bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Structured Pathways for Postcardiac Arrest Care: A Systematic Review and Meta-Analysis
Authors: Storm Christian , Leithner Christoph , Krannich Alexander , Suarez Jose I. , Stevens Robert D.
Published: May 2019

Objectives:

Recent research has demonstrated value in selected therapeutic and prognostic interventions delivered to patients following cardiac arrest. The aim of this work was to determine if the implementation of a structured care pathway, which combines different interventions, could improve outcomes in survivors of cardiac arrest.

Data Sources:

PubMed and review of citations in retrieved articles.

Study Selection:

Randomized trials and prospective observational studies conducted in adult cardiac arrest patients, which evaluated the impact on outcome of a structured care pathway, defined as an organized set of interventions designed specifically for postcardiac arrest patients.

Data Extraction:

Data collected included study characteristics and methodologic quality, populations enrolled, interventions that were part of the cardiac arrest structured care pathway, and outcomes. The principal outcome was favorable functional status defined as a Cerebral Performance Category score of 1–2 at or after hospital discharge.

Data Synthesis:

The systematic search retrieved 481 articles of which nine (total, 1,994 patients) were selected for systematic review, and six (1,422 patients) met criteria for meta-analysis. Interventions in the care pathways included early coronary angiography with or without percutaneous coronary intervention (eight studies), targeted temperature management (nine studies), and protocolized management in the ICU (seven studies). Neurologic prognostication was not a part of any of the structured pathways. Meta-analysis found significantly higher odds of achieving a favorable functional outcome in patients who were treated in a structured care pathway, when compared with standard care (odds ratio, 2.35; 95% CI, 1.46–3.81).

Conclusions:

Following cardiac arrest, patients treated in a structured care pathway may have a substantially higher likelihood of favorable functional outcome than those who receive standard care. These findings suggest benefit of a highly organized approach to postcardiac arrest care, in which a cluster of evidence-based interventions are delivered by a specialized interdisciplinary team. Given the overall low certainty of evidence, definitive recommendations will need confirmation in additional high-quality studies.
Impact on Patient Outcomes of Pharmacist Participation in Multidisciplinary Critical Care Teams: A Systematic Review and Meta-Analysis*
Authors: Lee Heeyoung , Ryu Kyungwoo , Sohn Youmin , Kim Jungmi , Suh Gee Young , Kim EunYoung
Published: May 2019

Objectives:

The objective of this systematic review and meta-analysis was to assess the effects of including critical care pharmacists in multidisciplinary ICU teams on clinical outcomes including mortality, ICU length of stay, and adverse drug events.

Data Sources:

PubMed, EMBASE, and references from previous relevant systematic studies.

Study Selection:

We included randomized controlled trials and nonrandomized studies that reported clinical outcomes such as mortality, ICU length of stay, and adverse drug events in groups with and without critical care pharmacist interventions.

Data Extraction:

We extracted study details, patient characteristics, and clinical outcomes.

Data Synthesis:

From the 4,725 articles identified as potentially eligible, 14 were included in the analysis. Intervention of critical care pharmacists as part of the multidisciplinary ICU team care was significantly associated with the reduced likelihood of mortality (odds ratio, 0.78; 95% CI, 0.73–0.83; p < 0.00001) compared with no intervention. The mean difference in ICU length of stay was –1.33 days (95% CI, –1.75 to –0.90 d; p < 0.00001) for mixed ICUs. The reduction of adverse drug event prevalence was also significantly associated with multidisciplinary team care involving pharmacist intervention (odds ratio for preventable and nonpreventable adverse drug events, 0.26; 95% CI, 0.15–0.44; p < 0.00001 and odds ratio, 0.47; 95% CI, 0.28–0.77; p = 0.003, respectively).

Conclusions:

Including critical care pharmacists in the multidisciplinary ICU team improved patient outcomes including mortality, ICU length of stay in mixed ICUs, and preventable/nonpreventable adverse drug events.
Frailty and Associated Outcomes and Resource Utilization Among Older ICU Patients With Suspected Infection
Authors: Fernando Shannon M. , McIsaac Daniel I. , Perry Jeffrey J. , Rochwerg Bram , Bagshaw Sean M. , Thavorn Kednapa , Seely Andrew J. E. , Forster Alan J. , Fiest Kirsten M. , Dave Chintan , Tran Alexandre , Reardon Peter M. , Tanuseputro Peter , Kyeremanteng Kwadwo
Published: May 2019

Objectives:

Suspected infection and sepsis are common conditions seen among older ICU patients. Frailty has prognostic importance among critically ill patients, but its impact on outcomes and resource utilization in older patients with suspected infection is unknown. We sought to evaluate the association between patient frailty (defined as a Clinical Frailty Scale ≥ 5) and outcomes of critically ill patients with suspected infection. We also evaluated the association between frailty and the quick Sequential Organ Failure Assessment score.

Design:

Analysis of a prospectively collected registry.

Setting:

Two hospitals within a single tertiary care level hospital system between 2011 and 2016.

Patients:

We analyzed 1,510 patients 65 years old or older (at the time of ICU admission) and with suspected infection at the time of ICU admission. Of these, 507 (33.6%) were categorized as “frail” (Clinical Frailty Scale ≥ 5).

Interventions:

None.

