bluuebunny/crossref_metadata_2025 huggingface dataset:
Study protocol for a randomised controlled trial evaluating the effectiveness of strengths model case management (SMCM) with Chinese mental health service users in Hong Kong
Authors: Tse Samson , Ng Sau Man Catalina , Yuen Wing Yan Winnie , Fukui Sadaaki , Goscha Richard J , Lo Wann Ka Iris
Published: May 2019

Introduction

Strengths-based approaches mobilise individual and environmental resources that can facilitate the recovery of people with mental illness. Strengths model case management (SMCM), developed by Rapp and Goscha through collaborative efforts at the University of Kansas, offers a structured and innovative intervention. As evidence of the effectiveness of strengths-based interventions come from Western studies, which lacked rigorous research design or failed to assure fidelity to the model, we aim to fill these gaps and conduct a randomised controlled trial (RCT) to test the effectiveness of SMCM for individuals with mental illness in Hong Kong.

Methods and analysis

This will be an RCT of SMCM. Assuming a medium intervention effect (Cohen’s d=0.60) with 30% missing data (including dropouts), 210 service users aged 18 years or above will be recruited from three community mental health centres. They will be randomly assigned to SMCM groups (intervention) or SMILE groups (control) in a 1:1 ratio. The SMCM groups will receive strengths model interventions from case workers, whereas the SMILE groups will receive generic care from case workers with an attention placebo. The case workers will all be embedded in the community centres and will be required to provide a session with service users in both groups at least once every fortnight. There will be two groups of case workers for the intervention and control groups, respectively. The effectiveness of the SMCM will be compared between the two groups of service users with outcomes at baseline, 6 and 12 months after recruitment. Functional outcomes will also be reported by case workers. Data on working alliances and goal attainment will be collected from individual case workers. Qualitative evaluation will be conducted to identify the therapeutic ingredients and conditions leading to positive outcomes. Trained outcome assessors will be blind to the group allocation.

Ethics and dissemination

Ethical approval from the Human Research Ethics Committee at the University of Hong Kong has been obtained (HRECNCF: EA1703078). The results will be disseminated to service users and their families via the media, to healthcare professionals via professional training and meetings and to researchers via conferences and publications.

Trial registration number

12617001435370; Pre-results.
Self-regulated learning lens on trainee perceptions of the mini-CEX: a qualitative study
Authors: Kipen Eva , Flynn Eleanor , Woodward-Kron Robyn
Published: May 2019

Objectives

The formative aspect of the mini-clinical evaluation exercise (mini-CEX) in postgraduate medical workplace-based assessment is intended to afford opportunities for active learning. Yet, there is little understanding of the perceived relationship between the mini-CEX and how trainees self-regulate their learning. Our objective was to explore trainees’ perceptions of their mini-CEX experiences from a learning perspective, using Zimmerman’s self-regulated learning theoretical framework as an interpretive lens.

Design

Qualitative, using semi-structured interviews conducted in 2017. The interviews were analysed thematically.

Setting

Geriatric medicine training.

Participants

Purposive sampling was employed to recruit geriatric medicine trainees in Melbourne, Australia. Twelve advanced trainees participated in the interviews.

Results

Four themes were found with a cyclical inter-relationship between three of these themes: namely, goal setting, task translation and perceived outcome. These themes reflect the phases of the self-regulated learning framework. Each phase was influenced by the fourth theme, supervisor co-regulation. Goal setting had motivational properties that had significant impact on the later phases of the cycle. A ‘tick box’ goal aligned with an opportunistic approach and poorer perceived educational outcomes. Participants reported that external feedback following assessment was critical for their self-evaluation, affective responses and perceived outcomes.

Conclusions

Trainees perceived the performance of a mini-CEX as a complex, inter-related cyclical process, influenced at all stages by the supervisor. Based on our trainee perspectives of the mini-CEX, we conclude that supervisor engagement is essential to support trainees to individually regulate their learning in the clinical environment.
Assessment of the advantage of the serum S100B protein biomonitoring in the management of paediatric mild traumatic brain injury—PROS100B: protocol of a multicentre unblinded stepped wedge cluster randomised trial
Authors: Bouvier Damien , Balayssac David , Durif Julie , Mourgues Charline , Sarret Catherine , Pereira Bruno , Sapin Vincent
Published: May 2019

Introduction

S100B serum analysis in clinical routine could reduce the number of cranial CT (CCT) scans performed on children with mild traumatic brain injury (mTBI). Sampling should take place within 3 hours of trauma and cut-off levels should be based on paediatric reference ranges. The aim of this study is to evaluate the utility of measuring serum S100B in the management of paediatric mTBI by demonstrating a decrease in the number of CCT scans prescribed in an S100B biomonitoring group compared with a ‘conventional management’ control group, with the assumption of a 30% relative decrease of the number of CCT scans between the two groups.

