bluuebunny/crossref_metadata_2025 huggingface dataset:
Antibiotic-impregnated bone cement for preventing infection in patients receiving primary total hip and knee arthroplasty
Authors: Zhang Jin , Zhang Xiao-Yu , Jiang Feng-Li , Wu Yi-Ping , Yang Bei-Bei , Liu Zi-Yun , Liu Dong
Published: December 2019

Background:

Surgical-site infections after primary total joint arthroplasty (TJA) are a significant issue. Antibiotic-impregnated bone cement (AIBC) has been widely used for the treatment of infected joints, but routine use of AIBC in primary TJA remains controversial. In this systematic review, we evaluated the efficacy of AIBC in reducing surgical-site infections after primary TJA.

Methods:

We systematically searched Pubmed, EMbase, Cochrane Library, CMB, CNKI, and WanFang Data for studies (published until June 1, 2019) evaluating AIBC use in reducing infection rates. Two reviewers independently screened the literature according to inclusion and exclusion criteria, extracted data, and assessed the methodological quality of included studies. Meta-analysis was performed using Review Manager 5.3 software. The registration number is CRD42017078341 in PROSPERO.

Results:

In total, 10 studies were included, resulting in a sample size of 13,909 arthroplasty cases. The overall pooled data demonstrated that, compared with systemic antibiotics, AIBC was more effective in decreasing deep infection rates (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.14–0.89, P = .030), although there were higher superficial infection rates with AIBC (OR = 1.53, 95% CI = 1.11–2.11, P = .010). Compared to systemic antibiotics alone, AIBC with systemic antibiotics significantly decreased deep infection rates (OR = 0.55, 95% CI = 0.41–0.75, P = .0001) but there was no difference in superficial infection rates (OR = 1.43, 95% CI = 0.81–2.54, P = .220). In the subgroup analysis, both randomized controlled trials and cohort studies had reduced deep infection rates after primary TJA (OR = 0.61, 95% CI = 0.37–0.99, P = .050 and OR = 0.49, 95% CI = 0.34–0.70, P = .0001, respectively). AIBC decreased deep infection rates in both total hip and knee arthroplasty (OR = 0.25, 95% CI = 0.12–0.52, P = .0002 and OR = 0.62, 95% CI = 0.45–0.87, P = .005, respectively). Deep infection rates were significantly decreased by AIBC with gentamicin (OR = 0.31, 95% CI = 0.20–0.49, P < .00001) but unaffected by AIBC with cefuroxime (OR = 0.35, 95% CI = 0.10–1.20, P = .100). Deep infection rates in the AIBC and control groups were similar when laminar airflow was applied to the operating room (OR = 0.90, 95% CI = 0.60–1.35, P = .620); however, without laminar airflow, the efficacy of AIBC in decreasing deep infection rates was significantly higher than that of control group (OR = 0.21, 95% CI = 0.08–0.59, P = .003).

Conclusions:

AIBC may significantly decrease deep infection rates after primary total hip and knee arthroplasty, with or without systemic antibiotics.
Polymorphism of MPT64 and PstS1 in Mycobacterium tuberculosis is not likely to affect relative immune reaction in human
Authors: Xiao Tongyang , Jiang Yi , Li Guilian , Pang Hui , Zhao Lili , Zhao Xiuqin , Wan Kanglin
Published: December 2019

Background:

MPT64 and PstS1 are the earliest known immune-dominant antigens of Mycobacterium tuberculosis and have been commonly used as candidates in the diagnosis of tuberculosis.

Methods:

We constructed recombinant plasmids pET-32a-Rv0934 and pET-32a-Rv1980c to express both wild and mutant forms of MPT64 and PstS1 and purified them. From November 9 to December 9, 2016, and November 9 to December 10, 2017, 96 patients with tuberculosis, 53 patients without tuberculosis, and 96 healthy volunteers were enrolled in this study. We used the purified proteins as antigens to perform T-spot and enzyme-linked immunosorbent assay (ELISA) for samples obtained from healthy volunteers and tuberculosis patients.

Results:

Regarding T-spot, the area under the curve (AUC) values for MPT64-wild protein (MPT64-H37Rv) and MPT64-mutant protein (MPT64-FJ05395) were 0.723 and 0.750, respectively. The AUC values for PstS1-H37Rv, PstS1-FJ05132, and PstS1-JL06035 were 0.817, 0.796, and 0.745, respectively. With regard to ELISA, the AUC values for MPT64-H37Rv and MPT64-FJ05395 were 0.525 and 0.528, respectively, while those for PstS1-H37Rv, PstS1-FJ05132, PstS1-JL06035 were 0.588, 0.509, and 0.560, respectively. There was no difference between wild and mutant proteins when we used them as antigens to perform T-spot and ELISA assays.

Conclusion:

MPT64 and PstS1 are likely candidate diagnostic antigens for M tuberculosis T-spot test, at least in combination with other proteins. Polymorphisms of MPT64 and PstS1 had little effect on cell-mediated and humoral immunity in the host.
A rare case of extraluminal gastrointestinal stromal tumor of the ileum presenting with lower urinary tract symptoms
Authors: Yu Chung-Hao , Ting Hui-Kung , Kao Chien-Chang , Tsai Wen-Chiuan , Wu Sheng-Tang , Yu Dah-Shyong
Published: December 2019

Introduction:

Benign prostatic hyperplasia, bladder outlet obstruction, and overactive bladder are major causes of lower urinary tract symptoms (LUTS). Tumor compression of the urinary bladder resulting in LUTS was clinically observed. Gastrointestinal stromal tumors (GISTs) presenting with LUTS have not been reported before. Herein, we report a patient with extraluminal GIST of the ileum who had LUTS without gastrointestinal symptoms during the clinical course.