Measurements and Main Results:

The primary outcome was in-hospital mortality. A total of 558 patients (37.0%) died in-hospital. Frailty was associated with increased risk of in-hospital death (adjusted odds ratio, 1.81 [95% CIs, 1.34–2.49]). Frailty was also associated with higher likelihood of discharge to long-term care (adjusted odds ratio, 2.06 [95% CI, 1.50–2.64]) and higher likelihood of readmission within 30 days (adjusted odds ratio, 1.83 [95% CI, 1.38–2.34]). Frail patients had increased ICU resource utilization and total costs. The combination of frailty and quick Sequential Organ Failure Assessment greater than or equal to 2 further increased the risk of death (adjusted odds ratio, 7.54 [95% CI, 5.82–9.90]).

Conclusions:

The presence of frailty among older ICU patients with suspected infection is associated with increased mortality, discharge to long-term care, hospital readmission, resource utilization, and costs. This work highlights the importance of clinical frailty in risk stratification of older ICU patients with suspected infection.
Lung Recruitability in Severe Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation
Authors: Camporota Luigi , Caricola Elena V. , Bartolomeo Nicola , Di Mussi Rossella , Wyncoll Duncan L. A. , Meadows Christopher I. S. , Amado-Rodriguez Laura , Vasques Francesco , Sanderson Barnaby , Glover Guy W. , Barrett Nicholas A. , Shankar-Hari Manu , Grasso Salvatore
Published: May 2019

Objectives:

Quantification of potential for lung recruitment may guide the ventilatory strategy in acute respiratory distress syndrome. However, there are no quantitative data on recruitability in patients with severe acute respiratory distress syndrome who require extracorporeal membrane oxygenation. We sought to quantify potential for lung recruitment and its relationship with outcomes in this cohort of patients.

Design:

A single-center, retrospective, observational cohort study.

Setting:

Tertiary referral severe respiratory failure center in a university hospital in the United Kingdom.

Patients:

Forty-seven adults with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation.

Intervention:

None.

Measurements and Main Results:

In patients with severe acute respiratory distress syndrome—mainly of pulmonary origin (86%)—the potential for lung recruitment and the weight of nonaerated, poorly aerated, normally aerated, and hyperaerated lung tissue were assessed at low (5 cmH2O) and high (45 cmH2O) airway pressures. Patients were categorized as high or low potential for lung recruitment based on the median potential for lung recruitment value of the study population. The median potential for lung recruitment was 24.3% (interquartile range = 11.4–37%) ranging from –2% to 76.3% of the total lung weight. Patients with potential for lung recruitment above the median had significantly shorter extracorporeal membrane oxygenation duration (8 vs 13 d; p = 0.013) and shorter ICU stay (15 vs 22 d; p = 0.028), but mortality was not statistically different (24% vs 46%; p = 0.159).

Conclusions:

We observed significant variability in potential for lung recruitment in patients with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation. Patients with high potential for lung recruitment had a shorter ICU stay and shorter extracorporeal membrane oxygenation duration.
Structure and Characteristics of Diabetes Self-management Applications
Authors: Angelini Sara , Alicastro Gregorio Marco , Dionisi Sara , Di Muzio Marco
Published: May 2019

Diabetes is one of the most common chronic conditions, and a good self-management regimen is needed in order to control the disease and prevent complications. In the last few years, the number of health information technologies has increased, and while there are many smartphone applications for diabetic patients, their effectiveness is still unclear. This systematic review aims to outline structure and characteristics that can make an application for diabetes management effective and safe and improve usability and the chances of success for a mobile health service. Applications found in the literature have been analyzed to evaluate the different features. Findings of the review suggest that patients seem to be more attracted by tools that are helpful in everyday management of diabetes, and that allow them to save time and increase safety. The personalization of the application is essential to obtain success in promoting use, and applications should be based upon patients' predisposition to use technological tools that will ensure better outcomes.
Bedside Usability Surveys
Authors: Graves Krisanne , Titus Courtney , Gordon Mary D. , Braun Curt
Published: May 2019

Errors in healthcare are a leading cause of death in the United States. Equipment usability and user interfaces remain an area not fully elucidated. Infusion pumps play a vital role in care delivery, often essential for critical therapies. While pump function is comparatively simple, their programming, configuration, and form provide opportunity for error. Our purpose was to assess qualities nurses identified as important to pump operation by electronic survey. A self-developed usability survey was distributed to a random sample of 500 nurses, stratified by unit type and employed at the large academic quaternary care hospital. The overall response rate was 48% (n = 240). Descriptive and inferential statistics describe the responses and represent more than 5500 weekly infusions. Nurses described confident use of the system with some differences by unit type. Ninety percent of respondents indicated they have omitted use of the dose error reduction system, which should raise safety concerns. Users reported issues with the user interface and error prevention systems. Qualitative items elicited suggestions for improving aspects of the pump. Employing a usability survey in a clinical area proved to be a simple, inexpensive way to gather more information on the use and potential improvements of infusion pumps.
Enrichment of melanoma-associated T cells in 6-thioguanine-resistant T cells from metastatic melanoma patients
Authors: Zuleger Cindy L. , Newton Michael A. , Ma Xiuyu , Ong Irene M. , Pei Qinglin , Albertini Mark R.
Published: May 2019

