repair is associated with a reduced risk of subsequent genitourinary fistula formation.
Short-Term Health-Related Quality of Life After Hysterectomy Compared With Myomectomy for Symptomatic Leiomyomas
Authors: Nicholson Wanda K. , Wegienka Ganesa , Zhang Shuaiqi , Wallace Kedra , Stewart Elizabeth , Laughlin-Tommaso Shannon , Thomas Laine , Jacoby Vanessa L. , Marsh Erica E. , Wise Lauren , Borah Bijan J. , Spies James , Venable Sateria , Anchan Raymond M. , Larry Maxwell G. , Diamond Michael , Lytle Barbara , Myers Evan R.
Published: July 2019

OBJECTIVE:

To compare short-term health-related quality of life (HRQOL) 6–12 weeks after hysterectomy or myomectomy for the treatment of symptomatic leiomyomas.

METHODS:

We conducted a prospective comparative effectiveness analysis of data. In an existing multisite registry, we compared 6–12-week postsurgical HRQOL using the disease-specific Uterine Fibroid Symptom Quality of Life and the generic EuroQoL 5-Dimension Health Questionnaire, in women from the ages of 18–54 years with documented leiomyomas undergoing hysterectomy or myomectomy. Propensity score weighting was used to adjust for confounding, and analyses were also stratified by route of surgery.

RESULTS:

A total of 1,295 patients (727 with hysterectomy and 568 with myomectomy) enrolled from registry initiation in November 2015 until June 2018 met inclusion criteria. At baseline, leiomyoma-specific HRQOL (44.0±25.4 and 50.2±25.3, P<.01), symptom severity (60.7±23.6 and 51.7±24.6, P<.01), and generic HRQOL (69.3±20.4 and. 73.4±18.9, P<.01) were significantly different between the hysterectomy compared with myomectomy groups, respectively. Differences were eliminated by propensity adjustment. Substantial improvement in HRQOL measures were seen in both groups at 6–12 weeks, with the mean propensity-adjusted symptom severity score 4 points lower in hysterectomy patients (mean difference −4.6; 95% CI −7.0 to −2.3), compared with myomectomy patients. Hysterectomy patients had better scores on the concern and self-consciousness subscales compared with myomectomy patients. When stratified by surgical route, these two subscale findings were similar between minimally invasive hysterectomy and minimally invasive myomectomy. Symptom severity scores did not differ after abdominal myomectomy compared with abdominal hysterectomy, but subscale scores on activity and energy/mood were higher with myomectomy.

CONCLUSION:

Both hysterectomy and myomectomy were associated with substantial improvement in HRQOL at short-term follow-up, with small but statistically significant differences in symptom severity and certain subscales.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT02260752.
Medication Abortion Provided Through Telemedicine in Four U.S. States
Authors: Kohn Julia E. , Snow Jennifer L. , Simons Hannah R. , Seymour Jane W. , Thompson Terri-Ann , Grossman Daniel
Published: July 2019

OBJECTIVE:

To assess outcomes of medication abortion provided through telemedicine compared with standard medication abortion at Planned Parenthood health centers in four U.S. states.

METHODS:

In this retrospective cohort study, we analyzed electronic health records for patients receiving telemedicine compared with standard medication abortion at 26 health centers in Alaska, Idaho, Nevada, and Washington from April 2017 to March 2018. All patients had on-site ultrasound scans, laboratory testing, and counseling and provided informed consent before meeting with the clinician. Telemedicine patients met with a clinician by secure videoconference platform; standard patients met with a clinician in person. We also reviewed adverse event reports submitted during this period. Study outcomes included ongoing pregnancy, receipt of or referral for aspiration procedure, and clinically significant adverse events. To compare outcomes between the telemedicine and standard groups, we performed logistic regression accounting for gestational age and health center clustering.

