bluuebunny/crossref_metadata_2025 huggingface dataset:
Distance to invasive heart centre, performance of acute coronary angiography, and angioplasty and associated outcome in out-of-hospital cardiac arrest: a nationwide study
Authors: Tranberg Tinne , Lippert Freddy K. , Christensen Erika F. , Stengaard Carsten , Hjort Jakob , Lassen Jens Flensted , Petersen Frants , Jensen Jan Skov , Bäck Caroline , Jensen Lisette Okkels , Ravkilde Jan , Bøtker Hans Erik , Terkelsen Christian Juhl
Published: February 2017

Aims

To evaluate whether the distance from the site of event to an invasive heart centre, acute coronary angiography (CAG)/percutaneous coronary intervention (PCI) and hospital-level of care (invasive heart centre vs. local hospital) is associated with survival in out-of-hospital cardiac arrest (OHCA) patients.

Methods and results

Nationwide historical follow-up study of 41 186 unselected OHCA patients, in whom resuscitation was attempted between 2001 and 2013, identified through the Danish Cardiac Arrest Registry. We observed an increase in the proportion of patients receiving bystander CPR (18% in 2001, 60% in 2013, P < 0.001), achieving return of spontaneous circulation (ROSC) (10% in 2001, 29% in 2013, P < 0.001) and being admitted directly to an invasive centre (26% in 2001, 45% in 2013, P < 0.001). Simultaneously, 30-day survival rose from 5% in 2001 to 12% in 2013, P < 0.001. Among patients achieving ROSC, a larger proportion underwent acute CAG/PCI (5% in 2001, 27% in 2013, P < 0.001). The proportion of patients undergoing acute CAG/PCI annually in each region was defined as the CAG/PCI index. The following variables were associated with lower mortality in multivariable analyses: direct admission to invasive heart centre (HR 0.91, 95% CI: 0.89–0.93), CAG/PCI index (HR 0.33, 95% CI: 0.25–0.45), population density above 2000 per square kilometre (HR 0.94, 95% CI: 0.89–0.98), bystander CPR (HR 0.97, 95% CI: 0.95–0.99) and witnessed OHCA (HR 0.87, 95% CI: 0.85–0.89), whereas distance to the nearest invasive centre was not associated with survival.

Conclusion

Admission to an invasive heart centre and regional performance of acute CAG/PCI were associated with improved survival in OHCA patients, whereas distance to the invasive centre was not. These results support a centralized strategy for immediate post-resuscitation care in OHCA patients.
Margin estimation and disturbances of irradiation field in layer-stacking carbon-ion beams for respiratory moving targets
Authors: Tajiri Shinya , Tashiro Mutsumi , Mizukami Tomohiro , Tsukishima Chihiro , Torikoshi Masami , Kanai Tatsuaki
Published: February 2017

Carbon-ion therapy by layer-stacking irradiation for static targets has been practised in clinical treatments. In order to apply this technique to a moving target, disturbances of carbon-ion dose distributions due to respiratory motion have been studied based on the measurement using a respiratory motion phantom, and the margin estimation given by the square root of the summation Internal margin2+Setup margin2 has been assessed. We assessed the volume in which the variation in the ratio of the dose for a target moving due to respiration relative to the dose for a static target was within 5%. The margins were insufficient for use with layer-stacking irradiation of a moving target, and an additional margin was required. The lateral movement of a target converts to the range variation, as the thickness of the range compensator changes with the movement of the target. Although the additional margin changes according to the shape of the ridge filter, dose uniformity of 5% can be achieved for a spherical target 93 mm in diameter when the upward range variation is limited to 5 mm and the additional margin of 2.5 mm is applied in case of our ridge filter. Dose uniformity in a clinical target largely depends on the shape of the mini-peak as well as on the bolus shape. We have shown the relationship between range variation and dose uniformity. In actual therapy, the upper limit of target movement should be considered by assessing the bolus shape.
Water in the upper mantle and deep crust of eastern China: concentration, distribution and implications
Authors: Xia Qun-Ke , Liu Jia , Kovács István , Hao Yan-Tao , Li Pei , Yang Xiao-Zhi , Chen Huan , Sheng Ying-Ming
Published: February 2017

Understanding the concentration and distribution of water in the Earth's mantle plays a substantial role in studying its chemical, physical and dynamic processes. After a decade of research, a comprehensive dataset of water content in upper-mantle samples has been built for eastern China, which is now the only place with water-content data from such diverse types of natural samples, and provides an integrated picture of the water content and its distribution in the upper mantle at a continental scale. The main findings include the following: (i) the temporal heterogeneity of the water content in the lithospheric mantle from early Cretaceous (∼120 Ma) to Cenozoic (<40 Ma) was tightly connected with the stability of the North China Craton (from its destruction to its consolidation); (ii) the heterogeneous water content in the Cenozoic lithospheric mantle beneath different blocks of eastern China was not only inherited from tectonic settings from which they came, but was also affected later by geological processes they experienced; (iii) the distinct water content between the lowermost crust and lithospheric mantle of eastern China and its induced rheological contrast at the base of the crust indicate that the continental crust–mantle boundary could behave either in a coupled or decoupled manner beneath different areas and/or at different stages; (iv) the alkali basalts of eastern China demonstrate a heterogeneous distribution of water content in the mantle; local and regional comparisons of the water content between the lithospheric mantle and basalts' source indicate that the Cenozoic alkali basalts in eastern China were not sourced from the lithospheric mantle. Instead, the inferred high water contents in the mantle sources suggest that the Cenozoic eastern China basalts were likely sourced from the mantle transition zone (MTZ); and (v) both oceanic and continental crusts may carry a certain amount of water back into the deep mantle of eastern China by plate subduction. Such recycled crustal materials have not only created a local water-rich zone, but have also introduced crustal geochemical signatures into the mantle, both accounting for crustal geochemical imprints in the intra-plate magmatic rocks of eastern China.
Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU*
Authors: Sundén-Cullberg Jonas , Rylance Rebecca , Svefors Jesper , Norrby-Teglund Anna , Björk Jonas , Inghammar Malin
Published: February 2017

Objectives:

To study the prognostic value of fever in the emergency department in septic patients subsequently admitted to the ICU.