Patient concerns:

A 68-year-old man visited the genitourinary outpatient department because of frequent urination with mild dysuria. He also complained of poor appetite, fatigue, and body weight loss of 10 kg over 6 months. A large presacral solid mass lesion compressing the bladder and surrounded by the bowel with gas content was identified through abdominal computed tomography.

Diagnosis:

GIST of the ileum with mesenteric invasion was revealed by pathological examination.

Interventions:

Exploratory laparotomy with removal of the pelvic tumor and segmental resection of the ileum was performed.

Outcomes:

Now, he received adjuvant imatinib target therapy for 1 year with stable condition.

Conclusion:

Extravesical compression or invasion of the urinary bladder by a pelvic mass lesion is common but is rarely accompanied by GISTs of the ileum. Specific findings identified through imaging should alert the surgeon to this specific entity and prepare thoroughly before surgical intervention.
Penile resurfacing using a reverse bilateral anterior scrotal artery flap
Authors: Gao Qing-Guo , Qu Wenrui
Published: December 2019

Rationale:

Circumcision is one of the most frequently used surgical procedures worldwide. Extensive penile skin defects, which can occur as a rare but severe complication of circumcision, are serious and frustrating problems for patients who experience them. Procedures for correcting these problems can pose a challenge to plastic surgeons in the clinic.

Patient concerns:

A 31-year-old man was admitted to our care with an extensive defect of the penile skin caused by a circumcision performed 20 days previously.

Primary diagnoses:

Infection, necrosis, and defects of the penile skin.

Interventions:

A reverse bilateral anterior scrotal flap was used to correct complete penile skin loss following debridement of the infected and necrotic tissue.

Outcomes:

The patient experienced no complications during the 10-year follow-up period. The patient reported normal erectile function and the ability to perform intercourse.

Lessons:

The reverse bilateral anterior scrotal artery flap is suitable for repairing skin defects of the penis and allows for satisfactory cosmetic and functional improvement following defects of the penile skin.
Two cases of intrauterine pregnancy with tubal stump pregnancy after in vitro fertilization and embryo transfer following ipsilateral salpingectomy
Authors: Xi Qi , Yu Yang , Zhang Xinyue , Zhang Hongguo , Jiang Yuting , Liu Ruizhi , Zhang Han
Published: December 2019

Rationale:

The recently increased rate of heterotopic pregnancies (HPs) has been largely attributed to the increased use of assisted reproduction technologies (ARTs). HP is a rare and potentially life-threatening condition. It is unusual in natural conception cycles, occurring in 1:10,000 to 1:50,000 pregnancies. However, with the increased use of ART such as in vitro fertilization and embryo transfer (IVF–ET), the incidence has risen to 0.5–1%.

Patient concerns:

Case 1 was a 28-year-old woman who presented to our center complaining of a sudden onset of right-side lower abdominal pain with a small amount of vaginal bleeding. She had undergone IVF–ET and received a thawed embryo transfer with two embryos 23 days previously. She had a history of right salpingectomy for an ectopic pregnancy during the downregulation of her ovulatory cycle 1 year ago. Case 2 was a 25-year-old woman who presented to our center complaining of a sudden onset of right-side lower abdominal pain. She had also undergone thawed embryo transfer following IVF–ET with two embryos 35 days previously. She had a history of right salpingectomy for an ectopic pregnancy 1.5 years previously.

Diagnoses:

Both patients were diagnosed as having a heterotopic pregnancy.

Interventions:

Patient 1 underwent emergency laparoscopy; patient 2 underwent emergency laparotomy and both were treated medically to prevent abortion of the intrauterine pregnancies.

Outcomes:

Patient 1 had an incomplete abortion and underwent uterine curettage on the day 10 after the operation. Patient 2 experienced no further complications during pregnancy and a healthy baby girl was born at the 38th gestational week.

Lessons:

Reproductive physicians need to pay more attention to patients who have received more than one embryo at transfer, especially those with a history of salpingectomy.
Improving the position of resuscitation team leader with simulation (IMPORTS); a pilot cross-sectional randomized intervention study
Authors: Saiboon Ismail M. , Apoo Farah N. , Jamal Shamsuriani M. , Bakar Afliza A. , Yatim Fadzlon M. , Jaafar Johar M. , Berg Benjamin W.
Published: December 2019

Background:

Leadership and teamwork are important contributory factors in determining cardiac resuscitation performance and clinical outcome. We aimed to determine whether fixed positioning of the resuscitation team leader (RTL) relative to the patient influences leadership qualities during cardiac resuscitation using simulation.

Methods:

A cross-sectional randomized intervention study over 12 months’ duration was conducted in university hospital simulation lab. ACLS-certified medical doctors were assigned to run 2 standardized simulated resuscitation code as RTL from a head-end position (HEP) and leg-end position (LEP). They were evaluated on leadership qualities including situational attentiveness (SA), errors detection (ED), and decision making (DM) using a standardized validated resuscitation-code-checklist (RCC). Performance was assessed live by 2 independent raters and was simultaneously recorded. RTL self-perceived performance was compared to measured performance.