RESULTS:

A total of 5,952 patients underwent medication abortion (738 telemedicine and 5,214 standard). Mean gestational age was 50.4 days for telemedicine patients compared with 48.9 days for standard patients (prevalence ratio 1.02; 95% CI 1.00–1.03). We had outcome data for 4,456 (74.9%) patients; follow-up within 45 days of abortion was lower among telemedicine patients (60.3%) than standard patients (76.9%) (prevalence ratio 0.83; 95% CI 0.78–0.88). Among patients with follow-up data, ongoing pregnancy was less common among telemedicine patients (2/445, 0.5%) than standard patients (71/4,011, 1.8%) (adjusted odds ratio [OR] 0.23; 95% CI 0.14–0.39). Aspiration procedures were less common among telemedicine patients (6/445, 1.4%) than standard patients (182/4,011, 4.5%) (adjusted OR 0.28; 95% CI 0.17–0.46). Fewer than 1% of patients in each group reported clinically significant adverse events. No deaths were reported.

CONCLUSION:

Findings from this study conducted across geographically diverse settings support existing evidence that outcomes for medication abortion provided through telemedicine are comparable with standard provision of medication abortion. Differences in observed outcomes may be due to differential follow-up between groups.
Association Between First-Trimester Subchorionic Hematomas and Pregnancy Loss in Singleton Pregnancies
Authors: Naert Mackenzie N. , Khadraoui Hanaa , Muniz Rodriguez Alberto , Naqvi Mariam , Fox Nathan S.
Published: July 2019

OBJECTIVE:

To assess the association of a first-trimester subchorionic hematoma with pregnancy loss in women with singleton pregnancies.

METHODS:

We conducted a retrospective cohort study of all women with singleton pregnancies presenting for prenatal care before 14 weeks of gestation over a 3-year period at a single obstetric practice. All patients had routine first-trimester ultrasound scans. We reviewed ultrasound data from the first ultrasound scan performed between 6 0/7 and 13 6/7 weeks of gestation and compared rates of pregnancy loss before 20 weeks in women with and without a subchorionic hematoma. Logistic regression analysis was used to control for potential confounding variables.

RESULTS:

From January 2015 to December 2017, a total of 2,446 women met inclusion criteria, 451 (18.4%) of whom had subchorionic hematomas. Women with subchorionic hematomas had their first ultrasound scans at an earlier gestational age (8 5/7 vs 9 6/7 weeks of gestation, P<.001) and were more likely to have vaginal bleeding (33.3% vs 8.1%, P<.001). Maternal age, race, use of in vitro fertilization, body mass index, prior number of losses, and medical comorbidities did not differ between the groups. On univariable analysis, subchorionic hematoma was associated with an increased risk of pregnancy loss before 20 weeks of gestation (7.5% vs 4.9%, P=.026); however, after adjusting for gestational age and vaginal bleeding, this association was no longer significant (adjusted odds ratio 1.13, 95% CI 0.74–1.74). In the 451 women with subchorionic hematomas, no characteristics of the subchorionic hematoma, including size by volume, largest diameter, presence of vaginal bleeding, and presence of an additional subchorionic hematoma, were associated with pregnancy loss. Post hoc power analysis showed we had 80% power to detect an increase in pregnancy loss before 20 weeks of gestation from 4.9% in women with no subchorionic hematoma to 8.3% in women with subchorionic hematoma.

CONCLUSION:

In this cohort of women with singleton pregnancies, subchorionic hematoma before 14 weeks of gestation was not independently associated with pregnancy loss before 20 weeks of gestation.
Screening and Treatment After Implementation of a Universal Perinatal Depression Screening Program
Authors: Miller Emily S. , Wisner Katherine L. , Gollan Jacqueline , Hamade Sara , Gossett Dana R. , Grobman William A.
Published: July 2019

OBJECTIVE:

To evaluate whether initiation of an institutional policy of universal perinatal depression screening was associated with sustained increases in frequency in screening and of depression treatment subsequent to a positive screen.

METHODS:

This retrospective cohort study included women receiving prenatal care in outpatient offices at a single academic medical center from 2008 to 2015. In 2009, an institutional policy of universal perinatal depression screening was disseminated in which screening twice antenatally and again postpartum were recommended. The frequency of screen completion at each recommended time point was compared between the prepolicy and postpolicy cohorts. A test of trend that assessed the frequency of screening each year after policy initiation was used to assess changes over time. The frequency with which care plans were created for women who screened positive for perinatal depression were compared before and after implementation.