This study examines whether 6-thioguanine resistant T cells (mutant) from metastatic melanoma patients are enriched for melanoma-associated T cells compared to T cells obtained analogously without thioguanine selection (wild-type). Melanoma-associated antigen pentamer staining was performed on 5 tumour and 9 peripheral blood samples from metastatic melanoma patients. T cell receptor beta chain repertoire was examined via Sanger sequencing of mutant and wild-type in blood and tumour from metastatic melanoma patients at times of tumour progression (n = 8) and via Illumina sequencing in tumour derived T cells and in uncultured T cells (uncultured), wild-type and mutant from blood before and after immune checkpoint blockade (n = 1). Mutant from tumour (3 of 5; P < 0.001), but not blood (0 of 9), were enriched compared to wild-type for binding melanoma-associated antigen pentamers. T cell receptor beta analysis in patients with tumour progression (n = 8) detected increased melanoma associated T cells in mutant compared to wild-type from blood (Monte Carlo P = 10−7). Comparison of blood samples before and after immune checkpoint blockade with prior tumor from one metastatic melanoma patient detected increased T cell receptor beta sharing between tumour and mutant compared to tumour and wild-type or tumour and uncultured: 11.0% (72/656), 1.5% (206/13 639) and 1.3% (381/29 807), respectively (Monte Carlo P = 10−7 for mutant versus wild-type and mutant versus uncultured). These data demonstrate that mutant in metastatic melanoma patients are enriched for melanoma-associated T cells and are candidate probes to study in vivo melanoma-reactive T cells.
Severe Relapse of Vaccine-Induced Guillain–Barré Syndrome After Treatment With Nivolumab
Authors: Yuen Carlen , Kamson David , Soliven Betty , Kramer Christopher , Goldenberg Fernando , Rezania Kourosh
Published: May 2019

Cancer immunotherapy with checkpoint inhibitors may result in neuromuscular immune-related adverse reactions, including Guillain–Barré syndrome (GBS)-like disease. On the other hand, checkpoint inhibitor therapy may result in exacerbation of underlying autoimmune diseases such as myasthenia gravis and multiple sclerosis. We present a patient who developed a severe and fatal relapse of postvaccination GBS after he was treated with nivolumab, a monoclonal antibody directed to programmed death–1 (PD-1), during a GBS treatment-related fluctuation. We recommend that caution be exercised in starting treatment with PD-1 inhibitors in the acute stage or early in the recovery period of GBS.
Immunoglobulin Treatment in Neuromuscular Medicine
Authors: Burakgazi Ahmet Z.
Published: May 2019

Intravenous immunoglobulin (IVIg) is used in the treatment of autoimmune diseases, including immune-mediated central and peripheral nervous system disorders. This article will review the indications, proposed mechanism of actions, and administration of immunoglobulin treatment in various neuropathies, neuromuscular junction disorders, and myopathies. IVIg may have more than one mechanism of action to alter the pathogenesis of underlying neuromuscular disease. IVIg treatment has been used as a first-line treatment in Guillain–Barre syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, multifocal motor neuropathy, and second-line off-label treatment in medically refractory cases of polymyositis, dermatomyositis, and myasthenia gravis. IVIg is a well-tolerated and effective treatment for these neuromuscular diseases. With this review article, we hope to increase clinicians' awareness of the indications and efficiencies of IVIg in a broad spectrum of neuromuscular diseases.
Adult Diagnosis of Type 1 Fiber Predominance Myopathy Caused by Novel Mutations in the RYR1 Gene
Authors: Peddareddygari Leema Reddy , Oberoi Kinsi , Sharer Leroy R. , Grewal Raji P.
Published: May 2019

We describe a 57-year-old patient with mild diffuse weakness that was incidentally detected when he was evaluated for restless leg syndrome. An electromyography confirmed the presence of a myopathy without suggestion of inflammatory myopathy. A muscle biopsy demonstrated type 1 fiber predominance with minimal inflammatory features suggesting a genetic myopathy. Exome sequencing revealed c.10648C > T variant (p.R3550W), and a novel variant, c.10749_10753delGGAGG (E3584Rfs*3), in the ryanodine receptor 1 (RYR1) gene transmitted through his asymptomatic father indicating these mutations are in trans. Prompted by these results, a 47-year-old sister presented for evaluation. Her examination showed mild proximal muscle weakness, and an electromyography confirmed a noninflammatory myopathy. Her genotype was identical to her affected brother confirming that in these siblings, the RYR1 mutations, transmitted in an autosomal recessive pattern, are the cause of their myopathy. The adult age at diagnosis of these affected siblings likely reflects the mild and minimally progressive nature of the myopathy.
Transthyretin Amyloidosis Presenting With Upper-Extremity Neuropathy and Paucity of Autonomic Impairment
Authors: Devarapalli Sandeep , Zhou Daniel J. , Dyck P. James B. , Piccione Ezequiel A.
Published: May 2019

We report a 73-year-old man with Val142Ile transthyretin (TTR) amyloidosis and an atypical clinical presentation of upper-extremity–predominant neuropathy without significant autonomic or cardiac involvement. TTR familial amyloid polyneuropathy commonly presents as length-dependent sensorimotor polyneuropathy with marked and early autonomic involvement. Multiple pathogenic mutations in TTR gene have been identified, of which Val50Met is commonly associated with TTR familial amyloid polyneuropathy, and Val142Ile is commonly associated with familial amyloid cardiomyopathy. Our patient is from a nonendemic region, without family history for amyloidosis. Predominant upper-extremity neuropathy, without significant cardiac or autonomic involvement, distinguishes this case from previously reported Val142Ile-mutated TTR amyloidosis.
Ultrasound in Multifocal Motor Neuropathy: Clinical and Electrophysiological Correlations
Authors: Breiner Ari , Ebadi Hamid , Bril Vera , Barnett Carolina , Katzberg Hans D.
Published: May 2019

Objectives:

Multifocal motor neuropathy (MMN) is a treatable autoimmune polyneuropathy, which may prove challenging diagnostically in the setting of absent conduction blocks or advanced axonal loss. Relatively few studies have examined the role of ultrasound (US) in MMN.