Results:

Thirty-four participants completed the study. Mean marks for SA were 3.74 (SD ± 0.96) at HEP and 3.54 (SD ± 0.92) at LEP, P = .48. Mean marks for ED were 2.43 (SD ± 1.24) at HEP and 2.21 (SD ± 1.14) at LEP, P = .40. Mean marks for DM were 4.53 (SD ± 0.98) at HEP and 4.47 (SD ± 0.73) at LEP, P = .70. The mean total marks were 10.69 (SD ± 1.82) versus 10.22 (SD ± 1.93) at HEP and LEP respectively, P = .29 which shows no significance difference in all parameters. Twenty-four participants (71%) preferred LEP for the following reasons, better visualization (75% of participants); more room for movement (12.5% of participants); and better communication (12.5% of participants). RTL's perceived performance did not correlate with actual performance

Conclusion:

The physical position either HEP or LEP appears to have no influence on performance of RTL in simulated cardiac resuscitation. RTL should be aware of the advantages and limitations of each position.
A comparative analysis of physical fitness of children and adolescents with HIV infection
Authors: Medeiros Rafaela Catherine da Silva Cunha de , Santos Isis Kelly dos , Damasceno de Goes Carlos Jean , Vasconcelos de Oliveira Anna Luiza , Medeiros Jason Azevedo de , Cobucci Ricardo Ney , Dantas Paulo Moreira Silva
Published: December 2019

Background:

The impaired physical capacity of children and adolescents with HIV can directly influence their physical performance, activities of daily living and social participation. The purpose of this systematic review protocol is to perform a systematic review and meta-analysis on physical fitness (cardiorespiratory capacity, agility, flexibility, strength, and muscular endurance) in children and adolescents with HIV, compared with healthy controls.

Methods:

We will be following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol (PRISMA-P) statement guidelines. There will be cross-sectional, longitudinal and case-controlled studies, and there will be no restrictions on language and year of publication in the search. The search strategy will be to use databases including: MEDLINE (via PubMed), EMBASE (via Ovid), Web of Science, Scopus, SportDiscus and CINAHL; The MeSH terms will be: physical fitness, fitness trackers, agility, flexibility, physical endurance, muscle strength, aerobic capacity, human immunodeficiency virus, HIV, children, and adolescents, to discuss and compare physical fitness (cardiorespiratory capacity, agility, flexibility, strength, and muscular endurance) in children and adolescents with HIV and healthy control. The reviewers will independently read the articles, extract the data information and analyze the risk of bias using the Cochrane criteria for observational studies. The Cohen's will be used to calculate the agreement between the revisions.

Results:

This study will provide a high-quality synthesis of observational studies on the analysis and comparison of physical fitness in children and adolescents with HIV compared with healthy controls.

Conclusion:

This systematic review will be very important for the creation of proposals aimed at providing high quality subsidies in the management of HIV during the development phase of children and adolescents.

Ethics and dissemination

Ethics approval is not required because individual patient data and privacy were not involved in this study.

PROSPERO registration number

CRD42019140955.

PROSPERO registration date

23/09/2019.
Evaluating and monitoring bone marrow hypoplasia in adults with aplastic anemia via high-resolution iliac magnetic resonance imaging in the current era
Authors: Yang Xiawan , Bai Yanliang , Guo Huihui , Shi Mingyue , Zhang Wanjun , Pei Yanru , Song Juanjuan , Drokow Emmanuel Kwateng , Huang Gairong , Liu Xiang , Xu Junling , Kai Sun
Published: December 2019

The diagnosis and monitoring of aplastic anemia (AA) rely heavily on a complete blood count (CBC), and multiple-site bone marrow (BM) aspirations and biopsies. However, these approaches have certain limitations. We aimed to assess high-resolution magnetic resonance imaging (MRI) as a complementary approach for evaluating BM hypoplasia and monitoring treatment response in adults with AA in the current era.

Twelve newly diagnosed AA patients and 12 sex- and age-matched healthy controls were enrolled in this study from January 2017 to August 2018. A bilateral iliac 3.0T MRI was used to collect data for each subject, and the signal intensity on the T1-weighted images (T1WIs) were expressed as a contrast-to-noise ratio (CNR). The MRI, CBC, and BM biopsy data were analyzed and compared.

A qualitative analysis identified a significant difference in MRI signal characteristics between the AA group and the healthy control group. The clinical classifications of very severe aplastic anemia (VSAA) and severe aplastic anemia (SAA) corresponded to pattern I and pattern II on the MR images, respectively. However, this imaging classification did not correlate with the biopsy-based BM cellularity measure. A quantitative analysis showed a significantly higher signal intensity in AA patients than in controls. A within-group comparison revealed that more severe types of AA, based on the clinical classification, corresponded to stronger signals. Notably, MRI could detect treatment response earlier than CBC, regardless of whether there were improvements in hematopoiesis.

MRI can be used to predict the therapeutic effects in patients with AA and is an important complementary tool for evaluating and monitoring BM hypoplasia.
Case report of coronary artery fistula
Authors: Punzo Bruna , Forte Ernesto , Salvatore Marco , Cavaliere Carlo , Cademartiri Filippo
Published: December 2019

Rationale:

Unlike invasive coronary angiography and echocardiography, cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) imaging allow a coronary artery fistula (CAF) comprehensive evaluation focusing on both coronary and myocardial findings.