RESULTS:

Of the 5,127 women who met inclusion criteria, 4,005 (78%) were in the postpolicy cohort. The frequency of completion of depression screening at the first prenatal visit (0.1% vs 65.5%), in the third trimester (0.0% vs 42.7%), and at the postpartum visit (69.5% vs 90.0%) increased after initiation of the policy (P<.001 for all). The improvement in postpartum depression screening completion persisted after controlling for potential confounders (adjusted odds ratio 5.3, 95% CI 4.4–6.5). After the initial increase in uptake of screening, the frequency of screening at the first and third trimester prenatal visits continued to increase over time (P<.001 for each), although this frequency remained stable for the postpartum visit (P=.29). Women with a positive postpartum depression screen were more likely to have depression treatment recommended or provided by their obstetrician postpolicy (64.7% vs 30.1%, P<.001).

CONCLUSION:

Implementation of an institutional policy of universal perinatal depression screening was associated with improvements in perinatal depression screening with concomitant improvements in depression treatment recommendations for women with a positive postpartum depression screen.
Effects of Educational Interventions on Human Papillomavirus Vaccine Acceptability
Authors: Cory Lori , Cha Beda , Ellenberg Susan , Bogner Hillary R. , Hwang Wei-Ting , Smith Jennifer S. , Haggerty Ashley , Morgan Mark , Burger Robert , Chu Christina , Ko Emily M.
Published: July 2019

OBJECTIVE:

To estimate whether targeted educational interventions can increase human papillomavirus (HPV) vaccine acceptability and knowledge among young women.

METHODS:

An exploratory phase of the study was conducted to determine baseline acceptance of the prophylactic HPV vaccine and barriers to acceptance. Based on the results of that phase of the study, a randomized controlled trial of women aged 12–26 at a single institution was completed. A sample size of at least 84 women in each of three study arms (control, educational handout, or educational video) was planned to detect a 20% difference in vaccine acceptability among arms. All participants completed a survey collecting data on demographics, HPV vaccine preferences, and HPV vaccine knowledge after completion of their randomization assignments. The primary outcome was HPV vaccine acceptability. The secondary outcome was HPV vaccine knowledge.

RESULTS:

From March 2017 through August 2017, 256 women were randomized to one of three study arms: control (n=85), educational handout (n=84), or educational video (n=87). Demographics were similar between study arms. Overall, 51.7% of participants in the educational video arm reported willingness to accept the HPV vaccine compared with 33.3% and 28.2% of participants in the educational handout and control arms, respectively (P<.01). Those in the educational video and handout arms had higher median HPV vaccine knowledge scores than those in the control arm (6 and 5 vs 3, P<.01). Both interventions were reported as helpful in learning (97.7% vs 92.9%, P=.15), but the educational video arm was more likely to be helpful in deciding on vaccination (86.2% vs 70.2%, P<.01).

CONCLUSION:

Targeted educational interventions increase HPV vaccine acceptability and knowledge among young women. Follow up studies are needed to determine whether these interventions also increase rates of vaccine uptake and series completion.

CLINICAL TRIAL REGISTRATION:

Clinicaltrials.gov, NCT03337269.
National Partnership for Maternal Safety
Authors: Krans Elizabeth E. , Campopiano Melinda , Cleveland Lisa M. , Goodman Daisy , Kilday Deborah , Kendig Susan , Leffert Lisa R. , Main Elliott K. , Mitchell Kathleen T. , O'Gurek David T. , D'Oria Robyn , McDaniel Deidre , Terplan Mishka
Published: July 2019

The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.
In-office wide-awake hand surgery versus traditional surgery in the operating room: a comparison of clinical outcomes and healthcare costs at an academic institution
Authors: Rabinowitz Justin , Kelly Thomas , Peterson Ann , Angermeier Eric , Kokko Kyle
Published: July 2019

Background:

Our study compared clinical outcomes and healthcare costs of A1 pulley release performed wide-awake in an office setting to A1 pulley release performed in an operating room with monitored anesthesia care (MAC) at a United States academic institution.