Methods:

Retrospective, cross-sectional study of patients with MMN who underwent peripheral nerve US. Charts were reviewed to extract clinical, sonographic, and electrophysiological data.

Results:

Eleven patients with MMN underwent US between 2013 and 2015; of these 11 patients, 7 had ≥3 abnormal nerve segments, and 6 had ≥5 sites of increased cross-sectional area (CSA). There was moderate correlation between the degree of amplitude drop observed in the median and ulnar motor nerves, and CSA. Significant correlation between CSA and limb strength was only observed for the median nerve.

Conclusions:

Peripheral nerve US shows promise as a diagnostic tool in MMN and may be helpful to distinguish MMN from motor neuron disease.
Impact of Refractory Myasthenia Gravis on Health-Related Quality of Life
Authors: Boscoe Audra N. , Xin Haichang , L'Italien Gilbert J. , Harris Linda A. , Cutter Gary R.
Published: May 2019

Objectives:

Myasthenia gravis (MG) may be refractory to traditional therapies. Quality of life (QOL) and disease burden in patients with refractory and nonrefractory MG were compared using Myasthenia Gravis Foundation of America MG Patient Registry data.

Methods:

Adults aged 18 years or older with MG diagnosed ≥2 years before enrollment were included. Participants with refractory MG had received ≥2 previous and 1 current MG treatment and had MG Activities of Daily Living Scale total score ≥6 at enrollment; other participants had nonrefractory MG. MG QOL 15-item scale (MG-QOL15) scores were compared.

Results:

In total, 56 participants with refractory and 717 participants with nonrefractory MG enrolled. Participants with refractory MG had significantly higher mean (SD) MG-QOL15 total scores [31.4 (11.1) vs. 20.8 (15.0), P < 0.0001] and were more likely to have had exacerbations, emergency department visits, and recent hospitalizations.

Conclusions:

Participants with refractory MG experience worse QOL and greater clinical burden than those with nonrefractory disease.
Development and Pragmatic Evaluation of a Rapid Response Team
Authors: Elliott Rosalind , Martyn Louise , Woodbridge Sarah , Fry Margaret , Foot Carole , Hickson Liz
Published: May 2019

In response to national and local drivers, a clinical emergency response system (CERS) incorporating an intensivist-led rapid response team (RRT) was implemented at a Sydney (Australia) hospital. The authors present a pragmatic evaluation of the 5 years since this major initiative was commenced. A “partner not conquer” philosophy was adopted. Implementation of the RRT was based on a collaborative pragmatic quality improvement approach. A team of intensive care specialist trained medical doctors (n = 2) and clinical nurse consultants (n = 2) set up the service with executive support and funding. Roles and responsibilities were clearly detailed, reinforcing a positive, partnership-driven culture. A constantly evolving education strategy was a critical element of implementation and maintenance. Ongoing evaluation includes process and patient outcome data. Serious patient deterioration-related incidents have decreased significantly (from 7 to 1 per year) and the RRT has been universally accepted by clinicians. Key lessons learned include the need for specific protected funding, a partnership approach ensuring hospital clinicians retain responsibility of patient treatment, ongoing education and reinforcement, and strong nursing leadership. However, generalizations cannot be made about the implementation of the CERS. It is important to consider context; “one size does not fit all.”
Social Support, Self-Efficacy, and Helplessness Following Myocardial Infarctions
Authors: Smallheer Benjamin A. , Dietrich Mary S.
Published: May 2019

Numerous factors impact patient recovery following an acute myocardial infarction (AMI). Negative emotional outcomes, such as learned helplessness, are predictors of mortality following AMI, though little is known about these relationships. The purpose of this study was to examine the relationships between social support and self-efficacy with learned helplessness in individuals post-AMI. Using a descriptive cross-sectional design, subjects with a diagnosed AMI within 12 months were recruited. Standardized instruments were used to evaluate social support and self-efficacy and their impact on learned helplessness. A statistically significant, direct relationship was found between social support and self-efficacy, and learned helplessness, suggesting that individuals with better social support and self-efficacy experience less learned helplessness within the first year following an AMI. In developing post-AMI treatment plans, health care staff need to consider encouraging a patient's supportive social network and self-efficacy as meaningful interventions against negative emotional outcomes.
Room Design—A Phenomenological-Hermeneutical Study
Authors: Sundberg Fredrika , Fridh Isabell , Olausson Sepideh , Lindahl Berit
Published: May 2019

Medical technology has progressed tremendously over the last few decades, but the same development cannot be seen in the design of these intensive care unit environments. Authors report results of a study of evidence-based room design, emphasizing the impact on conveying a caring attitude to patients. Ten nonparticipant observations were conducted in patient rooms with 2 different designs, followed by interviews. The data were analyzed using a phenomenological-hermeneutical approach. The results did not reveal that it was obvious that redesigned spaces resulted in a more caring attitude. The meanings of caring displayed during nursing activities were interpreted by interpreting gazes. Some of the nursing staff had an instrumental gaze, interpreted as caring with a task-orientated approach, while others communicated their caring with an attentive and attuned gaze, where the needs of the patients regulated the working shift. The study findings indicated that caring may not be perceived when nurses use a task-oriented approach. However, when nurses practice a person-centered approach, using an attentive and attuned gaze, caring is conveyed. Caring in intensive care contexts needs to be assisted by a supportive environment design that cultivates the caring approach.
Determining the Moral Sensitivities of Intensive Care Nurses
Authors: Kavurmacı Mehtap , Tan Mehtap
Published: May 2019

