bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Outcomes and Mortality Impact of Hyperbaric Oxygen Therapy in Patients With Carbon Monoxide Poisoning
Authors: Rose Jason J. , Nouraie Mehdi , Gauthier Marc C. , Pizon Anthony F. , Saul Melissa I. , Donahoe Michael P. , Gladwin Mark T.
Published: April 2018

Objectives:

Carbon monoxide poisoning affects 50,000 per year in the United States alone. Mortality is approximately 3%, and up to 40% of survivors suffer from permanent neurocognitive and affective deficits. Hyperbaric oxygen therapy has shown benefit on reducing the long-term neurologic sequelae of carbon monoxide poisoning but has not demonstrated improved survival. The objective of this study is to assess the efficacy of hyperbaric oxygen for acute and long-term mortality in carbon monoxide poisoning using a large clinical databank.

Design:

Retrospective analysis.

Setting:

University of Pittsburgh Medical Center healthcare system (Pittsburgh, PA).

Patients:

One-thousand ninety-nine unique encounters of adult patients with carbon monoxide poisoning.

Interventions:

None.

Measurements and Main Results:

Baseline demographics, laboratory values, hospital charge transactions, discharge disposition, and clinical information from charting were obtained from the electronic medical record. In propensity-adjusted analysis, hyperbaric oxygen therapy was associated with a reduction in inpatient mortality (absolute risk reduction, 2.1% [3.7–0.9%]; p = 0.001) and a reduction in 1-year mortality (absolute risk reduction, 2.1% [3.8–0.4%]; p = 0.013).

Conclusions:

These data demonstrate that hyperbaric oxygen is associated with reduced acute and reduced 1-year mortality. Further studies are needed on the mortality effects of hyperbaric oxygen therapy in carbon monoxide poisoning.
Ventilator Bundle and Its Effects on Mortality Among ICU Patients: A Meta-Analysis*
Authors: Pileggi Claudia , Mascaro Valentina , Bianco Aida , Nobile Carmelo G. A. , Pavia Maria
Published: April 2018

Objectives:

To assess the effectiveness of the ventilator bundle in the reduction of mortality in ICU patients.

Data Sources:

PubMed, Scopus, Web of Science, Cochrane Library for studies published until June 2017.

Study Selection:

Included studies: randomized controlled trials or any kind of nonrandomized intervention studies, made reference to a ventilator bundle approach, assessed mortality in ICU-ventilated adult patients.

Data Extraction:

Items extracted: study characteristics, description of the bundle approach, number of patients in the comparison groups, hospital/ICU mortality, ventilator-associated pneumonia–related mortality, assessment of compliance to ventilator bundle and its score.

Data Synthesis:

Thirteen articles were included. The implementation of a ventilator bundle significantly reduced mortality (odds ratio, 0.90; 95% CI, 0.84–0.97), with a stronger effect with a restriction to studies that reported mortality in ventilator-associated pneumonia patients (odds ratio, 0.71; 95% CI, 0.52–0.97), to studies that provided active educational activities was analyzed (odds ratio, 0.88; 95% CI, 0.78–0.99), and when the role of care procedures within the bundle (odds ratio, 0.87; 95% CI, 0.77–0.99). No survival benefit was associated with compliance to ventilator bundles. However, these results may have been confounded by the differential implementation of evidence-based procedures at baseline, which showed improved survival in the study subgroup that did not report implementation of these procedures at baseline (odds ratio, 0.82; 95% CI, 0.70–0.96).

Conclusions:

Simple interventions in common clinical practice applied in a coordinated way as a part of a bundle care are effective in reducing mortality in ventilated ICU patients. More prospective controlled studies are needed to define the effect of ventilator bundles on survival outcomes.
End-of-Life Care in ICUs in East Asia: A Comparison Among China, Korea, and Japan
Authors: Park So Young , Phua Jason , Nishimura Masaji , Deng Yiyun , Kang Yan , Tada Keiichi , Koh Younsuck
Published: April 2018

Objectives:

To compare physicians’ perceptions and practice of end-of-life care in the ICU in three East Asian countries cultures similarly rooted in Confucianism.

Design:

A structured and scenario-based survey of physicians who managed ICU patients from May 2012 to December 2012.

Setting:

ICUs in China, Korea, and Japan.

Subjects:

Specialists who are either intensivists or nonintensivist primary attending physicians in charge of patients (195 in China, 186 in Korea, 224 in Japan).

Interventions:

None.

Measurements and Main Results:

Country was independently associated with differences in the practice of limiting multiple forms of life-sustaining treatments on multivariable generalized linear model analysis. Chinese respondents were least likely to apply do-not-resuscitate orders, even if they existed (p < 0.001). Japanese respondents were most likely to practice do not resuscitate for terminally ill patients during cardiac arrest, even when no such prior order existed (p < 0.001). Korean respondents’ attitudes were in between those of Chinese and Japanese respondents as far as withdrawing total parenteral nutrition, antibiotics, dialysis, and suctioning was concerned. Chinese respondents were most uncomfortable discussing end-of-life care issues with patients, while Japanese respondents were least uncomfortable (p < 0.001). Chinese respondents were more likely to consider financial burden when deciding on limiting life-sustaining treatment (p < 0.001). Japanese respondents felt least exposed to personal legal risks when limiting life-sustaining treatment (p < 0.001), and the Korean respondents most wanted legislation to guide this issue (p < 0.001). The respondents’ gender, religion, clinical experience, and primary specialty were also independently associated with the different perceptions of end-of-life care.