Methods and analysis

The protocol is a randomised, multicentre, unblinded, prospective, interventional study (nine centres) using a stepped wedge cluster design, comparing two groups (S100B biomonitoring and control). Children in the control group will have CCT scans or be hospitalised according to the current recommendations of the French Society of Paediatrics (SFP). In the S100B biomonitoring group, blood sampling to determine serum S100B protein levels will take place within 3 hours after mTBI and subsequent management will depend on the assay. If S100B is in the normal range according to age, the children will be discharged from the emergency department after 6 hours’ observation. If the result is abnormal, CCT scans or hospitalisation will be prescribed in accordance with current SFP recommendations. The primary outcome measure will be the proportion of CCT scans performed (absence/presence of CCT scan for each patient) in the 48 hours following mTBI.

Ethics and dissemination

The protocol presented (Version 5, 03 November 2017) has been approved by the ethics committee Comité de Protection des Personnes sud-est 6 (first approval 08 June 2016, IRB: 00008526). Participation in the study is voluntary and anonymous. The study findings will be disseminated in international peer-reviewed journals and presented at relevant conferences.

Trial registration number

NCT02819778.
Medication decision-making for patients with renal insufficiency in inpatient and outpatient care at a US Veterans Affairs Medical Centre: a qualitative, cognitive task analysis
Authors: Elkhadragy Nervana , Ifeachor Amanda P , Diiulio Julie B , Arthur Karen J , Weiner Michael , Militello Laura G , Glassman Peter A , Zillich Alan J , Russ Alissa L
Published: May 2019

Background

Many studies identify factors that contribute to renal prescribing errors, but few examine how healthcare professionals (HCPs) detect and recover from an error or potential patient safety concern. Knowledge of this information could inform advanced error detection systems and decision support tools that help prevent prescribing errors.

Objective

To examine the cognitive strategies that HCPs used to recognise and manage medication-related problems for patients with renal insufficiency.

Design

HCPs submitted documentation about medication-related incidents. We then conducted cognitive task analysis interviews. Qualitative data were analysed inductively.

Setting

Inpatient and outpatient facilities at a major US Veterans Affairs Medical Centre.

Participants

Physicians, nurses and pharmacists who took action to prevent or resolve a renal-drug problem in patients with renal insufficiency.

Outcomes

Emergent themes from interviews, as related to recognition of renal-drug problems and decision-making processes.

Results

We interviewed 20 HCPs. Results yielded a descriptive model of the decision-making process, comprised of three main stages: detect, gather information and act. These stages often followed a cyclical path due largely to the gradual decline of patients’ renal function. Most HCPs relied on being vigilant to detect patients’ renal-drug problems rather than relying on systems to detect unanticipated cues. At each stage, HCPs relied on different cognitive cues depending on medication type: for renally eliminated medications, HCPs focused on gathering renal dosing guidelines, while for nephrotoxic medications, HCPs investigated the need for particular medication therapy, and if warranted, safer alternatives.

Conclusions

Our model is useful for trainees so they can gain familiarity with managing renal-drug problems. Based on findings, improvements are warranted for three aspects of healthcare systems: (1) supporting the cyclical nature of renal-drug problem management via longitudinal tracking mechanisms, (2) providing tools to alleviate HCPs’ heavy reliance on vigilance and (3) supporting HCPs’ different decision-making needs for renally eliminated versus nephrotoxic medications.
Predicting the success of vaginal birth after caesarean delivery: a retrospective cohort study in China
Authors: Li Yun-Xiu , Bai Zhi , Long Da-Jian , Wang Hai-Bo , Wu Yang-Feng , Reilly Kathleen H , Huang Su-Ran , Ji Yan-Jie
Published: May 2019

Objectives

To develop a nomogram to predict the likelihood of vaginal birth after caesarean section (VBAC) among women after a previous caesarean section (CS).

Design

A retrospective cohort study.

Setting

Two secondary hospitals in Guangdong Province, China.

Participants

Inclusion criteria were as follows: pregnant women with singleton fetus, age ≥18 years, had a history of previous CS and scheduled for trial of labour after caesarean delivery (TOLAC). Patients with any of the following were excluded from the study: preterm labour (gestational age <37 weeks), two or more CSs, contradictions for vaginal birth, history of other uterine incision such as myomectomy, and incomplete medical records.

Primary outcome measure

The primary outcome was VBAC, which was retrospectively abstracted from computerised medical records by clinical staff.

Results

Of the women who planned for TOLAC, 84.0% (1686/2006) had VBAC. Gestational age, history of vaginal delivery, estimated birth weight, body mass index, spontaneous onset of labour, cervix Bishop score and rupture of membranes were independently associated with VBAC. An area under the receiver operating characteristic curve (AUC) in the prediction model was 0.77 (95% CI 0.73 to 0.81) in the training cohort. The validation set showed good discrimination with an AUC of 0.70 (95% CI 0.60 to 0.79).

Conclusions

TOLAC may be a potential strategy for decreasing the CS rate in China. The validated nomogram to predict success of VBAC could be a potential tool for VBAC counselling.
Alcohol control policies and socioeconomic inequalities in hazardous alcohol consumption: a 22-year cross-sectional study in a Swiss urban population
Authors: Sandoval José Luis , Leão Teresa , Theler Jean-Marc , Favrod-Coune Thierry , Broers Barbara , Gaspoz Jean-Michel , Marques-Vidal Pedro , Guessous Idris
Published: May 2019

Objective

Harmful use of alcohol represents a large socioeconomic and disease burden and displays a socioeconomic status (SES) gradient. Several alcohol control laws were devised and implemented, but their equity impact remains undetermined.