Patient concerns:

We present the case of an asymptomatic patient suspected for CAF and referred to our structure for cardiovascular evaluation.

Diagnosis:

The patient was diagnosed a CAF without coronary artery disease on the basis of CMR and CCT.

Interventions:

The patient underwent an invasive coronary angiography after which the medical staff decided not to surgically treat the CAF. Therefore, a conservative treatment was chosen with strict temporal monitoring.

Outcomes:

After less than 1 year follow-up, the patient presented stable conditions without complaints.

Lessons:

Multimodal non-invasive imaging has a key role in patient assessment for disease diagnosis providing better understanding for prognosis and treatment.
A rare case of giant synovial osteochondromatosis of the thigh
Authors: Liu Shuzhong , Zhou Xi , Song An , Huo Zhen , Wang Yipeng , Liu Yong
Published: December 2019

Rationale:

Giant synovial osteochondromatosis of the thigh is a highly unusual disease without standard diagnosis and curative managements so far. Our focus is to report a very rare case of giant synovial osteochondromatosis successfully operated by surgical treatment. The management of these unique cases has certain educational significance in clinical practice.

Patient concerns:

A 63-year-old previously healthy man presented to our institution with a 4-year history of continuous progressive hip pain and local numbness of right side in January 2018. One month ago, the patient felt that the above symptoms were aggravated, and the right hip and proximal thigh were significantly swollen.

Diagnosis:

Computed tomography and magnetic resonance imaging of the hip revealed the irregular mass in his right thigh. Post-operative pathology confirmed the diagnosis of synovial osteochondromatosis of the thigh.

Interventions:

Considering the large volume of the mass and possibility of malignancy, the patient underwent surgical exploration and complete tumor resection.

Outcomes:

The patient's neurological deficits and symptoms improved significantly after the surgery, and the postoperative period was uneventful at the 1-year follow-up visit. There were no complications associated with the operation during the follow-up period.

Lessons:

Taken together, the lesion's clinical features, imaging results, and pathological characteristics are unique. Synovial osteochondromatosis of the thigh, although rare, should be part of the differential diagnosis when the patient presents with local pain, numbness, swelling or other symptoms. We recommend surgical treatment for the occupying lesion when the tumor has caused symptoms or neurological deficits.
Relationship between genetic mutations and clinical phenotypes in patients with Wilson disease
Authors: Zhu Qingwen , Zhu Keyu , Wang Jing , Bian Wenjun , Lu Jianxun
Published: December 2019

To study the relationship between genotype and clinical phenotype of major gene mutation sites in patients with Wilson disease (WD).

Clinical and laboratory data were collected from 40 children with WD admitted to the hospital by high-pass sequencing. The basic clinical data of patients included the following: age, sex, first symptom, K-F ring, clinical classification, serum Ceruloplasmin (CP), 24 hours urine copper. High Frequency Mutations were identified in WD patients: Exon 8, Ar9778Leu, and study the relationship between high frequency mutation and clinical phenotype.

The mutation frequency of 2333G>T(Arg778Leu) in Exon 8 was the highest (48%). The mutation frequency of Exon 13 at 2975C>T site was 29%. The age (t = 0.296, P = .768), sex (χ
2 = 0.005, P = .944), first symptom (χ
2 = 0.480, P = .449), K-F ring (χ
2 = 0.321, P = .17), clinical classification (χ
2 = 20.064, P > .969), serum CP levels (t = 0.007, P = .897) had no significant difference between Arg778Leu mutation group and non-Arg778Leu mutation group. Twenty-four-hour urinary copper levels (t = 12.134, P < .001,) in the Arg778Leu mutation group were higher than those in the Arg778Leu mutation group.

Arg778Leu mutation is associated with 24 hours urinary copper. The study of the association between the type of gene mutation and the clinical phenotype has important implications for the occurrence regularity, pathogenesis, and disease progression in patients with WD.
Successful treatment of fulminant myocarditis in an adult in emergency department
Authors: Liu Danyu , Xu Jun , Yu Xuezhong
Published: December 2019

Rationale:

Fulminant myocarditis (FM) has poor prognosis and the usual treatment is inotropes and symptomatic support. The initiation of extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP) in the emergency department (ED) is a rare event.

Patient concerns:

We report the case of a 45-year-old man with a complaint of 4 days of high fever and dry cough in the emergency department.

Diagnosis:

Transthoracic echocardiogram and the medical history showed presumptive diagnosis was fulminant myocarditis with cardiogenic shock.

Interventions:

The patient's condition deteriorated drastically and ECMO was initiated immediately after admission. He experienced electrical storm twice during ECMO support and was successfully treated with the combination with IABP.

Outcomes:

ECMO and IABP were continued for 11 and 14 days respectively. The patient was discharged on the 81th day after admission, with all his laboratory tests returned to normal.

Lessons subsections:

The early initiation of ECMO and IABP in the ED is potentially life-saving for suitable patients with FM. It appears promising but has not yet been routinely implemented in underdeveloped and developing countries.
Associations of nutrient intakes with glaucoma among Japanese Americans
Authors: Yoserizal Muhammad , Hirooka Kazuyuki , Yoneda Masayasu , Ohno Haruya , Kobuke Kazuhiro , Kawano Reo , Kiuchi Yoshiaki
Published: December 2019

The aim of this study was to investigate possible associations of nutrient intake on glaucoma in subjects of Japanese descent living in Los Angeles, CA.