Conclusions:

Despite similarities in cultures and a common emphasis on the role of family, differences exist in physician perceptions and practices of end-of-life ICU care in China, Korea, and Japan. These findings may be due to differences in the degree of Westernization, national healthcare systems, economic status, and legal climate.
Early Evidence of Sepsis-Associated Hyperperfusion—A Study of Cerebral Blood Flow Measured With MRI Arterial Spin Labeling in Critically Ill Septic Patients and Control Subjects*
Authors: Masse Marie-Hélène , Richard Marie Anne , D’Aragon Frédérick , St-Arnaud Charles , Mayette Michael , Adhikari Neill K. J. , Fraser William , Carpentier André , Palanchuck Steven , Gauthier David , Lanthier Luc , Touchette Matthieu , Lamontagne Albert , Chénard Jean , Mehta Sangeeta , Sansoucy Yanick , Croteau Etienne , Lepage Martin , Lamontagne François
Published: April 2018

Objectives:

Mechanisms underlying sepsis-associated encephalopathy remain unclear, but reduced cerebral blood flow, alone or in conjunction with altered autoregulation, is reported as a potential contributor. We compared cerebral blood flow of control subjects and vasopressor-dependent septic patients.

Design:

Randomized crossover study.

Setting:

MRI with arterial spin labeling.

Patients:

Ten sedated septic patients on mechanical ventilation (four with controlled chronic hypertension) and 12 control subjects (six with controlled chronic hypertension) were enrolled. Mean ± sd ages were 61.4 ± 10.2 and 44.2 ± 12.8 years, respectively (p = 0.003). Mean Acute Physiology and Chronic Health Evaluation II score of septic patients at ICU admission was 27.7 ± 6.6.

Interventions:

To assess the potential confounding effects of sedation and mean arterial pressure, we measured cerebral blood flow with and without sedation with propofol in control subjects and at a target mean arterial pressure of 65 mm Hg and greater than or equal to 75 mm Hg in septic patients. The sequence of sedation versus no sedation and mean arterial pressure targets were randomized.

Measurements and Main Results:

In septic patients, cerebral blood flow measured at a mean arterial pressure target of 65 mm Hg (40.4 ± 10.9 mL/100 g/min) was not different from cerebral blood flow measured at a mean arterial pressure target of greater than or equal to 75 mm Hg (41.3 ± 9.8 mL/100 g/min; p = 0.65). In control subjects, we observed no difference in cerebral blood flow measured without and with sedation (24.8 ± 4.2 vs 24.9 ± 5.9 mL/100 g/min; p = 0.93). We found no interaction between chronic hypertension and the effect of sedation or mean arterial pressure targets. Cerebral blood flow measured in sedated septic patients (mean arterial pressure target 65 mm Hg) was 62% higher than in sedated control subjects (p = 0.001).

Conclusions:

In septic patients, cerebral blood flow was higher than in sedated control subjects and did not vary with mean arterial pressure targets. Further research is required to understand the clinical significance of cerebral hyperperfusion in septic patients on vasopressors and to reassess the neurologic effects of current mean arterial pressure targets in sepsis.
Inclusion of Unstructured Clinical Text Improves Early Prediction of Death or Prolonged ICU Stay*
Authors: Weissman Gary E. , Hubbard Rebecca A. , Ungar Lyle H. , Harhay Michael O. , Greene Casey S. , Himes Blanca E. , Halpern Scott D.
Published: April 2018

Objectives:

Early prediction of undesired outcomes among newly hospitalized patients could improve patient triage and prompt conversations about patients’ goals of care. We evaluated the performance of logistic regression, gradient boosting machine, random forest, and elastic net regression models, with and without unstructured clinical text data, to predict a binary composite outcome of in-hospital death or ICU length of stay greater than or equal to 7 days using data from the first 48 hours of hospitalization.

Design:

Retrospective cohort study with split sampling for model training and testing.

Setting:

A single urban academic hospital.

Patients:

All hospitalized patients who required ICU care at the Beth Israel Deaconess Medical Center in Boston, MA, from 2001 to 2012.

Interventions:

None.

Measurements and Main Results:

Among eligible 25,947 hospital admissions, we observed 5,504 (21.2%) in which patients died or had ICU length of stay greater than or equal to 7 days. The gradient boosting machine model had the highest discrimination without (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.81–0.84) and with (area under the receiver operating characteristic curve, 0.89; 95% CI, 0.88–0.90) text-derived variables. Both gradient boosting machines and random forests outperformed logistic regression without text data (p < 0.001), whereas all models outperformed logistic regression with text data (p < 0.02). The inclusion of text data increased the discrimination of all four model types (p < 0.001). Among those models using text data, the increasing presence of terms “intubated” and “poor prognosis” were positively associated with mortality and ICU length of stay, whereas the term “extubated” was inversely associated with them.

Conclusions:

Variables extracted from unstructured clinical text from the first 48 hours of hospital admission using natural language processing techniques significantly improved the abilities of logistic regression and other machine learning models to predict which patients died or had long ICU stays. Learning health systems may adapt such models using open-source approaches to capture local variation in care patterns.
Impact of ICU Structure and Processes of Care on Outcomes After Severe Traumatic Brain Injury: A Multicenter Cohort Study
Authors: McCredie Victoria A. , Alali Aziz S. , Scales Damon C. , Rubenfeld Gordon D. , Cuthbertson Brian H. , Nathens Avery B.
Published: April 2018

Objectives:

It is uncertain whether dedicated neurocritical care units are associated with improved outcomes for critically ill neurologically injured patients in the era of collaborative protocol-driven care. We examined the association between dedicated neurocritical care units and mortality and the effects of standardized management protocols for severe traumatic brain injury.