Design:

Observational cohort study from the Swedish national quality register for sepsis.

Setting:

Thirty ICU’s in Sweden.

Patients:

Two thousand two hundred twenty-five adults who were admitted to an ICU within 24 hours of hospital arrival with a diagnosis of severe sepsis or septic shock were included.

Interventions:

None.

Measurements and Main Results:

Body temperature was measured and classified according to four categories (< 37°C, 37–38.29°C, 38.3–39.5°C, ≥ 39.5°C). The main outcome was in-hospital mortality. Odds ratios for mortality according to body temperature were estimated using multivariable logistic regression. Subgroup analyses were conducted according to age, sex, underlying comorbidity, and time to given antibiotics. Overall mortality was 25%. More than half of patients had a body temperature below 38.3°C. Mortality was inversely correlated with temperature and decreased, on average, more than 5% points per °C increase, from 50% in those with the lowest temperatures to 9% in those with the highest. Increased body temperature in survivors was also associated with shorter hospital stays. Patients with fever received better quality of care, but the inverse association between body temperature and mortality was robust and remained consistent after adjustment for quality of care measures and other factors that could have confounded the association. Among vital signs, body temperature was best at predicting mortality.

Conclusions:

Contrary to common perceptions and current guidelines for care of critically ill septic patients, increased body temperature in the emergency department was strongly associated with lower mortality and shorter hospital stays in patients with severe sepsis or septic shock subsequently admitted to the ICU.
ICU Acquisition Rate, Risk Factors, and Clinical Significance of Digestive Tract Colonization With Extended-Spectrum Beta-Lactamase–Producing Enterobacteriaceae: A Systematic Review and Meta-Analysis*
Authors: Detsis Marios , Karanika Styliani , Mylonakis Eleftherios
Published: February 2017

Objective:

To evaluate the acquisition rate, identify risk factors, and estimate the risk for subsequent infection, associated with the colonization of the digestive tract with extended-spectrum beta-lactamase–producing Enterobacteriaceae during ICU-hospitalization.

Data Sources:

PubMed, EMBASE, and reference lists of all eligible articles.

Study Selection:

Included studies provided data on ICU-acquired colonization with extended-spectrum beta-lactamase–producing Enterobacteriaceae in previously noncolonized and noninfected patients and used the double disk synergy test for extended-spectrum beta-lactamase–producing Enterobacteriaceae phenotypic confirmation. Studies reporting extended-spectrum beta-lactamase–producing Enterobacteriaceae outbreaks or data on pediatric population were excluded.

Data Extraction:

Two authors independently assessed study eligibility and performed data extraction.

Data Synthesis:

Thirteen studies (with 15,045 ICUs-patients) were evaluated using a random-effect model and a meta-regression analysis. The acquisition rate of digestive tract colonization during ICU stay was 7% (95% CI, 5–10) and it varies from 3% (95% CI, 2–4) and 4% (95% CI, 2–6) in the Americas and Europe to 21% (95% CI, 9–35) in the Western Pacific region. Previous hospitalization (risk ratio, 1.57 [95% CI, 1.07–2.31]) or antibiotic use (risk ratio, 1.65 [95% CI, 1.15–2.37]) and exposure to beta-lactams/beta-lactamase inhibitors (risk ratio, 1.78 [95% CI, 1.24–2.56]) and carbapenems (risk ratio, 2.13 [95% CI, 1.49–3.06]) during the ICU stay were independent risk factors for ICU-acquired colonization. Importantly, colonized patients were more likely to develop an extended-spectrum beta-lactamase–producing Enterobacteriaceae infection (risk ratio, 49.62 [95% CI, 20.42–120.58]). The sensitivity and specificity of prior colonization to predict subsequent extended-spectrum beta-lactamase–producing Enterobacteriaceae infection were 95.1% (95% CI, 54.7–99.7) and 89.2% (95% CI, 77.2–95.3), respectively.

Conclusions:

The ICU acquisition rate of extended-spectrum beta-lactamase–producing Enterobacteriaceae ranged from 5% to 10%. Previous use of beta-lactam/beta-lactamase or carbapenems and recent hospitalization were independent risk factors for extended-spectrum beta-lactamase–producing Enterobacteriaceae colonization, and colonization was associated with significantly higher frequency of extended-spectrum beta-lactamase–producing Enterobacteriaceae subsequent infection and increased mortality.
Case Volume-Outcomes Associations Among Patients With Severe Sepsis Who Underwent Interhospital Transfer*
Authors: Ofoma Uchenna R. , Dahdah John , Kethireddy Shravan , Maeng Daniel , Walkey Allan J.
Published: February 2017

Objectives:

Case volume-outcome associations bolster arguments to regionalize severe sepsis care, an approach that may necessitate interhospital patient transfers. Although transferred patients may most closely reflect care processes involved with regionalization, associations between sepsis case volume and outcomes among transferred patients are unclear. We investigated case volume-outcome associations among patients with severe sepsis transferred from another hospital.