Methods:

A retrospective chart review was performed on consecutive patients who underwent single-digit A1 pulley release wide-awake in an office setting or in an ambulatory surgical center with MAC. Clinical outcomes were assessed using the modified Disabilities Arm Shoulder and Hand (DASH) scores and a telephone questionnaire. Hospital financial records were reviewed for all patients and the summation of professional fee, anesthesiology fee, and hospital fee was calculated to determine healthcare cost. Financial comparisons were stratified by insurance carriers.

Results:

There were 76 patients with complete records: 43 wide-awake, 33 traditional. Both groups had significant improvement in postoperative quick DASH scores. When asked about subsequent surgery, 100% of wide-awake patients and 68% of traditional patients reported they would prefer to be wide-awake. Eighty percent of wide-awake patients said the procedure was less painful or comparable to a procedure at the dentist. Eighty-four percent of wide-awake patients said their experience was better than they expected, compared to 23% of traditional patients. The traditional group had significantly higher total healthcare costs ($2148.62 vs. $607.65), a more than 250% increase in healthcare spending. Professional reimbursement was significantly higher in the wide-awake group ($607.65 vs. $298.83).

Conclusions:

A1 pulley release performed with patients wide-awake in an office setting led to higher patient satisfaction, decreased healthcare spending and higher physician reimbursement than when performed in an operating room with sedation.
Onramp to Scholarship: Putting Clinical Faculty Members on the Path to Academic Productivity
Authors: Cahn Peter S.
Published: July 2019

Many faculty members in the health professions who come from a clinical background lack the research experience to produce original scholarship. Most faculty development programs focus on supporting individual projects, which helps faculty members who are already pursuing an intellectual question to locate useful resources. Those programs provide limited benefit, however, to faculty members without an identified academic project. An independent, health sciences graduate school designed and implemented a solution to create scholarship groups in which early career faculty members joined ongoing projects led by an experienced investigator. Groups presented internally at a midyear check-in and an end of the academic year poster session. Of the four groups launched in September 2017, three pursued systematic reviews or analyses of existing data. At the end of 9 months, all 4 groups had drafted a manuscript for peer review. Collectively, members of the group had made five poster presentations at national or international conferences and hosted one continuing education workshop. The experience suggests that collaborative projects are a viable form of faculty development to enhance scholarly productivity. Borrowing from the postdoctoral model of scientific mentoring, early career faculty members sacrifice some autonomy of intellectual pursuits in exchange for expert guidance. Senior investigators invest time in coaching novice researchers in exchange for additional intellectual labor and perspectives.
A New Multisource Feedback Tool for Evaluating the Performance of Specialty-Specific Physician Groups: Validity of the Group Monitor Instrument
Authors: Bindels Elisa , Boerebach Benjamin , van der Meulen Mirja , Donkers Jeroen , van den Goor Myra , Scherpbier Albert , Lombarts Kiki , Heeneman Sylvia
Published: July 2019

Introduction:

Since clinical practice is a group-oriented process, it is crucial to evaluate performance on the group level. The Group Monitor (GM) is a multisource feedback tool that evaluates the performance of specialty-specific physician groups in hospital settings, as perceived by four different rater classes. In this study, we explored the validity of this tool.

Methods:

We explored three sources of validity evidence: (1) content, (2) response process, and (3) internal structure. Participants were 254 physicians, 407 staff, 621 peers, and 282 managers of 57 physician groups (in total 479 physicians) from 11 hospitals.

Results:

Content was supported by the fact that the items were based on a review of an existing instrument. Pilot rounds resulted in reformulation and reduction of items. Four subscales were identified for all rater classes: Medical practice, Organizational involvement, Professionalism, and Coordination. Physicians and staff had an extra subscale, Communication. However, the results of the generalizability analyses showed that variance in GM scores could mainly be explained by the specific hospital context and the physician group specialty. Optimization studies showed that for reliable GM scores, 3 to 15 evaluations were needed, depending on rater class, hospital context, and specialty.