Design:

We surveyed trauma medical directors from centers participating in the American College of Surgeons Trauma Quality Improvement Program to obtain information about ICU structure and processes of care. Survey data were then linked to the Trauma Quality Improvement Program registry, and random-intercept hierarchical multivariable modeling was used to evaluate the association between dedicated neurocritical care units, the presence of standardized management protocols and mortality.

Setting:

Trauma centers in North America participating in Trauma Quality Improvement Program.

Patients:

Data were analyzed from 9,773 adult patients with isolated severe traumatic brain injury admitted to 134 Trauma Quality Improvement Program centers between 2011 and 2013.

Interventions:

None.

Measurements and Main Results:

Only 50 ICUs (37%) were dedicated neurocritical care units, whereas 84 (63%) were general ICUs. Rates of standardized management protocols were similar comparing dedicated neurocritical care units and general ICUs. Among severe TBI patients admitted to trauma centers enrolled in Trauma Quality Improvement Program, care in a dedicated neurocritical care unit did not improve risk-adjusted in-hospital survival (odds ratio, 0.97; 95% CI, 0.80–1.19; p = 0.79). However, the presence of a standardized management protocol for these patients was associated with lower risk-adjusted in-hospital mortality (odds ratio, 0.77; 95% CI, 0.63–0.93; p = 0.009).

Conclusions:

Compared with dedicated neurocritical care models, standardized management protocols for severe traumatic brain injured patients are process-targeted intervention strategies that may improve clinical outcomes.
Early Enteral Nutrition Provided Within 24 Hours of ICU Admission: A Meta-Analysis of Randomized Controlled Trials*
Authors: Tian Feng , Heighes Philippa T. , Allingstrup Matilde J. , Doig Gordon S.
Published: April 2018

Objectives:

To identify, appraise, and synthesize the most current evidence to determine whether early enteral nutrition alters patient outcomes from critical illness.

Data Sources:

Medline and Embase were searched. The close out date was November 20, 2017.

Study Selection:

Early enteral nutrition was defined as a standard formula commenced within 24 hours of ICU admission. Comparators included any form of nutrition support “except” early enteral nutrition. Only randomized controlled trials conducted in adult patients requiring treatment in an ICU were eligible for inclusion.

Data Extraction:

The primary outcome was mortality. Secondary outcomes included pneumonia, duration of mechanical ventilation, and ICU and hospital stay.

Data Synthesis:

Six-hundred ninety-nine full-text articles were retrieved and screened. Sixteen randomized controlled trials enrolling 3,225 critically ill participants were included. Compared with all other types of nutrition support, commencing enteral nutrition within 24 hours of ICU admission did not result in a reduction in mortality (odds ratio, 1.01; 95% CI, 0.86–1.18; p = 0.91; I
2 = 32%). However, there was a differential treatment effect between a priori identified subgroups (p = 0.032): early enteral nutrition reduced mortality compared with delayed enteral intake (odds ratio, 0.45; 95% CI, 0.21–0.95; p = 0.038; I
2 = 0%), whereas a mortality difference was not detected between early enteral nutrition and parenteral nutrition (odds ratio, 1.04; 95% CI, 0.89–1.22; p = 0.58; I
2 = 30%). Overall, patients who were randomized to receive early enteral nutrition were less likely to develop pneumonia (odds ratio, 0.75; 95% CI, 0.60–0.94; p = 0.012; I
2 = 48%).

Conclusions:

Overall, there was no difference between early enteral nutrition and all other forms of nutrition support. A priori planned subgroup analysis revealed early enteral nutrition reduced mortality and pneumonia compared with delayed enteral intake; however, there were no clear clinical advantages of early enteral nutrition over parenteral nutrition.
Depressive Symptoms, Antidepressant Use, and Hypertension in Young Adulthood
Authors: Crookes Danielle M. , Demmer Ryan T. , Keyes Katherine M. , Koenen Karestan C. , Suglia Shakira F.
Published: April 2018

Background:

Among adults, depressive symptoms are associated with higher rates of cardiovascular disease; however, the evidence is mixed regarding the association between depressive symptoms and hypertension, especially among young adults. The deleterious effects of some antidepressant medications on blood pressure may contribute to mixed findings.

Methods:

Adolescents enrolled in Add Health (N = 11,183) (1994–2008) completed an abbreviated Center for Epidemiologic Studies Depression Scale at three waves (mean ages, 16, 22, and 29). Antidepressant use was measured at age 22 and at age 29. Hypertension at age 29 was defined as measured systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater, or staff-inventoried anti-hypertensive medication use.

Results:

The prevalence of hypertension at age 29 was 20%. High depressive symptoms in adolescence or young adulthood were not associated with hypertension in young adulthood. Antidepressant use at age 29 was associated with increased prevalence of hypertension (prevalence ratio [PR], 1.4; 95% CI, 1.2, 1.7) and an interaction with sex was observed (PRMen, 1.6; 95% CI, 1.2, 2.0; PRWomen, 1.2; 95% CI, 0.89, 1.6; pinteraction = 0.0227). Selective serotonin reuptake inhibitor and non–selective serotonin reuptake inhibitor antidepressant use were associated with hypertension (PRSSRI, 1.3; 95% CI, 1.0, 1.6; PRnon-SSRI, 1.6; 95% CI, 1.2, 2.1).