Design:

Serial cross-sectional study using the Nationwide Inpatient Sample.

Setting:

United States nonfederal hospitals, years 2003–2011.

Patients:

One hundred forty-one thousand seven hundred seven patients (weighted national estimate of 717,732) with severe sepsis transferred from another acute care hospital.

Interventions:

None.

Measurements and Main Results:

We examined associations between quintiles of annual hospital severe sepsis case volume for the receiving hospital and in-hospital mortality among transferred patients with severe sepsis. Secondary outcomes included hospital length of stay and total charges. Transferred patients accounted for 13.2% of hospitalized severe sepsis cases. In-hospital mortality was 33.2%, with median length of stay 11 days (interquartile range, 5–22), and median total charge $70,722 (interquartile range, $30,591–$159,013). Patients transferred to highest volume hospitals had higher predicted mortality risk, greater number of acutely dysfunctional organs, and lower adjusted in-hospital mortality when compared with the lowest-volume hospitals (odds ratio, 0.80; 95% CI, 0.67–0.90). In stratified analysis (p < 0.001 for interaction of case volume by organ failure), mortality benefit associated with case volume was limited to patients with single organ dysfunction (n = 48,607, 34.3% of transfers) (odds ratio, 0.66; 95% CI, 0.55–0.80). Treatment at highest volume hospitals was significantly associated with shorter adjusted length of stay (incidence rate ratio, 0.86; 95% CI, 0.75–0.98) but not costs (% charge difference, 95% CI: [–]18.8, [–]37.9 to [+]0.3).

Conclusions:

Hospital mortality was lowest among patients with severe sepsis who were transferred to high-volume hospitals; however, case volume benefits for transferred patients may be limited to patients with lower illness severity.
Evaluation of Reperfusion Pulmonary Edema by Extravascular Lung Water Measurements After Pulmonary Endarterectomy
Authors: Stéphan François , Mazeraud Aurélien , Laverdure Florent , Camous Julien , Fadel Elie
Published: February 2017

Objectives:

Reperfusion pulmonary edema is a specific complication of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Extravascular lung water measurement may be valuable for diagnosing reperfusion pulmonary edema. The primary objective of this study was to describe and assess the clinical significance of extravascular lung water variations after pulmonary endarterectomy.

Design:

Prospective observational study.

Setting:

Nineteen-bed cardiothoracic ICU.

Patients:

Consecutive patients who were hemodynamically stable after pulmonary endarterectomy were divided into two groups based on whether their preoperative pulmonary vascular resistance indicated severe or nonsevere chronic thromboembolic pulmonary hypertension (> 900 or ≤ 900 dynes·s/cm5, respectively).

Interventions:

Hemodynamic variables obtained by right heart catheterization and transpulmonary thermodilution measurements were recorded 1 hour, 1 day, and 2 days after pulmonary endarterectomy. Extravascular lung water was indexed to predicted body weight (EVLWPBW).

Measurements and Main Results:

We studied 31 patients. Overall, 26 patients (84%) experienced reperfusion pulmonary edema during the first 72 hours after pulmonary endarterectomy. EVLWPBW significantly increased between the first hour after pulmonary endarterectomy and day 2 (10.2 ± 2.6 vs 11.4 ± 3.6; p = 0.03). EVLWPBW measured at the first hour after pulmonary endarterectomy is closely associated with reperfusion pulmonary edema occurrence in the next 48 hours (area under the receiver-operating characteristics curve = 0.88 ± 0.07). EVLWPBW correlated with duration of mechanical ventilation (ρ = 0.59; p < 0.0001) and ICU stay (ρ = 0.52; p < 0.0001). Patients with severe chronic thromboembolic pulmonary hypertension (n = 15) had higher EVLWPBW values at day 2 compared with those without (n = 16) (13.2 ± 3.6 vs 9.7 ± 2.7 mL/kg; p = 0.004). Cardiac output was measured simultaneously by pulmonary artery catheter and aortic transpulmonary thermodilution on 92 occasions; agreement was good, with a bias of 0.50 ± 0.95 L/min (95% CI, –1.36–2.36).

Conclusions:

Accurate extravascular lung water measurements were obtained after pulmonary endarterectomy. Extravascular lung water may prove valuable for diagnosing reperfusion pulmonary edema after pulmonary endarterectomy and had prognostic value. Extravascular lung water values were significantly higher in patients with severe compared with nonsevere chronic thromboembolic pulmonary hypertension.
Differences in Utilization of Life Support and End-of-Life Care for Medical ICU Patients With Versus Without Cancer
Authors: Koff Geoffrey , Vaid Urvashi , Len Edward , Crawford Albert , Oxman David A.
Published: February 2017

Objectives:

To explore differences in the utilization of life support and end-of-life care between patients dying in the medical ICU with cancer compared with those without cancer.

Design:

Retrospective review of 403 deaths or hospice transfers in the medical ICU from January 1, 2012, to June 30, 2013.

Setting:

Urban tertiary care university hospital.

Patients:

Consecutive medical ICU deaths or hospice transfers over an 18-month period.

Interventions:

None.

Measurements and Main Results:

One hundred eighty-two patients (45%) had a diagnosis of active cancer and 221 (55%) did not. Despite similar severity of illness, there were significant differences in the use of life support and end-of-life care. Patients without cancer had longer medical ICU length of stay (median, 5 vs 4 d; p = 0.0495), used mechanical ventilation more often and for longer (83.7% vs 70.9%, p = 0.002; 4 vs 3 d, p = 0.017), and initiated dialysis more frequently (26.7% vs 14.8%; p = 0.0038). Patients without active cancer had family meetings later (median, 3 vs 2 d; p = 0.001), less frequent palliative care consultation (17.6% vs 32.4%; p = 0.0006), and took longer to transition to do not resuscitate or comfort care (median, 4 vs 3 d; p = 0.048).