Discussion:

The GM provides valid and reliable feedback on the performance of specialty-specific physician groups. When interpreting feedback, physician groups should be aware that rater classes' perceptions of their group performance are colored by the hospitals' professional culture and/or the specialty.
Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease Undergoing Percutaneous Coronary Intervention
Authors: Mishra Abhishek , Singh Maninder , Acker Warren W. , Kamboj Sukriti , Sporn Daniel , Stapleton Dwight , Kaluski Edo
Published: July 2019

Aim:

The objective of this article is to review the contemporary literature on the use of antithrombotic therapy in patients with atrial fibrillation (AF) and coronary artery disease after undergoing percutaneous coronary intervention (PCI). Special consideration was given to the type and duration of therapy, treatment strategies for the elderly (≥65 years of age), and strategies to reduce bleeding.

Methods:

Relevant studies were searched through MEDLINE/PubMed, Web of Science, Cochrane Library, ClinicalTrials.gov, and Google Scholar. Of the 236 publications retrieved, 76 were considered relevant including 35 randomized controlled trials, 17 meta-analyses, 16 observational studies, and 8 published major guidelines.

Results:

Most trials, meta-analyses, and guidelines support 1 month of triple therapy (TT) with an oral anticoagulant (OAC), dual antiplatelet agents (DAPT) with aspirin (ASA)/clopidogrel, and, afterward, dual therapy (DT) with OAC and single antiplatelet agent for an additional 11 months, or alternatively DT alone for 12 months after PCI. Individual consideration is given to the risk and impact of stent thrombosis (ST), thromboembolism, and bleeding. Several trials and meta-analyses have also suggested that shorter DAPT duration (≤6 months) may be safer than longer therapy (≥6 months) when weighing the risk of bleeding with ischemic outcomes, especially with newer generation drug-eluting stents. The selective use of proton-pump inhibitors in patients prone to gastrointestinal bleeding who are subjected to prolonged exposure with TT or DT may be beneficial. In the elderly, the risk of bleeding from TT, compared with DT, outweighs the benefit of reducing ischemic events.

Conclusions:

In conclusion, tailoring therapy to the individual patient is recommended considering the ischemic and bleeding risk as well as the risk of thromboembolism. For most patients with AF, 1 month of TT and subsequently DT for additional 11 months are recommended.
Collaborative Deprescribing in Borderline Personality Disorder: A Narrative Review
Authors: Fineberg Sarah K. , Gupta Swapnil , Leavitt Jacob
Published: July 2019

Learning objectives

After participating in this activity, learners should be better able to:

• Assess medication management in patients with borderline personality disorder (BPD)

• Evaluate the role of deprescribing as an active intervention in patients with BPD treated with polypharmacy

Psychopharmacology in borderline personality disorder (BPD) is complicated by comorbid disorders, substance use, sensitivity to side effects, risk of self-harm through medication misuse, and intense but transient symptoms. Patients’ relationships with medications may range from tenuous to highly enmeshed, and may profoundly influence the response to treatment. For these reasons, awareness of current evidence and flexible approaches are particularly relevant to prescribing in BPD. In this narrative review, we illustrate the current status of medication management in BPD by focusing on polypharmacy. We use a single vignette to explore the limitations of prescribing multiple medications and the factors contributing to polypharmacy. With the same vignette, and using the framework of deprescribing, we describe how medication regimens can be reduced to a necessary minimum. Deprescribing, originally developed in geriatric medicine, is an active intervention that involves a risk-benefit analysis for each medication, keeping in mind the patient’s medical and psychiatric status and his or her preferences and values. Deprescribing lends itself well to use in psychiatry and especially in BPD because of its emphasis on the patient’s preferences and on repeated conversations to revisit and update decisions. In addition to elaborating on the deprescribing framework, we provide recommendations for conducting these critical discussions about medications in BPD, with particular attention to the patient’s relationship to the medication. Finally, we summarize our recommendations and strategies for implementing flexible and responsive medication management for patients with BPD. We suggest areas of future research, including testing the efficacy of targeted intermittent medication treatments.
Increasing Incidence of Concussion: True Epidemic or Better Recognition?
Authors: Langer Laura , Levy Charissa , Bayley Mark
Published: July 2019

Objectives:

To provide updated estimates of the incidence of concussion from all causes diagnosed by all physicians in a large jurisdiction, as previous studies have examined only single causes of injury or from smaller specific populations.