This article reports results from a descriptive study involving nurses working in intensive care units of hospitals in the province of Erzurum, eastern Turkey. A total of 110 nurses agreed to participate in the study. The Moral Sensitivity Questionnaire and a personal information form, which was developed by researchers in accordance with the relevant literature, were used for data collection. The results indicated that intensive care nurses face frequent ethical problem and that moral sensitivity is required to assist in coping with the issues. Researchers report that nurses who were highly satisfied with their work possessed a heightened sensitivity about ethical issues when compared with those who were dissatisfied with their profession.
Thiamine Use in Sepsis
Authors: Counts Jacob P. , Rivera Victor F. , Kimmons Lauren A. , Jones G. Morgan
Published: May 2019

Every year, sepsis affects nearly 30 million people worldwide, with current annual estimates reporting as many as 6 million deaths. To combat the staggering number of patients who are affected by sepsis, clinicians continue to investigate novel treatment approaches. One treatment approach that has gained interest is the role that vitamins and nutrients play in the body's response to sepsis. Thiamine, in particular, has been studied because of its role in glucose metabolism and lactate production. This review provides a summary of the current literature surrounding the use of thiamine in the treatment of sepsis and describes the function of this essential nutrient in sepsis pathology. We also aim to provide clinicians with the necessary understanding to recognize the potential for thiamine deficiency, as well as detail the role of thiamine supplementation in the treatment of sepsis.
A Prospective Evaluation of the Reliability and Utility of Quality of Life Measures in Patients With Hepatocellular Carcinoma
Authors: Kim Gi-Ae , Kim Ha Il , Chang Seheon , An Jihyun , Lee Danbi , Lee Han Chu , Han Seungbong , Shim Ju Hyun
Published: May 2019

Objectives:

Little is known about how quality of life (QOL) can assist clinical decision-making for patients with hepatocellular carcinoma (HCC). This study aimed to investigate the reliability and validity of QOL as well as its prognostic value and utility.

Materials and Methods:

A prospective cohort of 300 HCC patients at various stages was recruited from 2015 to 2017 in Korea. The subjects answered the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core-30 (QLQ-C30) and QLQ-HCC18 and the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) questionnaire. Prognostic nomograms including the QOL scales were developed. The prediction performance of the Barcelona Clinic Liver Cancer (BCLC) and the American Joint Committee on Cancer (AJCC) staging systems when they were incorporated with QOL was investigated.

Results:

The EORTC QLQ-C30 and QLQ-HCC18 subscales showed higher reliability than FACT-Hep subscales. With regard to the validity, both questionnaires discriminated the patients by stages, treatment modalities, and performance status effectively. Multivariable analysis revealed that EORTC role functioning and EORTC appetite loss subscales were statistically associated with overall survival and disease progression. The developed nomograms accurately estimated the 1-year overall survival and disease progression–free rates. Incorporating the EORTC role functioning subscale or Hepatobiliary Cancer Subscale of FACT-Hep with the BCLC and AJCC systems improved the prognostic classification. Incorporating QOL into the AJCC system showed better predictive accuracy than incorporating performance status into it did.

Conclusions:

The findings suggest that QOL data can serve as a reliable predictive factor and assist prognostic calculation for HCC patients.
Deficient Emotional Self-Regulation in Children with Attention Deficit Hyperactivity Disorder: Mindfulness as a Useful Treatment Modality
Authors: Huguet Anna , Izaguirre Eguren Jon , Miguel-Ruiz Dolores , Vall Vallés Xavier , Alda José A.
Published: May 2019

Objective:

The aim of this study was to investigate the efficacy of a structured mindfulness group intervention program targeting deficient emotional self-regulation (DESR) in a sample of children with attention deficit hyperactivity disorder (ADHD).

Method:

Seventy-two children aged 7 to 12 years with ADHD were randomized into 2 groups (mindfulness and control). The dysregulation profile was measured using the Child Behavior Checklist (CBCL) Attention/Anxiety-Depression/Aggression scales.

Results:

Children with ADHD who received mindfulness-based group therapy showed lower levels of DESR after treatment, with a reduction in CBCL dysregulation profile (F (1,63) = 4.81; p = 0.032). All ADHD symptoms showed a moderately significant positive correlation with DESR (p < 0.01). Children with combined-type showed higher levels of DESR than children with inattentive-type (p = 0.018); however, no statistically significant changes were observed in the combined-type after mindfulness treatment.

Conclusion:

This study suggests that mindfulness in the form of structured group therapy might be clinically relevant in treating children with ADHD and thus make an impact on the overall clinical outcome, regardless of the ADHD subtype.
Safe, Effective Chin and Jaw Restoration With VYC-25L Hyaluronic Acid Injectable Gel
Authors: Ogilvie Patricia , Sattler Gerhard , Gaymans Frodo , Belhaouari Lakhdar , Weichman Barry M. , Snow Sean , Chawla Smita , Abrams Steve , Schumacher Andrew
Published: May 2019

BACKGROUND

VYC-25L, a hyaluronic acid soft-tissue filler with lidocaine, is designed to restore and create facial volume in the chin and jaw.