We ascertained if an SES gradient in hazardous alcohol consumption exists in Geneva (Switzerland) and assessed the equity impact of the alcohol control laws implemented during the last two decades.

Design

Repeated cross-sectional survey study.

Setting

We used data from non-abstinent participants, aged 35–74 years, from the population-based cross-sectional Bus Santé study (n=16 725), between 1993 and 2014.

Methods

SES indicators included educational attainment (primary, secondary and tertiary) and occupational level (high, medium and low). We defined four survey periods according to the implemented alcohol control laws and hazardous alcohol consumption (outcome variable) as >30 g/day for men and >20 g/day for women.

The Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were used to quantify absolute and relative inequalities, respectively, and were compared between legislative periods.

Results

Lower educated men had a higher frequency of hazardous alcohol consumption (RII=1.87 (1.57; 2.22) and SII=0.14 (0.11; 0.17)). Lower educated women had less hazardous consumption ((RII=0.76 (0.60; 0.97)and SII=−0.04 (−0.07;−0.01]). Over time, hazardous alcohol consumption decreased, except in lower educated men.

Education-related inequalities were observed in men in all legislative periods and did not vary between them. Similar results were observed using the occupational level as SES indicator. In women, significant inverse SES gradients were observed using educational attainment but not for occupational level.

Conclusions

Population-wide alcohol control laws did not have a positive equity impact on hazardous alcohol consumption. Targeted interventions to disadvantaged groups may be needed to address the hazardous alcohol consumption inequality gap.
Quality improvement project aimed at improving the reliability of spontaneous awakening trials in a district general intensive care unit
Authors: Ferraioli Donna , Ferguson Laura , Carberry Martin
Published: May 2019

Traditionally regarded as good practice, continuous infusions of sedation and analgesic medications are used to reduce anxiety and distress and facilitate care of mechanically ventilated patients in the intensive care unit (ICU). Growing evidence has demonstrated that use of such infusions prolongs days spent invasively ventilated, increases the incidence of ICU acquired weakness and delirium and subsequently increasing the duration of their ICU and hospital stay. Several critical care guidelines recommend titrating to light sedation ±a daily sedation hold or spontaneous awakening trial (SAT). Given the known beneficial effects of sedation holds, we aimed to increase their use within our ICU, a 10-bedded unit with mixed ICU and high-ependency unit facilities in National Health Service Scotland. A retrospective case note review was performed to obtain baseline data of SAT eligible patients who received a sedation hold. The model for improvement 1 was used to implement an ICU protocol based on the ‘Wake up and breath’ guidelines 2 and measure the improvements made. The median percentage of SAT eligible patients that received a sedation hold increased from 47% to 96% during the project period. No significant adverse events were reported during this period and a reduction in ventilation and unit stay was observed. Quality improvement methods have facilitated successful and safe integration of a daily sedation hold protocol in our ICU.
Guidelines on the management of acute respiratory distress syndrome
Authors: Griffiths Mark J D , McAuley Danny Francis , Perkins Gavin D , Barrett Nicholas , Blackwood Bronagh , Boyle Andrew , Chee Nigel , Connolly Bronwen , Dark Paul , Finney Simon , Salam Aemun , Silversides Jonathan , Tarmey Nick , Wise Matt P , Baudouin Simon V
Published: May 2019

The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio<20 kPa), prone positioning was recommended for at least 12 hours per day. By contrast, high frequency oscillation was not recommended and it was suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure and the use of the neuromuscular blocking agent cisatracurium for 48 hours was suggested for patients with ARDS with ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios less than or equal to 27 and 20 kPa, respectively. Extracorporeal membrane oxygenation was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extracorporeal carbon dioxide removal.
Early real-world effectiveness of ustekinumab for Crohn’s disease
Authors: Harris Richard James , McDonnell Martin , Young David , Bettey Marion , Downey Louise , Pigott Lucinda , Felwick Richard , Gwiggner Markus , Cummings J R Fraser
Published: May 2019

Objective

To understand the effectiveness of ustekinumab in treating Crohn’s disease (CD) in a UK real-world setting.

Design

Retrospective cohort study using prospectively maintained clinical records.

Setting

Single UK inflammatory bowel disease centre.

Patients

Adult patients with an established diagnosis of CD prescribed ustekinumab outside of clinical trials at University Hospital Southampton (UHS).

Interventions

Ustekinumab, a monoclonal antibody to the shared p40 subunit of interleukin (IL) 12 and IL-23 as part of routine clinical care.

Main outcome measures

Effectiveness as measured by an improvement in physician’s global assessment, drug persistence and improvement in biomarkers (C-reactive protein (CRP), albumin and calprotectin).

Results

84 patients were included, 72 had a postinduction review and 49 had 1-year data. At postinduction clinical review, clinical response occurred in 53% of patients and clinical remission occurred in 8%. For patients on ustekinumab at 1 year, clinical response occurred in 71% and remission in 14%. Adverse events included four patients with infections requiring admission, one drug-related rash, five CD surgeries and two CD exacerbations.