In this cross-sectional study, 581 Japanese American participants in Los Angeles underwent an interview, fundus photography, comprehensive physical, and blood examinations, along with determining the body mass index status and any confounding factors. CDSketch was used to measure the cup-disc ratio and rim width of each fundus in the retinal photographs. A multivariate logistic regression test with adjustment for confounding factors was used to assess the association between glaucoma and nutrient intake.

A total of 61 of 581 participants were diagnosed with glaucoma in this study. Multivariate logistic regression analysis showed that a high intake of iron (odds ratio [OR]: 1.303, P = .004), low intake of vitamin A (OR: 0.365, P = .019), and vegetable fat (OR: 0.957, P = .004) were associated with an increased risk of glaucoma.

Current findings showed that high iron intake and low vitamin A and vegetable fat intake appeared to be associated with an increased risk of glaucoma in subjects of Japanese descent living in the Los Angeles populations.
Being a Research Mentor
Authors: Clark Rebecca Culver , Jennings Cathy D. , Carter Kimberly F.
Published: December 2019

OBJECTIVES

This qualitative study was designed to describe the experiences of mentors for a nursing research fellowship at a southeastern US academic medical center.

BACKGROUND

Mentoring is an important aspect of nursing and is a key strategy to develop nurse leaders and faculty. Research mentors have been identified as essential for novice researchers to be able to complete clinical studies. However, there has been limited research on the experience of nursing research mentors, despite the emphasis on the critical nature of this role.

METHODS

Eight mentors for 23 studies over 8 years of a nursing research fellowship participated in a study outlining their experiences as research mentors.

RESULTS

Common themes emerged from mentors' identification of key components in the research mentoring process and elements necessary for effective support of frontline nurse researchers.

CONCLUSIONS

Recommendations for developing effective, confident research mentors are drawn from the analyses.
Data Entry Automation Improves Cost, Quality, Performance, and Job Satisfaction in a Hospital Nursing Unit
Authors: Bauer Jeffrey C. , John Eileen , Wood Christopher L. , Plass Debra , Richardson Dale
Published: December 2019

OBJECTIVE

An Automated Data Entry Process Technology tool was developed to free nurses from data entry tasks, thus creating time for patient care and other activities associated with improvements in performance and job satisfaction.

BACKGROUND

Manually transferring data from patient measurement devices to electronic health records (EHRs) is an intensive, error-prone task that diverts nurses from patient care while adversely affecting job performance and employee satisfaction.

METHODS

Performance improvement analytics were used to compare matched sets of manual and automated EHR data entries for 1933 consecutive vital signs records created by 49 RNs and certified nursing assistants in a 23-bed medical-surgical unit at a large tertiary hospital. Performance and quality effects were evaluated via nurses' responses to a postintervention survey.

RESULTS

Data errors decreased from approximately 20% to 0; data transfer times were reduced by 5 minutes to 2 hours per measurement event; nurses had more time for direct patient care; and job satisfaction improved.

CONCLUSION

Data entry automation eliminates data errors, substantially reduces delays in getting data into EHRs, and improves job satisfaction by giving nurses more time for direct patient care. Findings are associated with improvements in quality, work performance, and job satisfaction, key goals of nursing leaders.
The Impact of Interprofessional Shared Governance and a Caring Professional Practice Model on Staff's Self-report of Caring, Workplace Engagement, and Workplace Empowerment Over Time
Authors: Olender Lynda , Capitulo Kathleen , Nelson John
Published: December 2019

OBJECTIVE

To describe the impact of the implementation of interprofessional shared governance and a caring professional practice model (Relationship-Based Care [RBC]) on the staff's self-report of caring, work engagement, and workplace empowerment over a 4-year time frame.

BACKGROUND

Shared or interprofessional governance has moved mainstream within healthcare settings, particularly within agencies seeking to sustain high reliability in the offering of quality patient care services and/or interest in meeting Magnet® standards or embarking upon the Pathway to Excellence®. Nurse leaders report that organizations having implemented shared governance thrive, citing professional governance as key to workplace engagement and empowerment, particularly related to quality care initiatives. Transition to interprofessional shared governance structures typically takes 2 to 3 years. It is unknown whether related outcome variables are sustainable over time.

METHODS

Utilizing Watson's theory of human caring and appreciative inquiry as underlying frameworks, a longitudinal, quantitative study design was employed. Interprofessional focus groups and introductory sessions were offered to inform and engage all personnel within the medical center. Motivated units were identified, professional shared governance council members elected, and unit-specific education provided. Quality improvement initiatives were facilitated within unit councils, and formal leadership programs to enhance project guidance and to support staff empowerment skills for the managers of the units that were up-and-running were provided. Preimplementation and postimplementation measurements of staff's caring, workplace engagement and work empowerment were assessed, compared, and trended across units over time.

RESULTS

Only work empowerment scores among staff working within RBC units were sustainable and increased progressively and significantly over time. Work engagement levels initially rose and then stabilized over time. Caring levels remained stable despite the implementation of a caring professional practice model. Statistically significant correlations were noted between work engagement and empowerment, followed by the relationship between work engagement and caring, followed by the relationship between empowerment and caring.