Conclusions:

Among patients dying in the medical ICU, the diagnosis of active cancer influences the intensity of life support utilization and the quality of end-of-life care. Patients with active cancer use less life support and may receive better end-of-life care than similar patients without cancer. These differences are likely due to biases or misunderstandings about the trajectory of advanced nonmalignant disease among patients, families, and perhaps providers.
Increased Time to Initial Antimicrobial Administration Is Associated With Progression to Septic Shock in Severe Sepsis Patients
Authors: Whiles Bristol B. , Deis Amanda S. , Simpson Steven Q.
Published: February 2017

Objectives:

To determine if time to initial antimicrobial is associated with progression of severe sepsis to septic shock.

Design:

Retrospective cohort.

Setting:

Six hundred fifty-six bed urban academic medical center.

Patients:

Emergency department patients greater than or equal to 18 years old with severe sepsis and/or septic shock and antimicrobial administration within 24 hours. Patients with shock on presentation were excluded.

Interventions:

Not available.

Measurements and Main Results:

We identified 3,929 severe sepsis patients, with overall mortality 12.8%. Nine hundred eighty-four patients (25.0%) progressed to septic shock. The median time to antimicrobial was 3.77 hours (interquartile range = 1.96–6.42) in those who progressed versus 2.76 hours (interquartile range = 1.60–4.82) in those who did not (p < 0.001). Multivariate logistic regression demonstrated that male sex (odds ratio = 1.18; 95% CI, 1.01–1.36), Charlson Comorbidity Index (odds ratio = 1.18; 95% CI, 1.11–1.27), number of infections (odds ratio = 1.05; 95% CI, 1.02–1.08), and time to first antimicrobial (odds ratio = 1.08; 95% CI, 1.06–1.10) were associated with progression. Each hour until initial antimicrobial administration was associated with a 8.0% increase in progression to septic shock. Additionally, time to broad-spectrum antimicrobial was associated with progression (odds ratio = 1.06; 95% CI, 1.05–1.08). Time to initial antimicrobial was also associated with in-hospital mortality (odds ratio = 1.05; 95% CI, 1.03–1.07).

Conclusions:

This study emphasizes the importance of early, broad-spectrum antimicrobial administration in severe sepsis patients admitted through the emergency department, as longer time to initial antimicrobial administration is associated with increased progression of severe sepsis to septic shock and increased mortality.
Causes and Consequences of Treatment Variation in Moderate and Severe Traumatic Brain Injury: A Multicenter Study
Authors: Cnossen Maryse C. , Polinder Suzanne , Andriessen Teuntje M. , van der Naalt Joukje , Haitsma Iain , Horn Janneke , Franschman Gaby , Vos Pieter E. , Steyerberg Ewout W. , Lingsma Hester
Published: February 2017

Objectives:

Although guidelines have been developed to standardize care in traumatic brain injury, between-center variation in treatment approach has been frequently reported. We examined variation in treatment for traumatic brain injury by assessing factors influencing treatment and the association between treatment and patient outcome.

Design:

Secondary analysis of prospectively collected data.

Setting:

Five level I trauma centers in the Netherlands (2008–2009).

Patients:

Five hundred three patients with moderate or severe traumatic brain injury (Glasgow Coma Scale, 3–13).

Interventions:

We examined variation in seven treatment parameters: direct transfer, involvement of mobile medical team, mechanical ventilation, intracranial pressure monitoring, vasopressors, acute neurosurgical intervention, and extracranial operation.

Measurements and Main Results:

Data were collected on patient characteristics, treatment, and 6-month Glasgow Outcome Scale-Extended. Multivariable logistic regression models were used to assess the extent to which treatment was determined by patient characteristics. To examine whether there were between-center differences in treatment, we used unadjusted and adjusted random effect models with the seven treatment parameters as dependent variables. The influence of treatment approach in a center (defined as aggressive and nonaggressive based on the frequency intracranial pressure monitoring) on outcome was assessed using multivariable random effect proportional odds regression models in those patients with an indication for intracranial pressure monitoring. Sensitivity analyses were performed to test alternative definitions of aggressiveness. Treatment was modestly related to patient characteristics (Nagelkerke R
2 range, 0.12–0.52) and varied widely among centers, even after case-mix correction. Outcome was more favorable in patients treated in aggressive centers than those treated in nonaggressive centers (OR, 1.73; 95% CI, 1.05–3.15). Sensitivity analyses, however, illustrated that the aggressiveness-outcome association was dependent on the definition used.

Conclusions:

The considerable between-center variation in treatment for patients with brain injury can only partly be explained by differences in patient characteristics. An aggressive treatment approach may imply better outcome although further confirmation is required.
RBC Transfusion Improves Cerebral Oxygen Delivery in Subarachnoid Hemorrhage
Authors: Dhar Rajat , Zazulia Allyson R. , Derdeyn Colin P. , Diringer Michael N.
Published: February 2017

Objectives:

Impaired oxygen delivery due to reduced cerebral blood flow is the hallmark of delayed cerebral ischemia following subarachnoid hemorrhage. Since anemia reduces arterial oxygen content, it further threatens oxygen delivery increasing the risk of cerebral infarction. Thus, subarachnoid hemorrhage may constitute an important exception to current restrictive transfusion practices, wherein raising hemoglobin could reduce the risk of ischemia in a critically hypoperfused organ. In this physiologic proof-of-principle study, we determined whether transfusion could augment cerebral oxygen delivery, particularly in vulnerable brain regions, across a broad range of hemoglobin values.