Conclusions

Ustekinumab was well tolerated in a complex UK CD population and demonstrated benefit to patients in terms of clinical response and improvement of biomarkers and with some patients attaining clinical remission. No unexpected safety signals were seen.
Clinical implications of electrocardiographic bundle branch block in primary care
Authors: Rasmussen Peter Vibe , Skov Morten Wagner , Ghouse Jonas , Pietersen Adrian , Hansen Steen Møller , Torp-Pedersen Christian , Køber Lars , Haunsø Stig , Olesen Morten Salling , Svendsen Jesper Hastrup , Melgaard Jacob , Graff Claus , Holst Anders Gaardsdal , Nielsen Jonas Bille
Published: May 2019

Objectives

Electrocardiographic bundle branch block (BBB) is common but the prognostic implications in primary care are unclear. We sought to investigate the relationship between electrocardiographic BBB subtypes and the risk of cardiovascular (CV) outcomes in a primary care population free of major CV disease.

Methods

Retrospective cohort study of primary care patients referred for electrocardiogram (ECG) recording between 2001 and 2011. Cox regression models were used to estimate hazard ratios (HR) as well as absolute risks of CV outcomes based on various BBB subtypes.

Results

We included 202 268 individuals with a median follow-up period of 7.8 years (Inter-quartile range [IQR] 4.9–10.6). Left bundle branch block (LBBB) was associated with heart failure (HF) in both men (HR 3.96, 95% CI 3.30 to 4.76) and women (HR 2.51, 95% CI 2.15 to 2.94) and with CV death in men (HR 1.80, 95% CI 1.38 to 2.35). Right bundle branch block (RBBB) was associated with pacemaker implantation in both men (HR 3.26, 95% CI 2.74 to 3.89) and women (HR 3.69, 95% CI 2.91 to 4.67), HF in both sexes and weakly associated with CV death in men. Regarding LBBB, we found an increasing hazard of HF with increasing QRS-interval duration (HR 1.25, 95% CI 1.11 to 1.42 per 10 ms increase in men and HR 1.23, 95% CI 1.08 to 1.40 per 10 ms increase in women). Absolute 10-year risk predictions across age-specific and sex-specific subgroups revealed clinically relevant differences between having various BBB subtypes.

Conclusions

Opportunistic findings of BBB subtypes in primary care patients without major CV disease should be considered warnings of future HF and pacemaker implantation.
Underuse of ECG monitoring in oncology patients receiving QT-interval prolonging drugs
Authors: Pezo Rossanna C , Yan Andrew T , Earle Craig , Chan Kelvin K
Published: May 2019

Objective

We examined use of ECG monitoring in oncology patients prescribed QT-prolonging drugs.

Methods

Patients ≥66 years diagnosed with cancer between 2005 and 2011 were identified through the Ontario Cancer Registry and linked to multiple population-based administrative databases to ascertain demographics, comorbidities, prescription drug use, systemic therapy and ECG. QT-prolonging drugs were identified as per drug lists developed by the Arizona Center for Education and Research on Therapeutics. Univariable and multivariable analyses were used to examine factors associated with ECG use in patients on first-line systemic therapy.

Results

A total of 48 236 patients (median age 74; 49% women) received one or more drugs associated with a risk of QT-interval prolongation but only 27% of patients had an ECG performed. Factors associated with more ECG use on multivariable analysis included recent cancer diagnosis (p for trend <0.001 between 2005 and 2011), use of concurrent QT-prolonging drugs (OR=1.15 per each additional QT-prolonging drug, 95% CI 1.12 to 1.17) and the presence of coronary artery disease (OR 1.31; 95% CI 1.25 to 1.38) and heart failure (OR 1.25; 95% CI 1.17 to 1.35). Use of anticancer (OR 0.74; 95% CI 0.70 to 0.79) and antiemetic (OR 0.93; 95% CI 0.88 to 0.99) QT-prolonging drugs was paradoxically associated with less ECG use.

Conclusions

Our study highlights common use of QT-prolonging drugs and underuse of ECG in oncology patients. Since ECG is an inexpensive, non-invasive and widely available test, it may be readily incorporated in the monitoring of patients for toxicities in routine clinical practice.
Impact on long-term mortality of access and non-access site bleeding after primary percutaneous coronary intervention
Authors: Matic Dragan M , Asanin Milika R , Vukcevic Vladan D , Mehmedbegovic Zlatko H , Marinkovic Jelena M , Kocev Nikola I , Marjanovic Marija M , Mrdovic Igor B , Antonijevic Nebojsa M , Milosevic Aleksandra D , Zivkovic Milorad N , Krljanac Gordana V , Stankovic Sanja Dj , Milasinovic Dejan G , Lasica Ratko M , Stankovic Goran R
Published: May 2019

Objectives

The influence of the bleeding site on long-term survival after the primary percutaneous coronary intervention (PCI) is poorly understood. This study sought to investigate the relationship between in-hospital access site versus non-access site bleeding and very late mortality in unselected patients treated with primary PCI.

Methods

Data of the 2715 consecutive patients with ST-segment elevation myocardial infarction treated with primary PCI, enrolled in a prospective registry of a high volume tertiary centre, were analysed. Bleeding events were assessed according to the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 4-year mortality.