OBJECTIVE

To evaluate the safety and effectiveness of VYC-25L in subjects with chin retrusion.

METHODS

Adults with chin retrusion (145°–165° glabella–subnasale–pogonion facial angle) were randomized (3:1) to receive VYC-25L in the chin/jaw at study onset (treatment group) or 3 months later (control group). Primary effectiveness end point was mean change in facial angle from baseline at Month 3. Safety assessments included injection site responses (ISRs), recorded in a subject diary, and adverse events (AEs).

RESULTS

VYC-25L was administered to 119 subjects (treatment group: n = 90; control group: n = 29). Mean change in facial angle from baseline at Month 3 was significantly greater in the treatment versus control group (difference: 2.51°; p < .0001). Effectiveness was also demonstrated by the proportion of subjects with improved/much improved Global Aesthetic Improvement Scale scores and responses on FACE-Q Satisfaction and Psychological Well-Being Scales. Treatment benefit remained evident at Month 12. Common ISRs were firmness (95.8%), tenderness (95.8%), and swelling (91.6%). No serious treatment-related AEs were reported.

CONCLUSION

VYC-25L significantly improved glabella–subnasale–pogonion facial angle and was generally safe and well tolerated.
Optimizing patient partnership in primary care improvement: A qualitative study
Authors: Alidina Shehnaz , Martelli Peter F. , J. Singer Sara , Aveling Emma-Louise
Published: May 2019

Background

The need to expand and better engage patients in primary care improvement persists.

Purpose

Recognizing a continuum of forms of engagement, this study focused on identifying lessons for optimizing patient partnerships, wherein engagement is characterized by shared decision-making and practice improvement codesign.

Methodology

Twenty-three semistructured interviews with providers and patients involved in improvement efforts in seven U.S. primary care practices in the Academic Innovations Collaborative (AIC). The AIC aimed to implement primary care improvement, emphasizing patient engagement in the process. Data were analyzed thematically.

Results

Sites varied in their achievement of patient partnerships, encountering material, technical, and sociocultural obstacles. Time was a challenge for all sites, as was engaging a diversity of patients. Technical training on improvement processes and shared learning “on the job” were important. External, organizational, and individual-level resources helped overcome sociocultural challenges: The AIC drove provider buy-in, a team-based improvement approach helped shift relationships from providers and recipients toward teammates, and individual qualities and behaviors that flattened hierarchies and strengthened interpersonal relationships further enhanced “teamness.” A key factor influencing progress toward transformative partnerships was a strong shared learning journey, characterized by frequent interactions, proximity to improvement decision-making, and learning together from the “lived experience” of practice improvement. Teams came to value not only patients’ knowledge but also changes wrought by working collaboratively over time.

Conclusion

Establishing practice improvement partnerships remains challenging, but partnering with patients on improvement journeys offers distinctive gains for high-quality patient-centered care.

Practice Implications

Engaging diverse patient partners requires significant disruption to organizational norms and routines, and the trend toward team-based primary care offers a fertile context for patient partnerships. Material, technical, and sociocultural resources should be evaluated not only for whether they overcome specific challenges but also for how they enhance the shared learning journey.
Effect of Graft Shift Direction on Graft Detachment and Endothelial Cell Survival After Descemet Membrane Endothelial Keratoplasty
Authors: Yuda Kentaro , Kato Naoko , Takahashi Hidenori , Shimizu Toshiki , Oyakawa Itaru , Matsuzawa Akiko , Yuda Kenji , Hayashi Takahiko
Published: May 2019

Purpose:

To investigate the effects of graft shift orientation on clinical outcomes after Descemet membrane endothelial keratoplasty (DMEK).

Methods:

This study used intraoperative video images to retrospectively examine the effect of graft shift direction in 50 eyes of 50 patients. Correlations were assessed between graft shift direction and multiple parameters.

Results:

The graft detachment rate was higher in eyes with an inferior graft shift than in those without (superior, 0% and 5.0%; nasal, 0% and 20.0%; inferior, 16.7% and 55.0%; temporal, 16.7% and 45.0%; and any segment, 23.3% and 65.0%; for graft shift–negative and graft shift–positive cases, respectively). Postoperative endothelial cell density reduction was higher in eyes with an inferior graft shift (1 month, 23.6% ± 13.7% and 37.5% ± 18.8%; 3 months, 31.6% ± 16.4% and 45.2% ± 15.2%; and 6 months, 39.8% ± 14.9% and 50.7% ± 16.6%; for graft shift–negative and graft shift–positive cases, respectively). Eyes with a superior graft shift had lower postoperative endothelial cell density reduction than those without (1 month, 36.9% ± 16.6% and 20.0% ± 13.1%; 3 months, 45.3% ± 13.3% and 27.4% ± 16.2%; and 6 months, 51.3% ± 14.6% and 35.9% ± 14.5%; for graft shift–negative and graft shift–positive cases, respectively). Graft shift direction did not affect postoperative best-corrected visual acuity or central corneal thickness.

Conclusions:

Graft shift direction in DMEK, especially inferior graft shift, affected the postoperative graft detachment rate. Superior graft shift had a beneficial effect on postoperative corneal endothelial values. These data suggest that inferior graft shift should be avoided in DMEK.
Outcomes of Wider Area Bleb Revision Using Bleb Knife With Adjunctive Mitomycin C
Authors: Nakakura Shunsuke , Noguchi Asuka , Tanabe Hirotaka , Tabuchi Hitoshi , Asaoka Ryo , Kiuchi Yoshiaki
Published: May 2019

Precis:

Wider area bleb revision using bleb knife with adjunctive mitomycin C (MMC) had a good success rate, according to strict success criteria, except in patients with neovascular glaucoma (NVG).