Conclusions:

In this sample, antidepressant use, but not depressive symptoms, was associated with hypertension in young adulthood. Further research is recommended to examine joint and independent relationships between depression and antidepressant use and hypertension among young adults. See video abstract at, http://links.lww.com/EDE/B355.
The Reduction of Measles Transmission During School Vacations
Authors: Klinkenberg Don , Hahné Susan J. M. , Woudenberg Tom , Wallinga Jacco
Published: April 2018

Background:

Historically, measles incidence has shown clear seasonal patterns driven by the school calendar, but since the start of mass vaccination in developed countries there are only occasional outbreaks, which may have changed the effect of school vacations on transmission. In 2013–2014, a large measles epidemic took place in a low vaccination coverage area in The Netherlands, allowing us to quantify current-day measles transmission and the effect of school vacations.

Methods:

We fitted a dynamic transmission model to notification and hospitalization time series data of the Dutch 2013–2014 measles epidemic. Our primary aim was to estimate the reduction in contact rate during school vacations and the number of cases averted due to the vacation. In addition, because the summer vacations were time-staggered in three regions, we could distinguish within-region from across-region effects of school vacations.

Results:

We estimated a 53% (95% credible interval: 45%, 60%) reduction in contact rate during school vacations, resulting in 4900 (3400–7100) averted cases (estimated outbreak size: 16,600 [12,600–23,200]). There was a shift from mainly local transmission during school term to mainly cross-regional transmission during vacations. With seroprevalence data, we derived a current-day estimate of 15 to 27 for R
0 (number of secondary cases per primary case in a susceptible population).

Conclusions:

School vacations are associated with greatly reduced overall measles transmission. However, transmission is not eliminated, and increased long-distance travel may even promote spread to other areas. Therefore, we estimate that school closure is unlikely to prevent measles epidemics unless there are still few cases and the community is well vaccinated.
Reducing Maternal Mortality and Severe Maternal Morbidity: The Role of Critical Care
Authors: SHAMSHIRSAZ AMIR A. , DILDY GARY A.
Published: April 2018

Throughout most of the 20th century, the risk of maternal mortality in high resource countries decreased dramatically; however, this trend recently has stalled in the United States and appears to have reversed. Equally alarming is that for every reported maternal death, there are numerous severe maternal morbidities or near misses. Shifting maternal demographics (eg, obesity, advanced maternal age, multifetal pregnancies), with attendant significant medical comorbidities (eg, hypertension, diabetes, cardiac disease) and the increase in cesarean deliveries significantly contribute to increased maternal morbidity and mortality. This chapter focuses on the role of critical care in reducing maternal mortality and morbidity.
Endothelial Dysfunction is Related to Glycemic Variability and Quality and Duration of Sleep in Adults With Type 1 Diabetes
Authors: Farabi Sarah S. , Quinn Laurie , Phillips Shane , Mihailescu Dan , Park Chang , Ali Mohammed , Martyn-Nemeth Pamela
Published: April 2018

Background:

Elevated cardiovascular disease risk in people with type 1 diabetes (T1DM) is incompletely understood. Glycemic control, glycemic variability, and sleep quality and duration may relate to cardiovascular disease risk in this population via endothelial dysfunction.

Objective:

The aim of this study was to examine relationships among glycemic control, glycemic variability, sleep quality and duration, and endothelial function in adults with T1DM.

Methods:

Endothelial function was measured using flow-mediated dilation. Glycemic control and glycemic variability were measured using A1C and a continuous glucose monitor, respectively; sleep quality and duration were measured with the Pittsburgh Sleep Quality Index.

Results:

Twenty subjects were recruited. Reduced flow-mediated dilation and higher glucose levels were associated with poorer sleep quality (r = −0.51, P = .01; r = 0.52, P = .03). Subjects with shorter sleep duration had greater glycemic variability.

Conclusions:

Endothelial dysfunction (a precursor to cardiovascular disease) relates to glycemic control, glycemic variability, and sleep quality in T1DM.
Physiology-directed cardiopulmonary resuscitation: advances in precision monitoring during cardiac arrest
Authors: Marquez Alexandra M. , Morgan Ryan W. , Ross Catherine E. , Berg Robert A. , Sutton Robert M.
Published: April 2018

Purpose of review

We review the recent advances in physiologic monitoring during cardiac arrest and offer an evidence-based framework for prioritizing physiologic targets during cardiopulmonary resuscitation (CPR).

Recent findings

Current CPR guidelines recommend a uniform approach for all patients in cardiac arrest, but newer data support a precision strategy that uses the individual patient's physiology to guide resuscitation. Coronary perfusion pressure and arterial DBP are associated with survival outcomes in recent animal and human studies. End-tidal carbon dioxide is a reasonable noninvasive alternative, but may be inferior to invasive hemodynamic endpoints. Cerebral oximetry and cardiac ultrasound are emerging physiologic indicators of CPR effectiveness.

Physiologic monitoring can and should be used to deliver precision CPR whenever possible and may improve outcomes after cardiac arrest.
Neuroprognostication postcardiac arrest: translating probabilities to individuals
Authors: Callaway Clifton W.
Published: April 2018

Purpose of review

Predicting neurological recovery in patients who are comatose after cardiac arrest is an important activity during postarrest care, and this prediction can affect survival. As no early test or clinical finding perfectly predicts potential for recovery, guidelines recommend using data from multiple examinations or tests to estimate patient prognosis.