CONCLUSIONS

The sustainability of work empowerment is likely related to the periodic provision of education for leaders regarding leading within an empowered work environment. A stronger focus on staff caring, particularly within quality improvement initiatives, with leadership guidance, will be paramount moving forward.
Virtual Simulation to Increase Self-efficacy Through Deliberate Practice
Authors: Mabry Jennifer , Lee Emily , Roberts Toni , Garrett Rebecca
Published: December 2019

Background

To reduce performance anxiety and increase engagement in medical-surgical simulations, virtual simulation (VS) was introduced prior to complex high-fidelity simulation to increase students' self-efficacy.

Problem

A presimulation preparation needed to be expanded for high-fidelity simulation involving emergent clinical situations.

Approach

Combined frameworks of Ericsson's theory of deliberate practice and Bandura's self-efficacy theory were applied. Students completed VS scenarios until a specific score of mastery was obtained, and then the same scenario was repeated in the high-fidelity simulation laboratory. A modified self-efficacy scale survey was administered presimulation and postsimulation. Data were collected on 3 cohorts of students (n = 151) over an academic year.

Outcomes

VS followed by high-fidelity simulation significantly increased student perception of self-efficacy in all 3 cohorts (P = .001, P = .037, P = .005).

Conclusion

Preparation for high-fidelity simulation using VS increases self-efficacy and allows students to engage in the simulation experience, thus achieving higher levels of mastery through deliberate practice.
Emergency Department Implementation of the Brain Trauma Foundation's Pediatric Severe Brain Injury Guideline Recommendations
Authors: Lumba-Brown Angela , Totten Annette , Kochanek Patrick M.
Published: December 2019

The “Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines” published in Pediatric Critical Care Medicine in 2019 provides new and updated recommendations applicable to the emergency department management of children with severe traumatic brain injury. Practice-changing takeaways include specific recommendations for administration of 3% hypertonic saline, administration of seizure prophylaxis, and avoiding hyperventilation.
Fast Brain Magnetic Resonance Imaging With Half-Fourier Acquisition With Single-Shot Turbo Spin Echo Sequence in Detection of Intracranial Hemorrhage and Skull Fracture in General Pediatric Patients
Authors: Kabakus Ismail Mikdat , Spampinato Maria Vittoria , Knipfing Michael , Cervantes Gustavo , Patel Avni , Eskandari Ramin , Yazdani Milad
Published: December 2019

Objective

The objective of this study was to determine the accuracy of fast brain magnetic resonance imaging (MRI) in the detection of intra- and extra-axial intracranial hemorrhage compared with standard-of-care computed tomography (CT) or MRI in pediatric patients. Unlike previous studies, we did not focus exclusively on patients with head trauma. We evaluated the fast brain MRI findings in a general pediatric population referred for indications other than evaluation of ventricular size.

Methods

We retrospectively reviewed 48 pediatric patients with indications other than hydrocephalus and shunt follow-up, who underwent a standard head CT or standard MRI within 15 days of the fast brain MRI. All fast brain MRI scans included half-Fourier acquisition with single-shot turbo spin echo (HASTE) sequences in the axial, coronal, and sagittal plane. Two neuroradiologists blinded to patient information and study indications reviewed the fast brain MRI studies independently and then concurrently.

Results

A total of 48 patients met the inclusion and exclusion criteria. The median and mean time interval between the standard and fast imaging were 2 and 3.9 days, respectively. The sensitivity and specificity of fast brain MRI to detect intraparenchymal hemorrhage were 100% and 97%, respectively. The sensitivity and specificity of fast brain MRI in the detection of extra-axial hemorrhage (subdural and/or epidural) were 86% and 96%, respectively. The sensitivity and specificity of fast brain MRI were, respectively, 10% and 100% for subarachnoid hemorrhage, 50% and 100% for intraventricular hemorrhage, and 47% and 97% for skull fracture, respectively.

Conclusions

Our results show that fast brain MRI with HASTE sequence is as sensitive as CT and standard MRI in the detection of intra-axial hemorrhage and has moderate sensitivity in the detection of extra-axial hemorrhage. Our preliminary results show that T2-weighted HASTE imaging may be suitable for the follow-up of intraparenchymal and extra-axial (subdural and/or epidural) hemorrhages.
Can We Expect Any Effect of Rituximab on Fatigue in Primary Sjögren Syndrome?
Authors: Hermans An-Marie , Vulsteke Jean-Baptiste , Lenaerts Jan , De Langhe Ellen
Published: December 2019

Introduction

Fatigue is a major determinant of impaired quality of life in primary Sjögren syndrome (pSS) patients. Effective therapeutic strategies are lacking.

Objectives

To review the potential benefit of rituximab, a chimeric anti-CD20 antibody, in the treatment of fatigue in pSS.

Methods

A systematic review on the effect of rituximab on fatigue-related outcome measures was conducted, retrieving evidence from CENTRAL (Cochrane Central Register of Controlled Trials), MEDLINE (via PubMed), EMBASE, and Scopus.

Results

No benefit of rituximab over placebo on any fatigue-related outcome measure could be demonstrated in the included trials. Significant effects were only observed when compared with baseline, but not when compared with placebo.