Results

The BARC type ≥2 bleeding occurred in 171 patients (6.3%). Access site bleeding occurred in 3.8%, and non-access site bleeding in 2.5% of patients. Four-year mortality was significantly higher for patients with bleeding (BARC type ≥2) than in patients without bleeding (BARC type 0+1), (36.3% vs 16.2%, p<0.001). Patients with non-access site bleeding had higher 4 year mortality (50.7% vs 26.5%, p=0.001). After multivariable adjustment, BARC type ≥2 bleeding was the independent predictor of 4 year mortality (HR 2.01; 95% CI 1.49 to 2.71, p<0.001). Patients with a non-access site bleeding were at 2-fold higher risk of very late mortality than patients with an access site bleeding (HR 2.62; 1.78 to 3.86, p<0.001 vs HR 1.57; 1.03 to 2.38, p=0.034).

Conclusions

Both access and non-access site BARC type ≥2 bleeding is independently associated with a high risk of 4-year mortality after primary PCI. Patients with non-access site bleeding were at higher risk of late mortality than patients with access site bleeding.
Maternal and fetal outcomes in pregnancies complicated by Marfan syndrome
Authors: Cauldwell Matthew , Steer Philip J , Curtis Stephanie L , Mohan Aarthi , Dockree Samuel , Mackillop Lucy , Parry Helen M , Oliver James , Sterrenberg Monique , Wallace Suzanne , Malin Gemma , Partridge Gemma , Freeman Leisa J , Bolger Aidan P , Siddiqui Farah , Wilson Dirk , Simpson Margaret , Walker Niki , Hodson Ken , Thomas Katherine , Bredaki Foteini , Mercaldi Rebecca , Walker Fiona , Johnson Mark R
Published: May 2019

Objectives

Information to guide counselling and management for pregnancy in women with Marfan syndrome (MFS) is limited. We therefore conducted a UK multicentre study.

Methods

Retrospective observational study of women with MFS delivering between January 1998 and March 2018 in 12 UK centres reporting data on maternal and neonatal outcomes.

Results

In total, there were 258 pregnancies in 151 women with MFS (19 women had prior aortic root replacements), including 226 pregnancies ≥24 weeks (two sets of twins), 20 miscarriages and 12 pregnancy terminations. Excluding miscarriages and terminations, there were 221 live births in 139 women. Only 50% of women received preconception counselling. There were no deaths, but five women experienced aortic dissection (1.9%; one type A and four type B—one had a type B dissection at 12 weeks and subsequent termination of pregnancy). Five women required cardiac surgery postpartum. No predictors for aortic dissection could be identified. The babies of the 131 (65.8%) women taking beta-blockers were on average 316 g lighter (p<0.001). Caesarean section rates were high (50%), particularly in women with dilated aortic roots. In 55 women, echocardiographic aortic imaging was available prepregnancy and postpregnancy; there was a small but significant average increase in AoR size of 0.84 mm (Median follow-up 2.3 months)

Conclusion

There were no maternal deaths, and the aortic dissection rate was 1.9% (mainly type B). There with no identifiable factors associated with aortic dissection in our cohort. Preconception counselling rates were low and need improvement. Aortic size measurements increased marginally following pregnancy.
Outcomes of untreated frequent premature ventricular complexes with normal left ventricular function
Authors: Lee Andrea K Y , Andrade Jason , Hawkins Nathaniel M , Alexander George , Bennett Matthew T , Chakrabarti Shanta , Laksman Zachary W , Krahn Andrew , Yeung-Lai-Wah John A , Deyell Marc William
Published: May 2019

Objective

The natural history of frequent premature ventricular complexes (PVCs) in association with preserved left ventricular ejection fraction (LVEF) is uncertain. The optimal management of this population is thus undefined. We studied the outcomes of untreated patients with frequent PVCs and preserved LVEF.

Methods

This cohort study prospectively evaluated consecutive patients from 2012 to 2017, with asymptomatic or minimally symptomatic frequent idiopathic PVCs (≥5% PVCs in 24 hours; normal LVEF; no cause identified on comprehensive evaluation). No suppressive therapy (ablation or antiarrhythmic drugs) were used and patients were followed with serial ambulatory ECG monitoring and echocardiography. The primary arrhythmic outcome was reduction in PVC burden to <1% on serial ambulatory monitoring. The primary echocardiographic outcome was a reduction of LVEF to <50%.

Results

One hundred patients met inclusion criteria (mean age 51.8 years, 57% female) with a median PVC burden of 18.4%. Reduction to <1% PVCs occurred in 44 of 100 patients (44.0%) at a median of 15.4 months (range 2.6 to 64.3). Recurrence was uncommon (4/44, 9.1%). Four patients (4.3%) with a persistently elevated PVC burden developed left ventricular dysfunction (LVEF <50%) during the follow-up period at a range of 53–71 months. The initial PVC burden did not predict subsequent resolution (HR 1.00(0.97, 1.03); p=0.86).