Purpose:

We determined the efficacy of wider area bleb revision after filtering surgery using bleb knife with adjunctive MMC.

Patients and Methods:

In this retrospective single-center study, we analyzed 86 patients with glaucoma (46 primary open-angle, 18 exfoliations, 13 secondary, and 9 neovascular) after bleb revision using bleb knife with adjunctive MMC after a minimum follow-up of 6 months. A Kaplan-Meier survival analysis with log-rank tests and Cox proportional hazards regression analyses were performed. The main outcome measure was a successful initial bleb revision using bleb knife with adjunctive MMC, arbitrarily defined as intraocular pressure (IOP) control <15 mm Hg without any IOP-lowering medication, additional bleb revision, or glaucoma surgery.

Results:

The mean time since the initial filtering surgery was 243.8 days, and the mean prebleb revision IOP was 22.0±4.8 mm Hg. The total cumulative success rate of the bleb revision using bleb knife with MMC was 49% at 6 months and 30% at 1 year. Patients with primary open-angle glaucoma had the best success rate (64% at 6 mo and 40% at 1 y). Log-rank tests revealed that patients with NVG had the worst prognosis (P<0.01). NVG was the only significant risk factor identified for short survival time (odds ratio, 167.10; 95% confidence interval, 1.78-15620.44; P=0.027).

Conclusion:

Wider area bleb revision using bleb knife with adjunctive MMC had a good success rate, according to strict success criteria, except in patients with NVG.
Microarchitecture of Schlemm Canal Before and After Cataract Extraction Surgery
Authors: Rubinstein Yair , Fogel-Levin Miri , Singer Reut , Levkovitch-Verbin Hani , Moros Iris , Sher Ifat , Rotenstreich Ygal , Skaat Alon
Published: May 2019

Precis:

Schlemm canal (SC) expands after cataract extraction (CE), both in the area and in volume by 25% as was measured using enhanced-depth imaging optical coherent tomography (EDI-OCT) in patients before and 1 week after CE.

Purpose:

This study aims to characterize the structural and volume changes on the microstructure of SC in patients before and after uneventful phacoemulsification CE by using EDI-OCT.

Materials and Methods:

Forty-one serial horizontal EDI-OCT B-scans (interval between B-scans, 69 µm) were obtained in the nasal corneoscleral limbus before and 1 week after CE. The structure of aqueous channels, conjunctival blood vessels and iris anatomy in each scan were used as landmarks to select for overlapping scans taken before and following CE. The SC cross-section area was measured in each of the selected scans and SC volume was determined following a 3-dimensional reconstruction.

Results:

Eleven eyes (6 females and 5 males) were imaged successfully before and after CE. Mean age was 70.54±11.38 years. The mean axial length was 23.10±0.87 mm. After CE, the mean best-corrected visual acuity in logMAR improved from 0.4±0.13 to 0.2±0.13 (P=0.028). There was no significant change in the mean intraocular pressure before and after CE (15.09±1.33 to 15.0±2.16 mm Hg; P=0.39). The mean SC cross-section area increased by 25%, from 4744±376 to 5941±1048 μm2 (P<0.001). SC volume in the analyzed region increased by 25% from 6,641,473±585,954 to 8,317,909±1,328,809 μm3 (P<0.001).

Conclusion:

CE expands SC dimensions in healthy eyes. EDI-OCT imaging of SC may prove useful in the evaluation of the SC dimensions in vivo before and after CE.
Use of Ceftazidime-avibactam for the Treatment of Extensively drug-resistant or Pan drug-resistant Klebsiella pneumoniae in Neonates and Children <5 Years of Age
Authors: Iosifidis Elias , Chorafa Elisavet , Agakidou Eleni , Kontou Aggeliki , Violaki Asimina , Volakli Eleni , Christou Eleni-Ifigeneia , Zarras Charalampos , Drossou-Agakidou Vassiliki , Sdougka Maria , Roilides Emmanuel
Published: May 2019

Background:

Emergence of extensively drug-resistant (XDR) or pan drug-resistant (PDR) Enterobacteriaceae is a major public threat especially for young patients. Treatment options for these bacteria are extremely limited with no safety data existing for neonates and children. Ceftazidime-avibactam has activity against Gram-negative bacteria producing Klebsiella pneumoniae carbapenemase, but virtually no data exist on its use in neonatal and pediatric patients.

Methods:

We present a single-center case series of neonates and children <5 years treated with ceftazidime-avibactam for XDR or PDR K. pneumoniae infections until August 2018. Medical records of patients who received ceftazidime-avibactam for at least 2 days (6 doses) were reviewed. Clinical, laboratory and microbiologic data were collected using a prestructured form. Adverse events and clinical/microbiologic responses and 15- and 30-day outcome were assessed.

Results:

In our case series, 8 patients (median age 53 days, range from 13 days to 4.5 years) received 9 courses of ceftazidime-avibactam at a dose of 62.5 mg/kg q8h for suspected or proven XDR/PDR K. pneumoniae infections including bloodstream infections (8 courses), central nervous system infections (2 courses) and urinary tract infection (1 course). All patients were critically ill and received other antibiotics prior and concomitantly with the administration of ceftazidime-avibactam. There was no treatment discontinuation due to adverse events. Clinical and microbiologic responses occurred in all patients, and no patient died by day 30.