Conclusions

The use of rituximab for the treatment of pSS-related fatigue cannot be supported by the currently available evidence.
Coaching as a Mechanism to Challenge Surgical Professional Identities
Authors: Byrnes Mary E. , Engler Tedi A. , Greenberg Caprice C. , Fry Brian T. , Dombrowski Janet , Dimick Justin B.
Published: December 2019

Background:

The “surgical personality” is a mostly negative academic and cultural image of the surgeon as egotistical, paternalistic, and inflexible. Because of this image, surgeons have been viewed as resistant to change and some behaviors, vulnerability, for example, are viewed as “suspect” because they seemingly threaten professional competency. We report on exit interviews of surgeons who participated in a coaching program and demonstrate how their narratives challenge the surgical “personality” and forge an evolving and more open professional surgical identity.

Methods:

We interviewed n = 34 bariatric surgeons at the end of a 2-year surgical coaching program. Transcribed interviews were analyzed in NVivo, computer-assisted qualitative data analysis software. Coding of transcripts was approached through iterative steps. We utilized an exploratory method; each member of our team independently examined 3 transcripts to evaluate emergent themes early in the investigation. The team met to discuss our independent themes and develop the codebook collectively. We created a descriptive framework for our first round of coding based on emerging themes and employed an interpretive framework to arrive at our themes.

Results:

Three major themes emerged from our data. Participants in this study discussed the ways that participation in the coaching program initially conflicted with their identity as a competent professional. Surgeons were acutely aware of how participation might have destabilized their surgical identity because they might be viewed as vulnerable. Despite these concerns about image, surgeons found impetus for improvement because of poor outcome scores or because they desired early career affirmation. Finally, surgeons report that the safe spaces of intentional coaching contributed to their ideas about how surgeons, and ultimately surgery, can change.

Conclusions:

Participation in a coaching program challenged how surgeons thought of themselves in relationship to social and peer expectations. Our results indicate that surgeons do feel peer and social pressures related to identity but are much more complex and nuanced than has been previously discussed. The safe space of intentional coaching allowed participants to practice vulnerability without the pressures of sometimes caustic professional norms. Participants in this study viewed coaching as the way to improve the culture of surgery.
Regionalization of emergency general surgery operations: A simulation study
Authors: Becher Robert D. , Sukumar Nitin , DeWane Michael P. , Gill Thomas M. , Maung Adrian A. , Schuster Kevin M. , Stolar Marilyn J. , Davis Kimberly A.
Published: December 2019

BACKGROUND

It has been theorized that a tiered, regionalized system of care for emergency general surgery (EGS) patients—akin to regional trauma systems—would translate into significant survival benefits. Yet data to support this supposition are lacking. The aim of this study was to determine the potential number of lives that could be saved by regionalizing EGS care to higher-volume, lower-mortality EGS institutions.

METHODS

Adult patients who underwent one of 10 common EGS operations were identified in the California Inpatient Database (2010–2011). An algorithm was constructed that “closed” lower-volume, higher-mortality hospitals and referred those patients to higher-volume, lower-mortality institutions (“closure” based on hospital EGS volume-threshold that optimized to 95% probability of survival). Primary outcome was the number of lives saved. Fifty thousand regionalization simulations were completed (5,000 for each operation) employing a bootstrap resampling method to proportionally redistribute patients. Estimates of expected deaths at the higher-volume hospitals were recalculated for every bootstrapped sample.

RESULTS

Of the 165,123 patients who underwent EGS operations over the 2-year period, 17,655 (10.7%) were regionalized to a higher-volume hospital. On average, 128 (48.8%) of lower-volume hospitals were “closed,” ranging from 68 (22.0%) hospital closures for appendectomy to 205 (73.2%) for small bowel resection. The simulations demonstrated that EGS regionalization would prevent 9.7% of risk-adjusted EGS deaths, significantly saving lives for every EGS operation: from 30.8 (6.5%) deaths prevented for appendectomy to 122.8 (7.9%) for colectomy. Regionalization prevented 4.6 deaths per 100 EGS patient-transfers, ranging from 1.3 for appendectomy to 8.0 for umbilical hernia repair.

CONCLUSION

This simulation study provides important new insight into the concept of EGS regionalization, suggesting that 1 in 10 risk-adjusted deaths could be prevented by a structured system of EGS care. Future work should expand upon these findings using more complex discrete-event simulation models.

LEVEL OF EVIDENCE

Therapeutic/Care Management, level IV.
An analysis of outcomes and predictors of intensive care unit bouncebacks in a mature trauma system
Authors: Bradburn Eric H. , Jammula Shreya , Horst Michael A. , Morgan Madison , Vernon Tawnya M. , Gross Brian W. , Miller Jo Ann , Cook Alan D. , Kim Patrick K. , Von Nieda Danielle , Rogers Frederick B.
Published: December 2019

BACKGROUND

With the recent birth of the Pennsylvania TQIP Collaborative, statewide data identified unplanned admissions to the intensive care unit (ICU) as an overarching issue plaguing the state trauma community. To better understand the impact of this unique population, we sought to determine the effect of unplanned ICU admission/readmission on mortality to identify potential predictors of this population. We hypothesized that ICU bounceback (ICUBB) patients would experience increased mortality compared with non-ICUBB controls and would likely be associated with specific patterns of complications.