Recent findings

Studies reported accuracy of initial clinical examination, progression of clinical examination, early (<24 h) brain imaging, electroencephalography (EEG), evoked potentials, later (>24 h) brain imaging, blood markers of brain injury, and cerebral oximetry for predicting good or poor outcome. In multiple cohorts, patients with status myoclonus with particular clinical or EEG features have potential for good outcome. When multiple tests were compared, each test provided independent information.

Absence of cortical functional recovery over time is detected using multiple testing modalities and remains strongly associated with poor outcome. Early recovery of cortical function increases the probability of good outcome. Concordant assessments from multiple tests increase confidence in prognostication.
Low Rates of Retention Into Hepatocellular Carcinoma (HCC) Surveillance Program After Initial HCC Screening
Authors: Robinson Ann , Tavakoli Hesam , Cheung Ramsey , Liu Benny , Bhuket Taft , Wong Robert J.
Published: April 2018

Goals:

To evaluate rates and predictors of retention into hepatocellular carcinoma (HCC) surveillance beyond initial screening among underserved cirrhosis patients.

Background:

Although initial HCC screening among cirrhosis patients remains low, few studies have evaluated retention to HCC surveillance beyond initial screening.

Methods:

We retrospectively evaluated all consecutive adults with cirrhosis from 2014 to 2017 at a single underserved safety net hospital system to determine rates of HCC surveillance at 6 months and at 1 year beyond initial screening. Rates of HCC surveillance was stratified by sex, race/ethnicity, and etiology of liver disease. Multivariate Cox proportional hazards models evaluated predictors of retention into HCC surveillance.

Results:

Among 235 cirrhosis patients [hepatitis C virus: 35.7%, hepatitis B virus (HBV): 15.7%, alcoholic cirrhosis: 36.2%, nonalcoholic steatohepatitis (NASH): 8.1%], mean age of cirrhosis diagnosis was 54.2±8.9 years. Overall, 74.8% received initial screening within 1 year of cirrhosis diagnosis. Among those who completed initial screening, 47.6% [95% confidence interval (CI), 41.4-54.2) received second surveillance within 1 year. On multivariate analyses, patients with NASH and HBV were significantly more likely to receive second HCC surveillance compared with hepatitis C virus, HBV (hazard ratio, 2.32; 95% CI, 1.18-4.56; P=0.014) and NASH (hazard ratio, 2.49; 95% CI, 1.22-5.11; P=0.012). No sex or race-specific/ethnicity-specific differences in HCC surveillance retention were observed.

Conclusions:

Although overall rates of initial HCC screening among cirrhosis patients is nearly 75%, retention into continued HCC surveillance is poor, with less than half of patients undergoing subsequent HCC surveillance. Cirrhosis patients with HBV and NASH were more likely to be retained into HCC surveillance.
Incidence, Admission Rates, and Predictors, and Economic Burden of Adult Emergency Visits for Acute Pancreatitis
Authors: Garg Sushil K. , Sarvepalli Shashank , Campbell James P. , Obaitan Itegbemie , Singh Dupinder , Bazerbachi Fateh , Singh Rajeshwar , Sanaka Madhusudhan R.
Published: April 2018

Introduction:

Acute pancreatitis (AP) is the most common gastroenterology-related reason for hospital admission, and a major source of morbidity and mortality in the United States. This study examines the National Emergency Database Sample, a large national database, to analyze trends in emergency department (ED) utilization and costs, risk factors for hospital admission, and associated hospital costs and length of stay (LOS) in patients presenting with AP.

Methods:

The National Emergency Database Sample (2006 to 2012) was evaluated for trends in ED visits, ED charges, hospitalization rates, hospital charges, and hospital LOS in patients with primary diagnosis of AP (further subcategorized by age and etiology). A survey logistic-regression model was used to determine factors predictive of hospitalization.

Results:

A total of 2,193,830 ED visits were analyzed. There was a nonsignificant 5.5% (P=0.07) increase in incidence of ED visits for AP per 10,000 US adults from 2006 to 2012, largely driven by significant increases in ED visits for AP in the 18 to <45 age group (+9.2%; P=0.025), AP associated with alcohol (+15.9%; P=0.001), and AP associated with chronic pancreatitis (+59.5%; P=0.002). Visits for patients aged ≥65 decreased over the time period. Rates of admission and LOS decreased during the time period, while ED and inpatient costs increased (62.1%; P<0.001 and 7.9%; P=0.0011, respectively). Multiple factors were associated with increased risk of hospital admission from the ED, with the strongest predictors being morbid alcohol use [odds ratio (OR), 4.53; P<0.0001], advanced age (age>84 OR, 3.52; P<0.0001), and smoking (OR, 1.75; P<0.0001).

Conclusions:

Despite a relative stabilization in the overall incidence of ED visits for AP, continued increases in ED visits and associated costs appear to be driven by younger patients with alcohol-associated and acute on chronic pancreatitis. While rates of hospitalization and LOS are decreasing, associated inflation-adjusted costs are rising. In addition, identified risk factors for hospitalization, such as obesity, alcohol use, and increased age, should be explored in further study for potential use in predictive models and clinical improvement projects.
Primary aldosteronism in the primary care setting
Authors: Buffolo Fabrizio , Monticone Silvia , Tetti Martina , Mulatero Paolo
Published: April 2018

Purpose of review

The aim of the present manuscript is to provide an overview of the most updated studies on the prevalence of primary aldosteronism in primary care and to compare these figures with the actual rate of diagnosis in clinical practice and with the prevalence of primary aldosteronism in specific subgroup of patients.