Design:

Physician Billing and National Ambulatory Care Reporting System (NACRS) databases were used to identify all Ontario residents with a diagnosis of concussion (ICD-9850.0 andICD-10S06.0) made by physicians between 2008 and 2016, excluding those with moderate to severe traumatic brain injury.

Results:

In total, 1 330 336 people were diagnosed with a concussion between 2008 and 2016. The annual average was 147 815, and 79% were diagnosed in the emergency department. The average annual incidence was 1153 per 100 000 residents. Incidence varied by age, sex, and geography; children younger than 5 years had the highest incidence of concussion, more than 3600 per 100 000 individuals of that age group. Males had higher incidence than females except in older than 65 years age groups. There was a Pearson correlation (+0.669) between sustaining a concussion and living in rural locations.

Conclusion:

The annual incidence of approximately 1.2% of the population is the highest rate of concussion ever reported thorough sampling methods and may represent a closer estimate of the true picture of concussion. Findings may inform future concussion treatment and healthcare planning.
A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Insomnia in Adolescents With Persistent Postconcussion Symptoms
Authors: Tomfohr-Madsen Lianne , Madsen Joshua W. , Bonneville Dominique , Virani Shane , Plourde Vickie , Barlow Karen M. , Yeates Keith Owen , Brooks Brian L.
Published: July 2019

Objective:

Cognitive-behavioral therapy for insomnia (CBT-I) is an effective insomnia treatment but has yet to be applied to adolescents with sleep disruption following concussion. This pilot study evaluated CBT-I to improve insomnia in adolescents with protracted concussion recovery.

Setting:

Tertiary pediatric hospital.

Participants:

Participants (N= 24) were 12 to 18 years old (M= 15.0, SD = 1.4), 15.1 weeks (SD = 9.2) postinjury, and presenting with sleep disruption and persistent postconcussion symptoms.

Design:

A single-blind, parallel-group randomized controlled trial (RCT) design comparing 6 weeks of CBT-I and a treatment-as-usual control group. Outcomes were measured before treatment, at treatment completion, and 4 weeks after completion.

Main Measures:

Primary outcome was Insomnia Severity Index. Secondary outcomes included Pittsburgh Sleep Quality Index, Dysfunctional Beliefs and Attitudes about Sleep Scale, 7-night sleep diary, PROMIS Depression, PROMIS Anxiety, and Health and Behavior Inventory.

Results:

Adolescents who received CBT-I demonstrated large and clinically significant improvements in insomnia ratings at posttreatment that were maintained at follow-up. They also reported improved sleep quality, fewer dysfunctional beliefs about sleep, better sleep efficiency, shorter sleep-onset latency, and longer sleep time compared with those with treatment as usual. There was also a modest reduction in postconcussion symptoms.

Conclusion:

In this pilot RCT, 6 weeks of CBT-I produced significant improvement in sleep in adolescents with persistent postconcussion symptoms. A larger trial is warranted.
Associations of Lifetime Traumatic Brain Injury Characteristics With Prospective Suicide Attempt Among Deployed US Army Soldiers
Authors: Campbell-Sills Laura , Stein Murray B. , Liu Howard , Agtarap Stephanie , Heeringa Steven G. , Nock Matthew K. , Ursano Robert J. , Kessler Ronald C.
Published: July 2019

Objective:

To estimate associations of lifetime traumatic brain injury (TBI) characteristics with prospective suicide attempt among US Army soldiers.

Method:

The Army STARRS (Study to Assess Risk and Resilience in Servicemembers) Pre/Post Deployment Study surveyed 3 Brigade Combat Teams that were deployed to Afghanistan in 2012. Lifetime TBI and past-month postconcussive/post-TBI symptoms were evaluated at predeployment baseline. Recency and number of TBIs were quantified, and TBI severity was classified on the basis of reports of alteration/loss of consciousness and memory lapse. Suicide attempt data came from administrative records and surveys administered after return from deployment. Logistic regression models estimated associations of TBI characteristics with prospective suicide attempt among baseline respondents who were deployed (n= 7677), adjusting for other risk factors including lifetime mental disorder.