METHODS

The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2012 to 2015 for all ICU admissions. Unadjusted mortality rates were compared between ICUBB and non-ICUBB counterparts. Multilevel mixed-effects logistic regression models assessed the adjusted impact of ICUBB on mortality and the adjusted predictive impact of 8 complications on ICUBB.

RESULTS

A total of 58,013 ICU admissions were identified from 2012 to 2015. From these, 53,715 survived their ICU index admission. The ICUBB rate was determined to be 3.82% (2,054/53,715). Compared with the non-ICUBB population, ICUBB patients had a significantly higher mortality rate (12% vs. 8%; p < 0.001). In adjusted analysis, ICUBB was associated with a 70% increased odds ratio for mortality (adjusted odds ratio, 1.70; 95% confidence interval, 1.44–2.00; p < 0.001). Adjusted analysis of predictive variables revealed unplanned intubation, sepsis, and pulmonary embolism as the strongest predictors of ICUBB.

CONCLUSION

Intensive care unit bouncebacks are associated with worse outcomes and are disproportionately burdened by respiratory complications. These findings emphasize the importance of the TQIP Collaborative in identifying statewide issues in need of performance improvement within mature trauma systems.

LEVEL OF EVIDENCE

Epidemiological study, level III.
Hospital resources do not predict accuracy of secondary trauma triage: A population-based analysis
Authors: Tillmann Bourke W. , Nathens Avery B. , Guttman Matthew P. , Pequeno Priscila , Scales Damon C. , Pechlivanoglou Petros , Haas Barbara
Published: December 2019

BACKGROUND

The identification of patients who require transfer from non–trauma centers to trauma centers (secondary triage) is complicated by high rates of undertriage and overtriage. The objective of this study was to evaluate variations in secondary triage accuracy across non–trauma centers and identify factors associated with highly accurate secondary triage.

METHODS

We performed a population-based study of injured patients who presented to non–trauma centers in a large regional trauma system. Patients were categorized as undertriaged, overtriaged, or appropriately triaged based on transfer status and presence of a severe injury (Injury Severity Score >15, death within 24 hours, or critical injury as defined by the American College of Surgeons). Mixed-effect models, adjusted for case mix and hospital resource, were used to compare triage accuracy across hospitals and identify factors associated with high-performing centers.

RESULTS

Among 118,973 patients identified at 182 non–trauma centers, 37,528 (31.5%) had severe injuries. The majority (76.9%) of severely injured patients were not transferred to a trauma center (undertriaged), while 9.6% of nonseverely injured patients were transferred to a trauma center (overtriaged). Mixed-effect models demonstrated that at the average hospital severely injured patients were 3.76 times more likely to be transferred than nonseverely injured patients (diagnostic odds ratio, 3.76; 95% confidence interval, 3.20–4.31). Despite significant variation in triage accuracy across hospitals, adjusted analyses suggested that local resources bore no relationship to triage accuracy.

CONCLUSION

Triage accuracy varies significantly across non–trauma centers, after adjusting for hospital resources. These findings suggest that other potentially modifiable factors play a key role in transfer decisions.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.
Abdominal aortic and junctional tourniquet versus zone III resuscitative endovascular balloon occlusion of the aorta in a swine junctional hemorrhage model
Authors: Schechtman David W. , Kauvar David S. , De Guzman Rodolfo , Polykratis I. Amy , Prince M. Dale , Kheirabadi Bijan S. , Dubick Michael A.
Published: December 2019

BACKGROUND

Junctional hemorrhage is a leading contributor to battlefield mortality. The Abdominal Aortic and Junctional Tourniquet (AAJT) and infrarenal (zone III) resuscitative endovascular balloon occlusion of the aorta (REBOA) are emerging strategies for controlling junctional hemorrhage, with AAJT currently available in select forward deployed settings and increasing interest in applying REBOA in the military prehospital environment. This study compared the hemostatic, hemodynamic, and metabolic effects of these devices used for junctional hemorrhage control.

METHODS

Shock was induced in anesthetized, mechanically ventilated swine with a controlled hemorrhage (20 mL/kg) and closed femur fracture followed by uncontrolled hemorrhage from a partial femoral artery transection (40% total hemorrhage volume). Residual femoral hemorrhage was recorded during 60-minute AAJT (n = 10) or zone III REBOA (n = 10) deployment, and the arterial injury was repaired subsequently. Animals were resuscitated with 15 mL/kg autologous whole blood and observed for 6 hours.

RESULTS

One animal in each group died during observation. Both devices achieved hemostasis with mean residual femoral blood loss in the AAJT and REBOA groups of 0.38 ± 0.59 mL/kg and 0.10 ± 0.07 mL/kg (p = 0.16), respectively, during the 60-minute intervention. The AAJT and REBOA augmented proximal blood pressure equally with AAJT allowing higher distal pressure than REBOA during intervention (p < 0.01). Following device deflation, AAJT animals had transiently lower mean arterial blood pressure than REBOA pigs (39 ± 6 vs. 54 ± 11 mm Hg p = 0.01). Both interventions resulted in similar degrees of lactic acidemia which resolved during observation. Similar cardiac and renal effects were observed between AAJT and REBOA.

CONCLUSION

The AAJT and REBOA produced similar hemostatic, resuscitative, and metabolic effects in this model of severe shock with junctional hemorrhage. Both interventions may have utility in future military medical operations.