Conclusions

A strategy of active surveillance is appropriate for the majority of patients with frequent idiopathic PVCs in association with preserved LVEF, owing to the low risk of developing left ventricular systolic dysfunction and the high rate of spontaneous resolution.
Practical application of non-contact alternating current electric field mixing for reagent-saving in situ hybridisation of HER2
Authors: Kurihara Nobuyasu , Imai Kazuhiro , Nanjo Hiroshi , Nakamura Ryuta , Wakamatsu Yuki , Akagami Koji , Terata Kaori , Wakita Akiyuki , Sato Yusuke , Motoyama Satoru , Akagami Yoichi , Minamiya Yoshihiro
Published: May 2019

Aims

Human epidermal growth factor receptor 2 (HER2)-targeted agents are effective against HER2-positive breast cancers. However, their lack of survival benefit in HER2-negative patients as well as their toxic effects and high cost highlight the need for accurate assessment of HER2 status. Our aim was to evaluate the clinical utility of a reagent-saving in situ hybridisation (Saving ISH) that facilitates hybridisation and saves HER2/chromosome enumeration probe by taking advantage of the non-contact mixing effect of an alternating current (AC) electric field.

Methods

With a new device, we apply a high-voltage, low-frequency AC electric field to the tissue sections, which mixes the probe within microdroplets as the voltage is switched on and off. Specimens (n=113) from patients with breast cancers identified immunohistochemically as HER2 0/1(+), (2+) or (3+) were used. The specimens were all tested using conventional dual ISH (DISH), DISH with an automated slide stainer (ASS) and Saving ISH (1:1–1:3 dilution).

Results

The Saving ISH with 1:2 probe dilution produced stable results with less non-specific staining while using smaller amounts of probe. The accuracy of HER2 status with Saving ISH was equal to standard. We found 96.4% agreement between DISH using ASS and Saving ISH (kappa coefficient=0.912).

Conclusions

These results suggest reagent-saving HER2 ISH could be used as a clinical tool for accurate and stable HER2 assessment, even when reagent concentrations vary.
Image-based analysis and long-term clinical outcomes of deep brain stimulation for Tourette syndrome: a multisite study
Authors: Johnson Kara A , Fletcher P Thomas , Servello Domenico , Bona Alberto , Porta Mauro , Ostrem Jill L , Bardinet Eric , Welter Marie-Laure , Lozano Andres M , Baldermann Juan Carlos , Kuhn Jens , Huys Daniel , Foltynie Thomas , Hariz Marwan , Joyce Eileen M , Zrinzo Ludvic , Kefalopoulou Zinovia , Zhang Jian-guo , Meng Fan-gang , Zhang ChenCheng , Ling Zhipei , Xu Xin , Yu Xinguang , Smeets Anouk YJM , Ackermans Linda , Visser-Vandewalle Veerle , Mogilner Alon Y , Pourfar Michael H , Almeida Leonardo , Gunduz Aysegul , Hu Wei , Foote Kelly D , Okun Michael S , Butson Christopher R
Published: May 2019

Background

Deep brain stimulation (DBS) can be an effective therapy for tics and comorbidities in select cases of severe, treatment-refractory Tourette syndrome (TS). Clinical responses remain variable across patients, which may be attributed to differences in the location of the neuroanatomical regions being stimulated. We evaluated active contact locations and regions of stimulation across a large cohort of patients with TS in an effort to guide future targeting.

Methods

We collected retrospective clinical data and imaging from 13 international sites on 123 patients. We assessed the effects of DBS over time in 110 patients who were implanted in the centromedial (CM) thalamus (n=51), globus pallidus internus (GPi) (n=47), nucleus accumbens/anterior limb of the internal capsule (n=4) or a combination of targets (n=8). Contact locations (n=70 patients) and volumes of tissue activated (n=63 patients) were coregistered to create probabilistic stimulation atlases.

Results

Tics and obsessive–compulsive behaviour (OCB) significantly improved over time (p<0.01), and there were no significant differences across brain targets (p>0.05). The median time was 13 months to reach a 40% improvement in tics, and there were no significant differences across targets (p=0.84), presence of OCB (p=0.09) or age at implantation (p=0.08). Active contacts were generally clustered near the target nuclei, with some variability that may reflect differences in targeting protocols, lead models and contact configurations. There were regions within and surrounding GPi and CM thalamus that improved tics for some patients but were ineffective for others. Regions within, superior or medial to GPi were associated with a greater improvement in OCB than regions inferior to GPi.

Conclusion

The results collectively indicate that DBS may improve tics and OCB, the effects may develop over several months, and stimulation locations relative to structural anatomy alone may not predict response. This study was the first to visualise and evaluate the regions of stimulation across a large cohort of patients with TS to generate new hypotheses about potential targets for improving tics and comorbidities.
Is E-FAST possible and useful on the battlefield? A feasibility study during medical courses in hostile environment (MEDICHOS): preliminary results
Authors: Renard Aurélien , Martinet C , Cungi P J , Combes E , Gasperini G , Cazes N , Carfantan C , Faivre A , Travers S , Kelway C , Benner P
Published: May 2019

Introduction

The extent of the French forces’ territory in the Sahel band generates long medical evacuations. In case of many victims, to respect the golden hour rule, first-line sorting is essential. Through simulation situations, the aim of our study was to assess whether the use of ultrasound was useful to military doctors.

Methods

In combat-like exercise conditions, we provided trainees with a pocket-size ultrasound. Every patient for whom the trainees chose to perform ultrasound in role 1 was included. An extended focused assessment with sonography for trauma (E-FAST) was performed with six basic sonographic views. We evaluated whether these reference views were obtained or not. Once obtained by the trainees, pathological views corresponding to the scenario were shown to assess whether the trainees modified their therapeutic management strategy and their priorities.