Results:

One hundred three soldiers made a suicide attempt over a median follow-up period of 30 months (weighted prevalence = 1.31% [0.14%]). In the final model estimating joint associations of TBI severity/recency and past-month postconcussive/post-TBI symptoms, only postconcussive/post-TBI symptoms were associated with a higher risk of suicide attempt (per standard score increase: AOR [adjusted odds ratio] = 1.31; 95% CI, 1.05-1.63;P= .012).

Conclusions:

Among the lifetime TBI characteristics evaluated at predeployment baseline, only past-month postconcussive/post-TBI symptoms were prospectively associated with an increased risk of suicide attempt following deployment. Detection of postconcussive/post-TBI symptoms could facilitate targeting of Army suicide prevention programs.
Utility of HSV Serology for Chronic Corneal Pathology
Authors: Wang John , Cherfan Daniel G. , Goshe Jeffrey M.
Published: July 2019

Objectives:

The purpose of this study is to determine the utility of obtaining herpes simplex virus (HSV) serology for patients presenting with chronic corneal pathology of unknown etiology for which HSV is a diagnostic consideration.

Methods:

A retrospective analysis was performed of all patients presenting to one cornea specialist (J.M.G.) between August 2011 and April 2018 with a chronic (>6 weeks) corneal condition for which HSV was suspected and serology was performed. Patient demographics, clinical presentation, treatment, final diagnosis, and follow-up duration were recorded.

Results:

Fifty-four patients with a median age of 52 (range: 5–85) years were included in the study. Patients were classified by presenting clinical features as corneal ulcer (46.2%), stromal keratitis (24.1%), superficial keratitis (18.5%), or keratouveitis (11.1%). The seroprevalence of HSV-1 and HSV-2 antibodies were 42.6% and 18.5%, including 5 patients (9.3%) positive for both HSV-1 and HSV-2. Serology impacted management for all patients with negative titers (48.1%), defined as discontinuing antiviral medication, electing not to start antiviral medication, or continuing antiviral medication for a non-HSV etiology (e.g., varicella zoster keratitis). No patients with HSV serology were ultimately diagnosed with HSV keratitis. Median follow-up duration was 1.5 years (range 0.8–6.6 years).

Conclusion:

Although only useful when negative, our study confirms that serology may be useful for excluding HSV as a diagnostic consideration for patients presenting with chronic corneal pathology. The seroprevalence of HSV antibodies for our patient cohort was comparable with previous population-based studies.
Sexual Identity, Adverse Life Experiences, and Cardiovascular Health in Women
Authors: Caceres Billy A. , Markovic Nina , Edmondson Donald , Hughes Tonda L.
Published: July 2019

Background:

Adverse life experiences (ALE; eg, discrimination and sexual abuse) may contribute to cardiovascular disease (CVD) risk in sexual minority women (SMW), but few studies have tested whether ALE explain the association of sexual identity with cardiovascular health (CVH) markers in women.

Objective:

The aim of this study was to examine sexual identity differences in CVH among women and the role of ALE.

Methods:

In the Epidemiologic Study of Risk in Women, we used multinomial logistic regression to assess sexual identity differences (SMW vs heterosexual women [reference group]) in CVH markers (ideal vs poor, intermediate vs poor) using the American Heart Association's Life's Simple 7 metric and the total score. Next, we tested whether the association of sexual identity with the total CVH score was attenuated by traditional CVD risk factors or ALE.

Results:

The sample consisted of 867 women (395 heterosexual, 472 SMW). Sexual minority women were more likely to have experienced discrimination (P < .001) and lifetime sexual abuse (P < .001) than heterosexual women. Sexual minority women were also less likely to meet ideal CVH criteria for current tobacco use (adjusted odds ratio, 0.43; 95% confidence interval, 0.24–0.73) or intermediate CVH criteria for body mass index (adjusted odds ratio, 0.60; 95% confidence interval, 0.40–0.92). Sexual minority women had a lower cumulative CVH score (B [SE] = −0.35 [0.14], P < .01) than heterosexual women. This difference was not explained by traditional CVD risk factors or ALE.

