bluuebunny/crossref_metadata_2025 huggingface dataset:
Diagnosis and management of traumatic bilateral chylothorax: a clinical conundrum
Authors: Jindal Rohit , Singh Jaspal , Garg Loveleen , Gupta Mayank
Published: July 2019

A 35-year-old man was admitted in the emergency department with a complaint of progressive dyspnoea and 4-day prior history of a road traffic accident. An initial evaluation was inconspicuous and he was discharged. Clinical examination and radiological imaging suggested bilateral pleural effusion for which bilateral intercostal drains were inserted. Further pleural fluid analysis aided the diagnosis of bilateral chylothorax. A conservative approach consisting of a fat-free diet, total parenteral nutrition and octreotide therapy was started. Upon failure of conservative management, thoracic duct ligation by thoracotomy was done. Chylous output decreased dramatically and subsequently, and the patient was discharged in a healthy condition. This case illustrates intricacies involved in the diagnosis and management of traumatic chylothorax. Also, conservative treatment forms the first line of management, but if ineffective, then early surgical intervention should be considered. Early diagnosis and timely intervention are keystone factors for a better outcome.
Hennekam syndrome: an uncommon cause of chylous ascites and intestinal lymphangiectasia in the tropics
Authors: Menon Jagadeesh , Venkatesh Vybhav , Thirunavukkarasu Balamurugan , Lal Sadhna Bhasin
Published: July 2019

Paediatric chylous ascites in tropics is commonly caused by infections and trauma. We describe the clinical characteristics of an uncommon inherited cause of chylous ascites, Hennekam syndrome, treated by nutritional modification.
Topical imiquimod-induced linear IgA bullous dermatosis
Authors: Tadiotto Cicogna Giulia , Ferranti Martina , Vaccari Daniele , Alaibac Mauro
Published: July 2019

A 68-year-old woman was referred to the unit of dermatology for a large basal cell carcinoma on the chin. She was treated with imiquimod cream 5%, and 4 weeks after she developed isolated and grouped tense serum-filled vesicles and bullae on lips, nose, scalp, ankles and lumbar area, and then expanded to the whole body. Histological examination was consistent with a subepidermal bullous dermatosis. Moreover, direct immunofluorescence showed linear deposition of IgA at the basement membrane zone supporting the diagnosis of linear IgA bullous dermatosis (LABD). Dapsone 50 mg/day was administered, and the lesions gradually improved within some weeks, and no new lesions appeared. The temporal relationship between the application of the drug and the development of the disease indicates a role of this topical agent in triggering LABD.
Treatment of complete ankylosed elbow with total arthroplasty
Authors: D’Ambrosi Riccardo , Formiconi Federica , Ursino Nicola , Rubino Maurizio
Published: July 2019

We reported the case of a 38-year-old patient who in 2017 presented to our institution after post-traumatic complete ankylosis of the elbow. He complained of stiffness and pain, and the radiographs revealed complete fusion of the humeroulnar joint. The Mayo Elbow Performance Score (MEPS) on admission was 31, and the elbow was fused at 90° flexed position. The patient underwent semiconstrained total elbow arthroplasty with Bryan-Morrey approach; after a 2.1 years follow-up, active arc of movement was 120°. The MEPS was excellent with a 100 points score, the patient was able to complete all activities of daily living. We did not report any complications. Total elbow arthroplasty has shown to be a good therapeutic option that make it possible to restore adequate functional range of motion and relieve pain in young patients with post-traumatic stiffness/arthritis of the elbow.
The role of Müller cells in tractional macular disorders: an optical coherence tomography study and physical model of mechanical force transmission
Authors: Govetto Andrea , Hubschman Jean-Pierre , Sarraf David , Figueroa Marta S , Bottoni Ferdinando , dell'Omo Roberto , Curcio Christine A , Seidenari Patrizio , Delledonne Giulia , Gunzenhauser Robert , Ferrara Mariantonia , Au Adrian , Virgili Gianni , Scialdone Antonio , Repetto Rodolfo , Romano Mario R
Published: July 2019

Background

To explore the role of foveal and parafoveal Müller cells in the morphology and pathophysiology of tractional macular disorders with a mathematical model of mechanical force transmission.