Recent findings

Over the last 20 years the clinical spectrum of low renin hypertension and primary aldosteronism has changed dramatically. Once considered only in the presence of severe hypertension and hypokalemia, it is now well known that primary aldosteronism is not uncommon even in patients with mild forms of hypertension and/or normokalemia. Moreover, recent evidence points toward a large proportion of normotensive study participants as being affected by subclinical primary aldosteronism, which represents a strong risk factor for incident hypertension. Moreover, primary aldosteronism patients are exposed to an increased risk of cardio and cerebrovascular events and metabolic comorbidities compared with patients affected by essential hypertension. Disappointingly, primary aldosteronism remains a largely underdiagnosed and undertreated disorder.

These recent findings further highlight the importance of widening the spectrum of patients who should be screened for primary aldosteronism, to reduce the cardiovascular risk associated with this medical condition.
Medicaid Managed Care in Florida and Racial and Ethnic Disparities in Preventable Emergency Department Visits
Authors: Hu Tianyan , Mortensen Karoline , Chen Jie
Published: April 2018

Background:

In an effort to address health care spending growth, coordinate care, and improve access to primary care in the Medicaid program, Florida implemented the Statewide Mandatory Managed Care (SMMC) program in May of 2014.

Objectives:

The objective of this study is to investigate the impact of implementation of mandatory managed care in Medicaid on the preventable emergency department (ED) utilizations, with a focus on racial/ethnic minorities.

Research Design:

The primary data source is the universe of Florida ED visit and inpatient discharge data from 2010 to 2015, maintained by the Florida Agency for Health Care Administration. We adopt the New York University Billing’s ED Classification Algorithm to create measures for preventable ED visits. Using difference-in-differences estimation, we examine preventable ED visits for Florida residents aged 18–64 with a primary payer of Medicaid (treatment group) and private health insurance (control group) pre-SMMC and post-SMMC reform.

Results:

Our findings show that SMMC is statistically significantly associated with more reductions in preventable ED visits among non-Hispanic African American (incidence rate ratio=0.81; 95% confidence interval, 0.70–0.94) and Hispanic (incidence rate ratio=0.72; 95% CI, 0.60–0.87) Medicaid enrollees relative to their white counterparts. We also find significant reduction of racial/ethnic disparities only in counties with above median preimplementation Medicaid managed care penetration rate.

Conclusions:

Our findings suggest that implementation of Medicaid mandatory managed care in Florida is associated with reduced racial/ethnic disparities in preventable ED visits.
Organizational Processes and Patient Experiences in the Patient-centered Medical Home
Authors: Aysola Jaya , Schapira Marilyn M. , Huo Hairong , Werner Rachel M.
Published: April 2018

Background:

There is increasing emphasis on the use of patient-reported experience data to assess practice performance, particularly in the setting of patient-centered medical homes. Yet we lack understanding of what organizational processes relate to patient experiences.

Objective:

Examine associations between organizational processes practices adopt to become PCMH and patient experiences with care.

Research Design:

We analyzed visit data from patients (n=8356) at adult primary care practices (n=22) in a large health system. We evaluated the associations between practice organizational processes and patient experience using generalized estimating equations (GEE) with an exchangeable correlation structure to account for patient clustering by practice in multivariate models, adjusting for several practice-level and patient-level characteristics. We evaluated if these associations varied by race/ethnicity, insurance type, and the degree of patient comorbidity

Measures:

Predictors include overall PCMH adoption and adoption of six organizational processes: access and communications, patient tracking and registry, care management, test referral tracking, quality improvement and external coordination. Primary outcome was overall patient experience.

Results:

In our full sample, overall PCMH adoption score was not significantly associated with patient experience outcomes. However, among subpopulations with higher comorbidities, the overall PCMH adoption score was positively associated with overall patient experience measures [0.2 (0.06, 0.4); P=0.006]. Differences by race/ethnicity and insurance type in associations between specific organizational processes and patient experience were noted.

Conclusion:

Although some organizational processes relate to patients’ experiences with care irrespective of the background of the patient, further efforts are needed to align practice efforts with patient experience.
Cholesterol transfer at endosomal-organelle membrane contact sites
Authors: Ridgway Neale D. , Zhao Kexin
Published: April 2018

Purpose of review

Cholesterol is delivered to the limiting membrane of late endosomes by Niemann–Pick Type C1 and C2 proteins. This review summarizes recent evidence that cholesterol transfer from endosomes to the endoplasmic reticulum and other organelles is mediated by lipid-binding proteins that localize to membrane contact sites (MCS).

Recent findings

LDL-cholesterol in the late endosomal/lysosomes is exported to the plasma membrane, where most cholesterol resides, and the endoplasmic reticulum, which harbors the regulatory complexes and enzymes that control the synthesis and esterification of cholesterol. A major advance in dissecting these cholesterol transport pathways was identification of frequent and dynamic MCS between endosomes and the endoplasmic reticulum, peroxisomes and plasma membrane. Positioned at these MCS are members of the oxysterol-binding protein (OSBP) and steroidogenic acute regulatory protein-related lipid-transfer family of lipid transfer proteins that bridge the opposing membranes and directly or indirectly mediate cholesterol transfer. OSBP-related protein 1L (ORP1L), ORP5 and ORP6 mediate cholesterol transfer to the endoplasmic reticulum that regulates cholesterol homeostasis. ORP1L and STARD3 also move cholesterol from the endoplasmic reticulum-to-late endosomal/lysosomes under low-cholesterol conditions to facilitate intraluminal vesicle formation. Cholesterol transport also occurs at MCS with peroxisomes and possibly the plasma membrane.