Conclusions:

Smoking, body mass index, and fasting glucose accounted for much of the CVH disparity due to sexual identity, but those differences were not explained by ALE. Health behavior interventions tailored to SMW should be considered.
Falls in Veterans Healthcare Administration Hospitals: Prevalence and Trends
Authors: Young-Xu Yinong , Soncrant Christina , Neily Julia , Boar Shoshana , Bulat Tatjana , Mills Peter D.
Published: July 2019

Introduction:

To provide up-to-date data on fall prevalence and trends in Veterans Health Administration (VHA) hospitals.

Methods:

Data were collected by the VHA Inpatient Evaluation Center (IPEC) between 2011 and 2017, to establish prevalence and trends of falls and major injuries occurring in acute care/intensive care units (AC/ICU), behavior health (BH), and community living center (CLC)/long-term care, using bed days of care (BDOC) as denominators.

Results:

A total of 204,681 falls were reported (rate = 4.8 falls/1,000 BDOC) during the study period, of which 2,549 (1.2%) resulted in a major injury (rate = 6.0/100,000 BDOC). Fall rates decreased over the 6-year study period for all unit types: 10% decrease for BH (p < .0001), 9% decrease for AC/ICU (p < .0001), and 3% decrease for CLC (p = .0043). Major injury rates remained consistent.

Conclusions:

In this large descriptive study, fall and major injury rates varied by nursing unit type in VHA hospitals. Over the 6-year study period, a clinically and statistically significant decrease in fall rates for BH and AC/ICU units was observed as well as a small but statistically significant decrease in fall rates for CLC units. No trend was observed for major injury rates.
Severe influenza: overview in critically ill patients
Authors: Sarda Cristina , Palma Pedro , Rello Jordi
Published: July 2019

Purpose of review

Overview of influenza infection, focusing on outcome and complications in critically ill patients. We also discuss relevant elements in immunopathogenesis and their role as predictors of severity.

Recent findings

Pandemic influenza A (H1N1) virus circulates seasonally and remains the predominant subtype among intensive care patients. Mortality in acute respiratory failure (ARF) is around 20%, independent of influenza subtypes. During severe infection, the imbalance between pro-inflammatory and anti-inflammatory molecules, such as Th1 and Th17 cytokines, is associated with complicated infections and mortality. Primary viral pneumonia presents in more than 70% of ICU influenza patients and more than 50% develop acute respiratory distress syndrome. Bacterial secondary infection occurs in 20% of severe cases and Streptococcus pneumoniae and Staphylococcus aureus remain the prevalent pathogens. Myocarditis and late-onset cardiovascular complications are associated with mortality. Antiviral therapy within 48 h after onset, avoidance of corticosteroids and rescue therapies for ARF or myocarditis, such as extracorporeal membrane oxygenation, improve survival.

The present review summarizes current knowledge on pathogenesis and clinical manifestations of severe influenza. Immunological dysfunction during viral infection correlates with severity and mortality among ICU patients. A theranostics strategy should be implemented to improve outcomes.
Meningitis and encephalitis management in the ICU
Authors: Robinson Christopher P. , Busl Katharina M.
Published: July 2019

Purpose of review

Management of patients with meningitis and encephalitis oftentimes requires ICU level of care. This article is an update on management for meningitis and encephalitis with focus on clinical care in the ICU. Information provided is based on a review of recent studies with focus on studies since 2017.

Recent findings

Advances in diagnostic and treatment approach for different pathogens are presented. Nosocomial meningitis now constitutes a major part of brain infections seen in ICUs in the developed world. Advances in ICU care of central nervous system (CNS) infections include application of newer diagnostic methods, improved understanding and delivery of antibiotics to the CNS, infection prevention for nosocomial infections, and application of neuromonitoring where indicated.

Advances in diagnostics and therapeutic approach to CNS infections are continually made. For intensivists, focus on neuromonitoring and brain resuscitation in critically ill patients with CNS infections may present a path to enhance preservation of brain function and improve outcomes.

Video abstract

http://links.lww.com/COCC/A22.