Design:

Prospective study measuring cerebral blood flow and oxygen extraction fraction using 15O-PET. Vulnerable brain regions were defined as those with baseline oxygen delivery less than 4.5 mL/100 g/min.

Setting:

PET facility located within the Neurology/Neurosurgery ICU.

Patients:

Fifty-two patients at risk for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage with hemoglobin 7–13 g/dL.

Interventions:

Transfusion of one unit of RBCs over 1 hour.

Measurements and Main Results:

Baseline hemoglobin was 9.7 g/dL (range, 6.9–12.9), and cerebral blood flow was 43 ± 11 mL/100 g/min. After transfusion, hemoglobin rose from 9.6 ± 1.4 to 10.8 ± 1.4 g/dL (12%; p < 0.001) and oxygen delivery from 5.0 (interquartile range, 4.4–6.6) to 5.5 mL/100 g/min (interquartile range, 4.8–7.0) (10%; p = 0.001); the response was comparable across the range of hemoglobin values. In vulnerable brain regions, transfusion resulted in a greater (16%) rise in oxygen delivery associated with reduction in oxygen extraction fraction, independent of Hgb level (p = 0.002 vs normal regions).

Conclusions:

This study demonstrates that RBC transfusion improves cerebral oxygen delivery globally and particularly to vulnerable regions in subarachnoid hemorrhage patients at risk for delayed cerebral ischemia across a wide range of hemoglobin values and suggests that restrictive transfusion practices may not be appropriate in this population. Large prospective trials are necessary to determine if these physiologic benefits translate into clinical improvement and outweigh the risk of transfusion.
Sodium Bicarbonate Versus Sodium Chloride for Preventing Contrast-Associated Acute Kidney Injury in Critically Ill Patients: A Randomized Controlled Trial
Authors: Valette Xavier , Desmeulles Isabelle , Savary Benoit , Masson Romain , Seguin Amélie , Sauneuf Bertrand , Brunet Jennifer , Verrier Pierre , Pottier Véronique , Orabona Marie , Samba Désiré , Viquesnel Gérald , Lermuzeaux Mathilde , Hazera Pascal , Dutheil Jean-Jacques , Hanouz Jean-Luc , Parienti Jean-Jacques , du Cheyron Damien
Published: February 2017

Objectives:

To test whether hydration with bicarbonate rather than isotonic sodium chloride reduces the risk of contrast-associated acute kidney injury in critically ill patients.

Design:

Prospective, double-blind, multicenter, randomized controlled study.

Setting:

Three French ICUs.

Patients:

Critically ill patients with stable renal function (n = 307) who received intravascular contrast media.

Interventions:

Hydration with 0.9% sodium chloride or 1.4% sodium bicarbonate administered with the same infusion protocol: 3 mL/kg during 1 hour before and 1 mL/kg/hr during 6 hours after contrast medium exposure.

Measurements and Main Results:

The primary endpoint was the development of contrast-associated acute kidney injury, as defined by the Acute Kidney Injury Network criteria, 72 hours after contrast exposure. Patients randomized to the bicarbonate group (n = 151) showed a higher urinary pH at the end of the infusion than patients randomized to the saline group (n = 156) (6.7 ± 2.1 vs 6.2 ± 1.8, respectively; p < 0.0001). The frequency of contrast-associated acute kidney injury was similar in both groups: 52 patients (33.3%) in the saline group and 53 patients (35.1%) in the bicarbonate group (absolute risk difference, –1.8%; 95% CI [–12.3% to 8.9%]; p = 0.81). The need for renal replacement therapy (five [3.2%] and six [3.9%] patients; p = 0.77), ICU length of stay (24.7 ± 22.9 and 23 ± 23.8 d; p = 0.52), and mortality (25 [16.0%] and 24 [15.9%] patients; p > 0.99) were also similar between the saline and bicarbonate groups, respectively.

Conclusions:

Except for urinary pH, none of the outcomes differed between the two groups. Among ICU patients with stable renal function, the benefit of using sodium bicarbonate rather than isotonic sodium chloride for preventing contrast-associated acute kidney injury is marginal, if any.
Antipyretic Therapy in Critically Ill Septic Patients: A Systematic Review and Meta-Analysis
Authors: Drewry Anne M. , Ablordeppey Enyo A. , Murray Ellen T. , Stoll Carolyn R. T. , Izadi Sonya R. , Dalton Catherine M. , Hardi Angela C. , Fowler Susan A. , Fuller Brian M. , Colditz Graham A.
Published: February 2017

Objective:

This meta-analysis aimed to examine the impact of antipyretic therapy on mortality in critically ill septic adults.

Data Sources:

Literature searches were implemented in Ovid Medline, Embase, Scopus, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, and ClinicalTrials.gov through February 2016.

Study Selection:

Inclusion criteria were observational or randomized studies of septic patients, evaluation of antipyretic treatment, mortality reported, and English-language version available. Studies were excluded if they enrolled pediatric patients, patients with neurologic injury, or healthy volunteers. Criteria were applied by two independent reviewers.

Data Extraction:

Two reviewers independently extracted data and evaluated methodologic quality. Outcomes included mortality, frequency of shock reversal, acquisition of nosocomial infections, and changes in body temperature, heart rate, and minute ventilation. Randomized and observational studies were analyzed separately.