Methods

In this retrospective observational study, spectral-domain optical coherence tomography images of tractional lamellar macular holes and patients with myopic foveoschisis were reviewed and analysed with a mathematical model of force transmission. Parafoveal z-shaped Müller cells were modelled as a structure composed of three rigid rods, named R1, R2 and R3. The angle formed between the rods was referred to as
θ
. R1, R2 and R3 lengths as well as the variation of the angle
θ
were measured and correlated with best corrected visual acuity (BCVA).

Results

In tractional lamellar macular holes, there was a significant reduction of the angle
θ
towards the foveal centre (p<0.001). By contrast, there were no significant differences in
θ
in myopic foveoschisis (p=0.570). R2 segments were more vertical in myopic foveoschisis. There was a significant association between lower
θ
angles at 200 µm temporal and nasal to the fovea and lower BCVA (p<0.001 and p=0.005, respectively). The stiffness of parafoveal Müller cells was predicted to be function of the angle
θ
, and it grew very rapidly as the
θ
decreased.

Conclusion

Parafoveal Müller cells in the Henle fibre layer may guarantee structural stability of the parafovea by increasing retinal compliance and resistance to mechanical stress. Small values of the angle
θ
were related to worse BCVA possibly due to damage to Müller cell processes and photoreceptor’s axons.
Glucocorticoids in elite sport: current status, controversies and innovative management strategies—a narrative review
Authors: Vernec Alan , Slack Andrew , Harcourt Peter Rex , Budgett Richard , Duclos Martine , Kinahan Audrey , Mjøsund Katja , Strasburger Christian J
Published: July 2019

The use of systemic glucocorticoids (GCs), as well as local injections, continues to be a controversial issue in the sport/anti-doping community. There is widespread and legitimate use of GCs for numerous health conditions, yet there are concerns about side effects and the possibility of enhanced athletic performance in limited settings. This is compounded by the uncertainty regarding the prevalence of GC use, mechanisms underlying physiological effects and complex pharmacokinetics of different formulations. While WADA continues to promote research in this complex area, some international sporting federations, major event organisers and professional sports leagues have introduced innovative rules such as needle policies, mandatory rest periods and precompetition guidelines to promote judicious use of GCs, focusing on athlete health and supervision of medical personnel. These complementary sport-specific rules are helping to ensure the appropriate use of GCs in athletes where overuse is a particular concern. Where systemic GCs are medically necessary, Therapeutic Use Exemptions (TUEs) may be granted after careful evaluation by TUE Committees based on specific and strict criteria. Continued vigilance and cooperation between physicians, scientists and anti-doping organisations is essential to ensure that GC use in sport respects not only principles of fairness and adherence to the rules but also promotes athlete health and well-being. The purpose of this narrative review is to summarise the use and management of GCs in sport illustrating several innovative programmes by sport leagues and federations.
Natriuretic peptide-guided treatment for heart failure: a systematic review and meta-analysis
Authors: McLellan Julie , Bankhead Clare R , Oke Jason L , Hobbs F D Richard , Taylor Clare J , Perera Rafael
Published: July 2019

Background

GUIDE-IT, the largest trial to date, published in August 2017, evaluating the effectiveness of natriuretic peptide (NP)-guided treatment of heart failure (HF), was stopped early for futility on a composite outcome. However, the reported effect sizes on individual outcomes of all-cause mortality and HF admissions are potentially clinically relevant.

Objective

This systematic review and meta-analysis aims to combine all available trial level evidence to determine if NP-guided treatment of HF reduces all-cause mortality and HF admissions in patients with HF.

Study selection

Eight databases, no language restrictions, up to November 2017 were searched for all randomised controlled trials comparing NP-guided treatment versus clinical assessment alone in adult patients with HF. No language restrictions were applied. Publications were independently double screened and extracted. Fixed-effect meta-analyses were conducted.