Results

168 patients were treated by 15 different trainee doctors. Of these 168 patients, ultrasound (E-FAST or point-of-care ultrasound) was performed on 44 (26%) of them. In 51% (n=20/39) of the situations, the practitioners considered that the realisation of ultrasound had a significant impact in terms of therapeutic and evacuation priorities. More specifically, it changed therapeutic decisions in 67% of time (n=26/39) and evacuation priorities in 72% of time (n=28/39).

Conclusion

This original work showed that ultrasound on the battlefield was possible and useful. To confirm these results, ultrasound needs to be democratised and assessed in a real operational environment.
Healthcare for servicewomen on military missions
Authors: Guo Jia-Yu , Hou Hui-Ru , Cao F
Published: May 2019

Increases in the number of women in critical positions on military missions place new demands for specialised healthcare services to promote performance. The main health problems servicewomen facing are musculoskeletal injuries, reproductive diseases, iron deficiency and mental health problems. Herein, we propose several suggestions based on the rich experiences of our hospital. First is to offer preventive measures for servicewomen health. Second is to equip servicewomen with portable medicine packet to treat common diseases. Third is to provide people-centred integrated care.
Type I interferons in host defence and inflammatory diseases
Authors: Crow Mary K. , Ronnblom Lars
Published: May 2019

Type I interferons (IFN) can have dual and opposing roles in immunity, with effects that are beneficial or detrimental to the individual depending on whether IFN pathway activation is transient or sustained. Determinants of IFN production and its functional consequences include the nature of the microbial or nucleic acid stimulus, the type of nucleic acid sensor involved in inducing IFN, the predominant subtype of type I IFN produced and the immune ecology of the tissue at the time of IFN expression. When dysregulated, the type I IFN system drives many autoimmune and non-autoimmune inflammatory diseases, including SLE and the tissue inflammation associated with chronic infection. The type I IFN system may also contribute to outcomes for patients affected by solid cancers or myocardial infarction. Significantly more research is needed to discern the mechanisms of induction and response to type I IFNs across these diseases, and patient endophenotyping may help determine whether the cytokine is acting as ‘friend’ or ‘foe’, within a particular patient, and at the time of treatment. This review summarises key concepts and discussions from the second International Summit on Interferons in Inflammatory Diseases, during which expert clinicians and scientists evaluated the evidence for the role of type I IFNs in autoimmune and other inflammatory diseases.
Heritability in genetic heart disease: the role of genetic background
Authors: Jansweijer Joeri A , van Spaendonck-Zwarts Karin Y , Tanck Michael W T , van Tintelen J Peter , Christiaans Imke , van der Smagt Jasper J , Vermeer Alexa M C , Bos J Martijn , Moss Arthur J , Swan Heikki , Priori Sylvia G , Rydberg Annika , Tfelt-Hansen Jacob , Ackerman Michael J , Olivotto Iacopo , Charron Philippe , Gimeno Juan R , van den Berg Maarten P , Wilde Arthur AM , Pinto Yigal M
Published: May 2019

Background

Mutations in genes encoding ion channels or sarcomeric proteins are an important cause of hereditary cardiac disease. However, the severity of the resultant disease varies considerably even among those with an identical mutation. Such clinical variation is often thought to be explained largely by differences in genetic background or ‘modifier genes’. We aimed to test the prediction that identical genetic backgrounds result in largely similar clinical expression of a cardiac disease causing mutation, by studying the clinical expression of mutations causing cardiac disease in monozygotic twins.

Methods

We compared first available clinical information on 46 monozygotic twin pairs and 59 control pairs that had either a hereditary cardiomyopathy or channelopathy.

Results

Despite limited power of this study, we found significant heritability for corrected QT interval (QTc) in long QT syndrome (LQTS). We could not detect significant heritability for structural traits, but found a significant environmental effect on thickness of the interventricular septum in hypertrophic cardiomyopathy.

Conclusions

Our study confirms previously found robust heritability for electrical traits like QTc in LQTS, and adds information on low or lacking heritability for structural traits in heritable cardiomyopathies. This may steer the search for genetic modifiers in heritable cardiac disease.
Why are patients not more involved in their own safety? A questionnaire-based survey in a multi-ethnic North London hospital population
Authors: Yoong Wai , Assassi Zouina , Ahmedani Iman , Abdinasir Rahma , Denning Max , Taylor Harriet , Chandrakumar Danya , Kwakye Michael , Nauta Maud
Published: May 2019

Purpose

Active patient participation in safety pathways has demonstrated benefits in reducing preventable errors, especially in relation to hand hygiene and surgical site marking. The authors sought to examine patient participation in a range of safety-related behaviours as well as factors that influence this, such as gender, education, age and language.

Design

A 20-point questionnaire was employed in a London teaching hospital to explore safety-related behaviours, particularly assessing patient’s willingness to challenge healthcare professionals and engagement in taking an active role in their own care while in hospital. Data was also collected on participant demographic details including gender, age, ethnicity, English language proficiency and education status.