Data Synthesis:

Eight randomized studies (1,507 patients) and eight observational studies (17,432 patients) were analyzed. Antipyretic therapy did not reduce 28-day/hospital mortality in the randomized studies (relative risk, 0.93; 95% CI, 0.77–1.13;I2= 0.0%) or observational studies (odds ratio, 0.90; 95% CI, 0.54–1.51;I2= 76.1%). Shock reversal (relative risk, 1.13; 95% CI, 0.68–1.90;I2= 51.6%) and acquisition of nosocomial infections (relative risk, 1.13; 95% CI, 0.61–2.09;I2= 61.0%) were also unchanged. Antipyretic therapy decreased body temperature (mean difference, –0.38°C; 95% CI, –0.63 to –0.13;I2= 84.0%), but not heart rate or minute ventilation.

Conclusions:

Antipyretic treatment does not significantly improve 28-day/hospital mortality in adult patients with sepsis.
Evaluation of Electronic Health Record Implementation in Hospitals
Authors: Tubaishat Ahmad
Published: February 2017

The effectiveness of electronic health records has not previously been widely evaluated. Thus, this national cross-sectional study was conducted to evaluate electronic health records, from the perspective of nurses, by examining how they use the records, their opinions on the quality of the systems, and their overall levels of satisfaction with electronic health records. The relationship between these constructs was measured, and its predictors were investigated. A random sample of Jordanian hospitals that used electronic health records was selected, and data were gathered using a self-administered questionnaire, based on the DeLone and McLean Information Systems Success model. In total, 1648 nurses from 17 different hospitals participated in the study. Results indicated that nurses were largely positive about the use and quality of the systems and were satisfied with electronic health records. Significant positive correlations were found between these constructs, and a number of demographical and situational factors were found to have an effect on nurses’ perceptions. The study provides a systematic evaluation of different facets of electronic health records, which is fundamental for recognizing the motives and challenges for success and for further enhancing this success. The work proves that nurses favor the use of electronic health records and are satisfied with it and perceive its high quality, and the findings should therefore encourage their ongoing implementation.
A Retrospective Analysis of the Efficacy of Pembrolizumab in Melanoma Patients With Brain Metastasis
Authors: Dagogo-Jack Ibiayi , Lanfranchi Michael , Gainor Justin F. , Giobbie-Hurder Anita , Lawrence Donald P. , Shaw Alice T. , Sullivan Ryan J.
Published: February 2017

A total of 50% of patients with melanoma will develop brain metastasis (BM). Pembrolizumab was approved for treatment of metastatic melanoma on the basis of significant systemic antitumor activity. Because of low enrollment of patients with BM in pembrolizumab trials, efficacy against melanoma BM remains unknown. We reviewed records of 89 consecutive patients with melanoma treated with pembrolizumab at our institution between May 1, 2014 and October 31, 2015 to determine the time to progression. Thirty-six (40%) patients had BM before pembrolizumab. Twenty-six (72%) patients with BM had received prior treatment for BM. With median follow-up of 17.2 months, 54 patients (61%) developed progressive disease on pembrolizumab. Intracranial progression occurred in 19 patients (21%), 3 of whom did not have BM before treatment. Median time to progression at any site was 6 months for those without BM (n=53), 5 months for those with treated BM (n=26), and 1.2 months for patients with untreated BM (n=10). Using a Cox regression model adjusted for baseline factors, there was a statistically significant (Wald χ2
P=0.003) reduction in the hazard of progression for patients without BM [hazard ratio, 0.19; 90% confidence interval, 0.08–0.42) and patients with treated BM (hazard ratio, 0.27; 90% confidence interval, 0.12–0.64) compared with those with untreated BM. In conclusion, melanoma patients with pretreated BM can have durable systemic responses to pembrolizumab. Large, prospective studies are needed to evaluate the intracranial antitumor activity of pembrolizumab in melanoma patients with untreated BM.
Electrodiagnostic Characterization of Hereditary Neuropathy With Liability to Pressure Palsies
Authors: Takahashi Sachiko , Chum Marvin , Kimpinski Kurt
Published: February 2017

Objectives:

The study objective was electrodiagnostic characterization of a large cohort of patients with genetically confirmed hereditary neuropathy with liability to pressure palsies (HNPP).

Methods:

A retrospective review was conducted on all patients with HNPP seen at the neuromuscular clinic (London, Canada) from 1977 to 2015. Clinical data obtained included patient characteristics, examination findings, and nerve conduction study results.

Results:

A total of 46 patients were analyzed. The mean age and median disease duration were 42.6 and 5.0 years, respectively. Most patients had abnormalities on sural nerve conduction studies. The most common focal neuropathies at compressive sites were ulnar nerve at the elbow (85.7%), distal median nerve at the wrist (84.4%), and fibular nerve at the fibular head (36.7%). Distal median neuropathy was associated with a mean terminal latency of 6.64 milliseconds.

Conclusions:

The presence of polyneuropathy, median terminal motor latency prolongation, and multiple compressive neuropathies are the most common findings associated with HNPP.
Diagnostic Criteria for Small Fiber Neuropathy
Authors: Blackmore Derrick , Siddiqi Zaeem A.
Published: February 2017

Objectives:

Despite its relative common occurrence, definitive diagnosis of small fiber neuropathy (SFN) remains problematic. In practice, patients with pain, numbness, and/or paresthesias in their lower limbs are diagnosed with SFN if found to have dissociated sensory loss in their feet, that is, impaired pinprick perception (PP) but relatively preserved vibration. We sought to assess the sensitivity and specificity of clinical examination and various diagnostic tools available for screening SFN.