Frequent contacts between organelles and the endo-lysosomal vesicles are sites for bidirectional transfer of cholesterol.
What have we learnt from the clinical outcomes trials with the cetrapibs?
Authors: Doggrell Sheila A.
Published: April 2018

Purpose of review

The current review considers what we have learnt from the clinical outcome trials with the cetrapibs; the inhibitors of cholesteryl ester transfer protein that increase HDL cholesterol levels; torcetrapib, dalcetrapib, evacetrapib and anacetrapib.

Recent findings

Although an off-target increase in blood pressure may have contributed to the failure of torcetrapib in Investigation of Lipid Level Management to Understand its Impact in Atherosclerotics Events, recent evidence shows that torcetrapib also increased atherogenic apoproteins, and this may have contributed to its failure. Evacetrapib and anacetrapib also increase atherogenic apoproteins. This may have contributed to lack of effect of evacetrapib in Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibition with Evacetrapib in Patients at a High Risk for Vascular Outcomes. The success of anacetrapib in Randomized Evaluation of the Effects of Anacetrapib through Lipid Modification is more likely to have been due to lowering LDL cholesterol than to increasing HDL cholesterol. The lack of potency in increasing HDL cholesterol was initially considered as a reason for the failure of dalcetrapib in dal-OUTCOMES, but recent genomic studies suggest that dalcetrapib may be effective in subjects with a particular genotype, and this is being clinically tested.

Collectively, these clinical outcome trials do not support raising HDL cholesterol by inhibiting cholesteryl ester transfer protein, as a mechanism for improving cardiovascular outcomes, in the total population of subjects with coronary artery disease.
Development of an enhanced recovery protocol for children undergoing gastrointestinal surgery
Authors: Raval Mehul V. , Heiss Kurt F.
Published: April 2018

Purpose of review

Enhanced recovery protocols (ERPs) have been adopted for a variety of adult surgical conditions and resulted in markedly improved outcomes, including decreased length of stays, complications, costs, and narcotic utilization. In this review, we describe the development and implementation of an ERP for children undergoing gastrointestinal surgery.

Recent findings

Existing ERP components from adult and pediatric surgical populations were reviewed and modified through an iterative process that included literature review, a national survey of practicing pediatric surgeons, and appropriateness assessment by a multidisciplinary expert panel. A single-center pilot implementing a gastrointestinal ERP demonstrated a steady increase in the number of ERP elements being employed over time with a simultaneous decrease in length of stays, decrease in median time to regular diet, decrease in median dose of intraoperative and postoperative narcotics, and decrease in median volume of intraoperative fluids. Balancing measures such as complication rates and 30-day readmission rates were stable or trended toward improved outcomes.

ERPs for children undergoing gastrointestinal surgery appear feasible, safe, and associated with improved outcomes. Further validation of these results and expansion to a wider breadth of children's surgical care will help to establish ERPs as a new standard of surgical care.
Failed Vacuum and the Long-term Hematologic Morbidity of the Offspring
Authors: Mastrolia Salvatore A. , Wainstock Tamar , Sheiner Eyal , Landau Daniella , Walfisch Asnat
Published: April 2018

Objective:

We aimed to investigate the effect of failed vacuum delivery leading to an emergency cesarean delivery on the long-term pediatric hematologic morbidity of the offspring.

Study Design:

In this population-based cohort study, the risk of long-term hematologic morbidity (up to the age of 18 y) was evaluated in children born following successful vacuum vaginal delivery, as compared with that of children born following a failed procedure leading to an emergent cesarean delivery. Multiple pregnancies and fetuses with congenital malformations were excluded. A Kaplan-Meier survival curve was constructed to compare cumulative pediatric hematologic morbidity, and a Cox proportional hazards model was used to control for confounders.

Results:

A total of 7978 neonates met the inclusion criteria. Vacuum delivery was successful in 7733 cases (96.9%), whereas it failed in 245 cases (3.1%). Total hematologic morbidity of the offspring up to 18 years of age was comparable between the groups (1.6% vs. 0.8%, P=0.8). The Kaplan-Meier survival curve showed no difference in the cumulative incidence of total hematologic morbidity (log rank, P=0.22). In the Cox regression model, failed vacuum delivery was not independently associated with long-term hematologic morbidity, as compared with a successful procedure, while adjusting for multiple confounders (adjusted hazards ratio [HR], 1.8; 95% confidence interval, 0.7-5.0; P=0.25).