Conclusions:

Administration of ceftazidime-avibactam appears to be well tolerated and efficacious against in vitro susceptible XDR or PDR Enterobacteriaceae without being associated with significant adverse events.
Hospital Readmissions to Nonindex Hospitals: Patterns and Determinants Following the Medicare Readmission Reduction Penalty Program
Authors: Hasan Md. Mahmudul , Noor-E-Alam Md. , Wang Xiaoyi , Zepeda E. David , J. Young Gary
Published: May 2019

Objective:

To examine patterns and determinants of nonindex readmissions for Medicare as well as non-Medicare patients both before and immediately after the adoption of Medicare's Hospital Readmission Reduction Program (HRRP) in 2012. Nonindex readmissions are readmissions to hospitals that are different from the one from which the patient was discharged.

Methods:

Observational analysis of statewide database from California comprising patient-level discharge reports. Mixed-effects logistic regression models examined the association between nonindex readmissions and both hospital- and patient-level characteristics.

Results:

Nonindex readmissions for the population studied were approximately 25%, but the percentage of such readmissions was significantly higher for non-Medicare patients than those enrolled in Medicare. Nonindex readmissions were associated with several patient- and hospital-level characteristics from which patients were discharged. The adoption of the HRRP did not have any appreciable impact on the general pattern of nonindex readmissions.

Conclusions:

A substantial percentage of hospital readmissions are to nonindex hospitals, but the general pattern and determinants of these events have not changed following the adoption of the HRRP. As preventable readmissions continue to gain attention as a key quality indicator for hospital care, further investigations are needed to understand the potential value of nonindex readmissions as a quality indicator for hospital care.
Factors Associated With Hospitalization Before the Start of Long-Term Care Among Elderly Disabled People
Authors: Arandelovic Andelija , Acampora Anna , Federico Bruno , Profili Francesco , Francesconi Paolo , Damiani Gianfranco
Published: May 2019

The growing number of elderly people with functional limitations, cognitive impairment, and disability is an organizational challenge for the health care sector. This study investigated the factors associated with hospitalization in the period between evaluation and the start of a long-term care (LTC) program for patients on the waiting list. A population-based historical cohort study was performed using data extracted from different administrative databases. The cohort included disabled individuals 65 years and older who were evaluated for entrance into an LTC program between January 1, 2012, and December 31, 2013, in Tuscany, Italy. The sample consisted of 11,429 subjects. The characteristics positively associated with hospital admission were residence zone {urban incidence rate ratio (IRR) = 0.83 (95% confidence interval [CI] 0.74–0.94)}, number of prescribed drugs IRR = 1.01 (95% CI 1.00–1.02), a Charlson Comorbidity Index of 2 IRR = 1.44 (95% CI 1.26–1.64), and lower social conditions IRR = 0.99 (95% CI 0.98–1.00). The rate of hospitalization for patients with heart failure, chronic obstructive pulmonary disease, and dementia was higher than for patients without these diseases. Our results indicate that it may be possible to predict factors that can lead to hospitalization before the start of an LTC program.
Differentiated Antiretroviral Therapy Distribution Models: Enablers and Barriers to Universal HIV Treatment in South Africa, Uganda, and Zimbabwe
Authors: Duffy Malia , Sharer Melissa , Davis Nicole , Eagan Sabrina , Haruzivishe Clara , Katana Milly , Makina Ndinda , Amanyeiwe Ugochukwu
Published: May 2019

Emerging HIV treatment distribution models across sub-Saharan Africa seek to overcome barriers to attaining antiretroviral therapy and to strengthen adherence in people living with HIV. We describe enablers, barriers, and benefits of differentiated treatment distribution models in South Africa, Uganda, and Zimbabwe. Data collection included semistructured interviews and focus group discussions with 163 stakeholders from policy, program, and patient levels. Four types of facility-based and 3 types of community-based models were identified. Enablers included policy, leadership, and guidance; functional information systems; strong care linkages; steady drug supply; patient education; and peer support. Barriers included insufficient drug supply, stigma, discrimination, and poor care linkages. Benefits included perceived improved adherence, peer support, reduced stigma and discrimination, increased time for providers to spend with complex patients, and travel and cost savings for patients. Differentiated treatment distribution models can enhance treatment access for patients who are clinically stable.
Bearing the Pain
Authors: DiTomasso Diane
Published: May 2019

Scientific advances over the past 150 years have influenced pain management practices during childbirth. Cultural attitudes about pain in childbirth have also affected these practices. The objective of this work is to examine the history of pain management in childbirth in the United States and explore the relationship between cultural attitudes and care practices. A historic review was chosen as the research method. Included were records that described pain management practices and records that explored the relationship between care practices and American cultural attitudes about pain in childbirth. The health science reference databases of CINAHL (EBSCO host), PubMed and the Cochrane Library were searched for English language articles. There were no limitations in years searched. Twenty-five primary records and 42 secondary records met inclusion criteria and were used in this work. Scientific developments as well as ever-changing cultural attitudes have greatly impacted pain management practices for childbirth in America. A highly complex and parallel, relationship exists between science and culture in regards to this history. To promote positive birth experiences for women, it is essential that obstetrical practices are congruent with cultural views regarding appropriate pain management in childbirth.