Findings

89 papers were included, reporting 19 trials (4554 participants), average ages 62–80 years. Pooled risk ratio estimates for all-cause mortality (16 trials, 4063 participants) were 0.87, 95% CI 0.77 to 0.99 and 0.80, 95% CI 0.72 to 0.89 for HF admissions (11 trials, 2822 participants). Sensitivity analyses, restricted to low risk of bias, produced similar estimates, but were no longer statistically significant.

Conclusions

Considering all the evidence to date, the pooled effects suggest that NP-guided treatment is beneficial in reducing HF admissions and all-cause mortality. However, there is still insufficient high-quality evidence to make definitive recommendations on the use of NP-guided treatment in clinical practice.

Trial registration number

Systematic Review Cochrane Database Number: CD008966.
”For this one, let me take the risk”: why surgical staff continued to perform caesarean sections during the 2014–2016 Ebola epidemic in Sierra Leone
Authors: Drevin Gustaf , Mölsted Alvesson Helle , van Duinen Alex , Bolkan Håkon A , Koroma Alimamy P , Von Schreeb Johan
Published: July 2019

Introduction

Routine health service provision decreased during the 2014–2016 Ebola virus disease (EVD) outbreak in Sierra Leone, while caesarean section (CS) rates at public hospitals did not. It is unknown what made staff provide CS despite the risks of contracting EVD. This study explores Sierra Leonean health worker perspectives of why they continued to provide CS.

Methods

This qualitative study documents the experiences of 15 CS providers who worked during the EVD outbreak. We interviewed surgical and non-surgical CS providers who worked at public hospitals that either increased or decreased CS volumes during the outbreak. Hospitals in all four administrative areas of Sierra Leone were included. Semistructured interviews averaged 97 min and healthcare experience 21 years. Transcripts were analysed by modified framework analysis in the NVivo V.11.4.1 software.

Results

We identified two themes that may explain why providers performed CS despite EVD risks: (1) clinical adaptability and (2) overcoming the moral dilemmas. CS providers reported being overworked and exposed to infection hazards. However, they developed clinical workarounds to the lack of surgical materials, protective equipment and standard operating procedures until the broader international response introduced formal personal protective equipment and infection prevention and control practices. CS providers reported that dutifulness and sense of responsibility for one’s community increased during EVD, which helped them justify taking the risk of being infected. Although most surgical activities were reduced to minimise staff exposure to EVD, staff at public hospitals tended to prioritise performing CS surgery for women with acute obstetric complications.

Conclusion

This study found that CS surgery during EVD in Sierra Leone may be explained by remarkable decisions by individual CS providers at public hospitals. They adapted practically to material limitations exacerbated by the outbreak and overcame the moral dilemmas of performing CS despite the risk of being infected with EVD.
Epidemiological transition in morbidity: 10-year data from emergency consultations in Dakar, Senegal
Authors: Gaye Bamba , Diop Massamba , Narayanan Kumar , Offredo Lucile , Reese Peter , Antignac Marie , Diop Vasenta , Mbacké Ahmadoul Badaviyou , Boyer Chatenet Louise , Marijon Eloi , Singh-Manoux Archana , Diop Ibrahima Bara , Jouven Xavier
Published: July 2019

Background

It is thought that low-income countries are undergoing an epidemiological transition from infectious to non-communicable diseases; however, this phenomenon is yet to be examined with long-term data on morbidity.

Methods

We performed a prospective evaluation of all emergency medical consultations at a major emergency service provider in Dakar, Senegal from 2005 to 2014. Using standardised definitions, the primary diagnosis for each consultation was classified using the International Classification of Diseases-10 and then broadly categorised as ‘infectious’, ‘non-communicable’ and ‘other’ diseases. Morbidity rates for each year in the 10-year observation period were plotted to depict the epidemiological transition over time. To quantify the yearly rate ratios of non-communicable over infectious diagnosis, we used a generalised Poisson mixed model.

Results

Complete data were obtained from 49 702 visits by African patients. The mean age was 36.5±23.2 and 34.8±24.3 years for women and men, respectively. Overall, infections accounted for 46.3% and 42.9% and non-communicable conditions 32.2% and 40.1% of consultations in women and men, respectively. Consultation for non-communicable compared with infectious conditions increased by 7% every year (95% CI: 5% to 9%; p<0.0001) over the 10 years. Consultations for non-communicable condition were more likely in women compared with men (RR=1.29, 95% CI: 1.18, 1.40) and at older ages (RR=1.27; 95% CI 1.25, 1.29 for 10-year increase in age).