Conclusions:

Failed vacuum delivery does not seem to be associated with an increased risk for pediatric hematologic morbidity of the offspring up to 18 years of age.
Management of Children With β-Thalassemia Intermedia: Overview, Recent Advances, and Treatment Challenges
Authors: Adly Amira A. , Ismail Eman A.
Published: April 2018

Our knowledge of the various clinical morbidities that thalassemia intermedia (TI) patients endure has substantially increased over the past decade. It is mandatory to grasp a solid understanding of disease-specific complications in order to tailor management. The optimal course of management for TI patients has been hard to identify, and several controversies remain with regard to the best treatment plan. Although advances in TI are moving at a fast pace, many complications remain with no treatment guidelines. Studies that expand our understanding of the mechanisms and risk factors, as well as clinical trials evaluating the roles of available treatments, will help establish management guidelines that improve patient care. Novel therapeutic modalities are now emerging. This article focuses on the management of children with β-TI. We present various clinical morbidities and their association with the underlying disease pathophysiology and risk factors. All therapeutic options, recent advances, and treatment challenges were reviewed.
Conceptualization and Operationalization of Certification in the US and Canadian Nursing Literature
Authors: Chappell Kathy , ElChamaa Rima , Jeong Dahn , Kendall-Gallagher Deborah , Salt Elizabeth , Reeves Scott , Moore Donald , Olson Curtis , Van Hoof Thomas , Lundmark Vicki , Danilovich Natalia , Kitto Simon
Published: April 2018

OBJECTIVE

To identify how certification is defined, conceptualized, and discussed in the nursing literature.

BACKGROUND

Although it is hypothesized that credentialing is associated with better patient outcomes, the evidence is relatively limited. Some authors have suggested that the lack of consistency used to define certification in nursing literature may be one of the dominant obstacles in credentialing research.

METHODS

This scoping review was guided by Arksey and O’Malley’s framework, and quantitative and qualitative analyses were conducted.

RESULTS

The final data set contained a total of 36 articles, of which 14 articles provided a referenced definition of certification. Thematic analysis of the definitions yielded 8 dominant themes.

CONCLUSION

The lack of a common definition of certification in nursing must be addressed to advance research into the relationship between certification processes in nursing and healthcare outcomes.
National Study of Nursing Research Characteristics at Magnet®-Designated Hospitals
Authors: Pintz Christine , Zhou Qiuping (Pearl) , McLaughlin Maureen Kirkpatrick , Kelly Katherine Patterson , Guzzetta Cathie E.
Published: April 2018

OBJECTIVE

To describe the research infrastructure, culture, and characteristics of building a nursing research program in Magnet®–designated hospitals.

BACKGROUND

Magnet recognition requires hospitals to conduct research and implement evidence-based practice (EBP). Yet, the essential characteristics of productive nursing research programs are not well described.

METHODS

We surveyed 181 nursing research leaders at Magnet-designated hospitals to assess the characteristics in their hospitals associated with research infrastructure, research culture, and building a nursing research program.

RESULTS

Magnet hospitals provide most of the needed research infrastructure and have a culture that support nursing research. Higher scores for the 3 categories were found when hospitals had a nursing research director, a research department, and more than 10 nurse-led research studies in the past 5 years.

CONCLUSIONS

While some respondents indicated their nurse executives and leaders support the enculturation of EBP and research, there continue to be barriers to full implementation of these characteristics in practice.
Exploring Nurse Manager Support of Evidence-Based Practice
Authors: Caramanica Laura , Spiva LeeAnna
Published: April 2018

OBJECTIVE

The study identifies what constitutes nurse manager (NM) support and other resources that enable clinical nurses (CNs) to engage in evidence-based practice (EBP).

BACKGROUND

Clinical nurses report that NM support enables them to use EBP but what constitutes NM support is still unclear.

METHODS

Nurse managers, CNs, and EBP mentors received specialized education and use a team approach for EBP. Data were collected preintervention, mid-intervention, and postintervention from observations, interviews, journaling, and surveys.

RESULTS

Results demonstrate how NMs can perform their role responsibilities and still engage CNs to develop a spirit of inquiry, seek answers to their clinical questions using EBP, and advance their clinical performance to improve patient outcomes. Four NM supportive behaviors emerged: cultivating a shared EBP vision, ensuring use of EBP, communicating the value of EBP, and providing resources for EBP.

CONCLUSION

Through education and support, NMs describe supportive behaviors necessary for the successful conduction of EBP by CNs.
A Survey of Somatic Mutations in 41 Genes in a Cohort of T-Cell Lymphomas Identifies Frequent Mutations in Genes Involved in Epigenetic Modification
Authors: Fernandez-Pol Sebastian , Ma Lisa , Joshi Rohan P. , Arber Daniel A.
Published: April 2018

Here, we utilize a high throughput sequencing panel that covers several genes known to be recurrently mutated in certain T-cell lymphoma subtypes as well as genes frequently mutated in other hematolymphoid malignancies, including myeloid neoplasms. This panel was applied to formalin-fixed, paraffin-embedded tissue from 84 biopsies from 78 patients selected for this study. The biopsies included ones a with a diagnosis of T-cell lymphoma (n=79), including peripheral T-cell lymphoma not otherwise specified (PTCL-NOS; n=26) and angioimmunoblastic T-cell lymphoma (AITL; n=13), as well as 5 cases of atypical T-cell proliferations. KMT2C and KMT2D, which code for proteins involved in histone modifications, were the 2 most frequently mutated genes in our cohort and were altered across a range T-cell lymphomas. Mutations in TET2 and DNMT3A, which are involved in regulating DNA methylation, were also found in a variety of T-cell lymphoma categories. The RHOA G17V mutation that is frequently found in AITL was identified 5 of 13 (40%) cases of AITL and in 3 of 26 (12%) cases of PTCL-NOS, but not in biopsies involved by other T-cell proliferations. Our study adds to the already significant evidence from other investigators that, among T-cell lymphomas, the RHOA G17V variant is specific for AITL and PTCL-NOS. In contrast, variants in epigenetic modifier genes do not appear to be particularly specific for T-cell lymphoma subcategories evaluated in our study.