Methods:

Medical records of 56 patients diagnosed with SFN were reviewed. Diagnosis was based on symptoms, detailed neurological examination that included PP, and abnormal results on at least one testing modality—quantitative sudomotor axon reflex (sweat) test (QSART), quantitative sensory testing (QST), and heart rate variability (HRV) testing.

Results:

Sensitivity of PP was relatively consistent between modalities of about 63% in presence of appropriate sensory symptoms. Laboratory testing diagnosed 88% of patients when both QSART and QST are employed. QST was most sensitive for detection of SFN with the heat-pain testing having higher sensitivity than cooling. Heart rate variability testing revealed low correlation across all groups.

Conclusions:

The diagnostic yield for SFN increases by combining clinical features with various testing modalities. In symptomatic patients, we propose the following diagnostic criteria for diagnosis of SFN:Definite SFN—abnormal neurological examination and both QSART and QST;Probable SFN—abnormal neurological examination, and either QSART or QST;Possible SFN—abnormal neurological exam, QSART, or QST.
Outcome Measures in Myasthenia Gravis: Incorporation Into Clinical Practice
Authors: Muppidi Srikanth
Published: February 2017

The development of validated assessment tools for evaluating disease status and response to interventions in patients with myasthenia gravis (MG) has been driven by clinical studies of emerging MG therapies. However, only a small proportion of MG-focused neurology practices have adopted these assessment tools for routine clinical use. This article reviews the suitability of 5 assessment instruments for incorporation into clinical practice, which should be driven by their ability to contribute to improved patient outcomes, and to be implemented within practice personnel and resource constraints. It is recommended that assessments based on both physician-evaluated and patient-reported outcomes be selected, to adequately evaluate both point-in-time symptom load and functional impact of MG symptoms over time. Provider resource allocation and reimbursement issues may be the most significant roadblocks to successful ongoing use of these tools; to that end, the addition of regular assessments to MG standards of care is recommended.
Whole Exome Sequencing Identifies Atypical Welander Distal Myopathy in Patient
Authors: Gass Jennifer , Blackburn Patrick , Jackson Jessica , Harris Kimberly , Selcen Duygu , Dimberg Elliot , Atwal Paldeep
Published: February 2017

Welander distal myopathy is a rare autosomal dominant disorder characterized by muscle weakness in the hands and feet. Exome sequencing of affected families discovered a segregating p.Glu384Lys pathogenic variant in TIA-1 as the main genetic cause of Welander distal myopathy. TIA-1 encodes an RNA-binding protein which serves as a key component of stress granules. This protein also regulates splicing and translation of mRNA. Our patient developed progressive weakness in his hands and feet during his late 40s that was misdiagnosed as a neuropathy that caused muscle atrophy. Follow-up genetic testing revealed a p.Glu384Lys pathogenic variant in TIA-1, and he was then diagnosed with Welander distal myopathy. Our case report underlines the importance of electrodiagnostic and genetic testing of patients.
What's in the Literature?
Authors: Lacomis David , Silvestri Nicholas J. , Fine Edward J. , Wolfe Gil I.
Published: February 2017

In this edition of this column, we review new studies concerning the pathophysiology, treatment, and outcomes of patients with necrotizing myopathy, genetic testing in congenital myopathies, and limb girdle muscular dystrophies, and the incidence of polyneuropathy in the myotonic dystrophies. Various studies in myasthenia gravis, including those concerning antibody testing, clinical features, and quality of life are also reviewed as are recent findings in congenital myasthenic syndromes. Finally, 2 studies concerning polyneuropathy are discussed, including one on the association of polyneuropathy in patients with the metabolic syndrome and one on laboratory testing in patients with otherwise idiopathic small fiber polyneuropathy.
Non-Neuraxial Labor Analgesia: Options
Authors: MARKLEY JOHN C. , ROLLINS MARK D.
Published: February 2017

Although it is the most effective method to treat labor pain, neuraxial analgesia may be undesired, contraindicated, unsuccessful, or unavailable. Providing safe choices for labor pain relief is a central goal of health care providers alike. Consequently, knowledge of the efficacy, clinical implementation, and side effects of various non-neuraxial strategies is needed to provide appropriate options for laboring patients. In addition to nonpharmacologic alternatives, inhaled nitrous oxide and systemic opioids represent two broad classes of non-neuraxial pharmacologic labor analgesia most commonly available. This review summarizes the current published literature for these non-neuraxial labor analgesic options.
Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Gynecology
Authors: JALLAD KARL , WALTERS MARK D.
Published: February 2017

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging field in minimally invasive surgery. NOTES can be performed via a variety of approaches, including through the stomach, esophagus, bladder, and rectum, but the majority of cases have been performed transvaginally. Potential advantages of natural orifice surgery in gynecology include the lack of abdominal incisions, less operative pain, shorter hospital stay, improved visibility, and the possibility to circumvent extensive lysis of adhesion to reach the pelvic cavity. This chapter provides a historical overview and the potential application of NOTES.
ROYAL COLLEGE OF OPHTHALMOLOGISTS' NATIONAL DATABASE STUDY OF VITREORETINAL SURGERY
Authors: Sallam Ahmed B. , Donachie Paul H. J. , Yorston David , Steel David H. W. , Williamson Tom H. , Jackson Timothy L. , Sparrow John M. , Johnston Robert L.
Published: February 2017

Background/Purpose:

To audit variations in primary rhegmatogenous retinal detachment (RD) anatomical failure rates between surgeons, grades of surgeons, and techniques of RD surgery.