Results

85% of the 175 patients surveyed would consider bringing a list of their medications to hospital, but only 60% would bring a list of previous surgeries. Only 45% would actively engage in the WHO Safer Surgery Checklist and over three quarters (80%) would not challenge doctors and nurses regarding hand hygiene, believing that they would cause offence. Female patients who had tertiary education, were fluent in English and less than 60 years of age were statistically more likely to feel responsible for their own safety and take an active role in safety-related behaviour while in hospital (p<0.05).

Conclusions

Many patients are not engaged in safety-related behaviour and do not challenge healthcare professionals on safety issues. Older male patients who were not tertiary educated or fluent in English need to be empowered to take an active role in such behaviour. Further research is required to investigate how to achieve this.
Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians
Authors: Clements Nathan , Vydra Darrell , Cushman Daniel M. , Nagpal Ameet , Julia Jonathan , Zheng Patricia , McCormick Zachary L.
Published: May 2019

Background

Epidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown.

Objective

Identify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures.

Methods

Cross-sectional survey study of 314 physician members of the Spine Interventional Society.

Results

41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs.

Conclusion

Current trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.
Effect of early versus delayed activation of thoracic epidural anesthesia on plasma pro-atrial natriuretic peptide to indicate deviations in central blood volume during esophagectomy
Authors: Strandby Rune B , Ambrus Rikard , Achiam Michael P , Goetze Jens P , Secher Niels H , Svendsen Lars B
Published: May 2019

Background and Objectives

A side effect to thoracic epidural anesthesia (TEA) is hypotension induced by central hypovolemia. This study addressed whether early activation (EA) versus late activation (LA) of TEA affects plasma pro-atrial natriuretic peptide (proANP) reflecting deviations in the central blood volume (CBV). We hypothesized that EA TEA would reduce plasma proANP, thus reflecting a decrease in CBV.

Methods

A randomized, controlled, single-blinded trial was conducted. Patients undergoing open esophagectomy were randomized to EA (n=25, after induction of general anesthesia) or LA TEA (n=25, after re-established gastric continuity) with the epidural catheter placed at the interspaces Th7-8 or Th8-9. Plasma proANP was determined repetitively along with hemodynamic variables and administration of fluid/vasopressors as postoperative complications were noted.

Results

With EA TEA, plasma proANP decreased following induction of anesthesia to the end of surgery (13%; 113±68 to 99±49 pmol/L; p=0.026), but that was not the case in the LA group (3%; 97±44 to 94±49 pmol/L; p=0.565) despite equal fluid balance (+1584±582 vs +1560±563 mL; p=0.888). Accordingly, the EA group required excessive treatment with vasopressors to maintain MAP >60 mm Hg during surgery (2.7±2 vs 1.6±1.4 ephedrine boluses; p=0.033 and infusion of phenylephrine for 216±86 vs 58±91 min; p<0.001). Plasma proANP and fluid balance were correlated only for EA patients (r=0.44; 95% CI 0.04 to 0.91; p=0.033).

Conclusions

EA TEA reduces plasma proANP indicating that CBV becomes affected. Based on a correlation between plasma proANP and fluid balance, a 2000 mL volume surplus of lactated Ringer’s solution is required to maintain plasma proANP stable during open esophagectomy.

Trial registration number

2014-002036-14 (https://www.clinicaltrialsregister.eu/ctr-search/search?query=2014-002036-14).
Management of acute bleeding in a shetland pony during surgery for foreign body removal
Authors: Corona Daniele , Brunisholz Herve' , Junge Hannah , Bettschart‐Wolfensberger Regula
Published: May 2019

A 180‐kg, male neutered 15‐year‐old shetland pony was referred to the authors’ clinic with a chronic purulent wound on the left flank and mild weight loss. Surgical treatment under sedation with local anaesthesia was already attempted twice, but each time within two months a new fistula was evident. Abdominal ultrasound exam revealed a possible abscess in the abdomen with no clear margins, indicative of extension of infected tissue or the presence of a foreign body. General anaesthesia for wound curettage surgery was scheduled. Complication during anaesthesia was a massive unexpected acute bleeding from adhesions of the abscess to the spleen, caused by a foreign body which had probably perforated the stomach.
Soil deformation and its recovery in logging trails of drained boreal peatlands
Authors: Lepilin D. , Laurén A. , Uusitalo J. , Tuittila E.-S.
Published: May 2019

Forestry-drained peatlands occupy approximately 15 million ha in boreal and temperate zones. In Finland, they represent almost one-fourth of the total forest area. They are subjected to the same harvesting operations as upland forests. Although the soil deformation caused by timber harvesting is well documented in upland forests, the knowledge on the soil disturbance induced by the harvesting machinery on peat soils is still lacking. To address this, we collected soil samples from six peatland sites that were thinned using a harvester–forwarder combination. Peat samples were taken from the trails formed by the machinery and outside the trails to a depth of 10 cm. To assess the recovery of soil properties after the disturbance, we sampled sites along a chronosequence with respect to time since harvesting. Soil deformation under the machinery appeared to increase the bulk density and field capacity of peat and decrease its total porosity; however, disturbed plots and control plots started to resemble each other in their soil properties within 15 years. The results imply that peat soil is sensitive to disturbance but has a high recovery potential.