Methods:

Clinical data of a total of 5,857 eyes undergoing primary RD surgery, from 2000 to 2013 were retrospectively extracted from 15 centers using the same commercially available electronic medical record system, from three vitreoretinal units using an in-house electronic medical record, and from the British and Eire Association of Vitreoretinal Surgeons online registry.

Results:

The 5,857 primary RD operations were performed by 117 surgeons: 3,349 (57.2%) by consultants, 520 (8.9%) by independent nonconsultants, and 1,988 (33.9%) by trainees. Surgery comprised pars plana vitrectomy for 4,666 (79.7%) operations, scleral buckle for 815 (13.9%), and pars plana vitrectomy + scleral buckle for 376 (6.4%). The RD reoperation rate at 6 months after primary surgery was 13.9% (725/5,202) and did not differ significantly between consultants and trainees (P = 0.382). For surgeons contributing ≥50 cases, the mean (range) reoperation rates were 13.1% (6.7%–26.8%), 15.1% (11.3%–18.2%), and 15.3% (9.4%–22.1%) for consultants, independent nonconsultants, and trainee surgeons, respectively. The scleral buckle failure rate was not significantly different from pars plana vitrectomy (P = 0.095). Data were not adjusted for case-mix complexity.

Conclusion:

The grades of surgeons and the technique of surgery were not associated with a significant difference in primary unadjusted RD failure rates.
EVALUATION OF MACULAR ISCHEMIA IN EYES WITH BRANCH RETINAL VEIN OCCLUSION
Authors: Kadomoto Shin , Muraoka Yuki , Ooto Sotaro , Miwa Yuko , Iida Yuto , Suzuma Kiyoshi , Murakami Tomoaki , Ghashut Rima , Tsujikawa Akitaka , Yoshimura Nagahisa
Published: February 2017

Purpose:

To quantitatively assess macular morphology and perfusion status using optical coherence tomography, and optical coherence tomography angiography in eyes with branch retinal vein occlusion when macular edema has completely resolved, and to investigate the impact on visual function.

Methods:

Thirty consecutive eyes with branch retinal vein occlusion–macular edema that resolved after treatment with intravitreal ranibizumab injections were included. Macular sensitivity was measured by microperimetry; defect length of foveal ellipsoid zone band was measured using optical coherence tomography; foveal avascular zone and parafoveal nonperfusion areas (NPA) were measured by optical coherence tomography angiography.

Results:

The logarithm of minimum angle of resolution visual acuity was significantly associated with the defect length of the foveal ellipsoid zone band (P = 0.005), the parafoveal NPA in the superficial capillary plexus (P = 0.007), and the parafoveal NPA in the deep capillary plexus (P = 0.006). Macular sensitivity correlated with parafoveal thickness on the affected side (P = 0.034), the defect length of the foveal ellipsoid zone band (P = 0.048), parafoveal NPA in the superficial capillary plexus (P = 0.008), and parafoveal NPA in the deep capillary plexus (P = 0.012). Multivariate analysis where the only significant parameters in the univariate analyses were used as the independent variables showed that parafoveal NPA was most significantly associated with the logarithm of minimum angle of resolution visual acuity (β = 0.500, P = 0.005) and macular sensitivity (β = −0.480, P = 0.007).

Conclusion:

In eyes with branch retinal vein occlusion–macular edema resolved by intravitreal ranibizumab treatments, visual function was strongly associated with parafoveal NPA size.
INTRAVITREAL DEXAMETHASONE IMPLANT IN RETINITIS PIGMENTOSA–RELATED CYSTOID MACULAR EDEMA
Authors: Mansour Ahmad M. , Sheheitli Huda , Kucukerdonmez Cem , Sisk Robert A. , Moura Raphael , Moschos Marilita M. , Lima Luiz H. , Al-Shaar Laila , Arevalo J. Fernando , Maia Mauricio , Foster Robert E. , Kayikcioglu Ozcan , Kozak Igor , Kurup Shree , Zegarra Hernando , Gallego-Pinazo Roberto , Hamam Rola N. , Bejjani Riad A. , Cinar Esat , Erakgün Ethem T. , Kimura Alan , Teixeira Anderson
Published: February 2017

Purpose:

To report the clinical outcome after intravitreal dexamethasone implant in patients with retinitis pigmentosa and cystoid macular edema.

Methods:

Multicenter retrospective case series of eyes with retinitis pigmentosa and cystoid macular edema that underwent intravitreal dexamethasone implant. Primary outcome measures were best-corrected visual acuity in LogMAR and central macular thickness. Statistical analyses used two-tailed comparison with Wilcoxon signed-rank test.

Results:

There were a total of 45 eyes from 34 patients with a mean age of 32.7 years (range 16–57) and mean follow-up of 15.5 ± 13.0 months. At Month 3 after the first injection, mean initial best-corrected visual acuity improved from 0.61 ± 0.38 (20/81) to 0.37 ± 0.16 (20/47) (P = 0.012), whereas mean central macular thickness (μm) decreased from 506 ± 288 μm to 311.7 ± 71.6 μm (P < 0.001) and mean intraocular pressure increased from 15.7 ± 2.3 mmHg to 19.8 ± 11.0 mmHg (P = 0.01). Fourteen eyes had multiple injections (1–7 reinjections) at a mean interval of 6 months. Treatment effect was durable with multiple injections, but with seven eyes developing visually significant cataracts.

Conclusion:

Best-corrected visual acuity improved up to 4 months in around half of the eyes. Eyes that benefited the most were pseudophakic, steroid nonresponsive, with large initial central macular thickness, and profuse fluorescein dye leakage.