Conclusion

Using high-quality disease morbidity data over a decade, we provide novel data showing the epidemiological transition of diseases as manifested in emergency service consultations in a large Sub-Saharan African city. These results can help reorientation of healthcare policy in Sub-Saharan Africa.
Protocol for a non-randomised pilot and feasibility study evaluating a multicomponent intervention to simplify medication regimens for people receiving community-based home care services
Authors: Sluggett Janet Kathleen , Page Amy Theresa , Chen Esa Y H , Ilomäki Jenni , Corlis Megan , Van Emden Jan , Hogan Michelle , Caporale Tessa , Angley Manya , Hilmer Sarah N , Ooi Choon Ean , Bell J Simon
Published: July 2019

Introduction

Managing medication regimens is one of the most complex and burdensome tasks performed by older people, and can be prone to errors. People living with dementia may require medication administration assistance from formal and informal caregivers. Simplified medication regimens maintain the same therapeutic intent, but have less complex instructions and administration schedules. This protocol paper outlines a study to determine the feasibility of a multicomponent intervention to simplify medication regimens for people receiving community-based home care services.

Methods and analysis

This is a non-randomised pilot and feasibility study. Research nurses will recruit 50 people receiving community-based home care services. All participants will receive the intervention from a clinical pharmacist, who will undertake medication reconciliation, assess each participant’s capacity to self-manage their medication regimen and apply a structured tool to identify opportunities for medication simplification. The pharmacist will communicate recommendations regarding medication simplification to registered nurses at the community-based home care provider organisation. The primary outcome will be a description of study feasibility (recruitment and retention rates, protocol adherence and stakeholder acceptability). Secondary outcomes include the change in number of medication administration times per day, medication adherence, quality of life, participant satisfaction, medication incidents, falls and healthcare utilisation at 4 months.

Ethics and dissemination

Ethical approval was obtained from the Monash University Human Research Ethics Committee and the community-based home care provider organisation’s ethical review panel. Research findings will be disseminated to consumers and caregivers, health professionals, researchers and healthcare providers through the National Health and Medical Research Council Cognitive Decline Partnership Centre and through conference presentations, lay summaries and peer-reviewed publications. This study will enable an improved understanding of medication management and administration among people receiving community-based home care services. This study will inform the decision to proceed with a randomised controlled trial to assess the effect of this intervention.

Trial registration number

ACTRN12618001130257; Pre-results.
Prescribing quality in secondary care patients with different stages of chronic kidney disease: a retrospective study in the Netherlands
Authors: Smits Kirsten PJ , Sidorenkov Grigory , van Ittersum Frans J , Waanders Femke , Bilo Henk JG , Navis Gerjan J , Denig Petra
Published: July 2019

Objectives

Insight in the prescribing quality for patients with chronic kidney disease (CKD) in secondary care is limited. The aim of this study is to assess the prescribing quality in secondary care patients with CKD stages 3–5 and possible differences in quality between CKD stages.

Design

This was a retrospective cohort study.

Setting

Data were collected at two university (n=569 and n=845) and one non-university nephrology outpatient clinic (n=1718) in the Netherlands.

Participants

Between March 2015 and August 2016, data were collected from patients with stages 3a–5 CKD seen at the clinics. Blood pressure measurements, laboratory measurements and prescription data were extracted from medical records. For each prescribing quality indicator, patients with incomplete data required for calculation were excluded.

Outcome measures

Potentially appropriate prescribing of antihypertensives, renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, phosphate binders and potentially inappropriate prescribing according to prevailing guidelines was assessed using prescribing quality indicators. Χ2or Fisher’s exact tests were used to test for differences in prescribing quality.

Results

RAAS inhibitors alone or in combination with diuretics (57% or 52%, respectively) and statins (42%) were prescribed less often than phosphate binders (72%) or antihypertensives (94%) when indicated. Active vitamin D was relatively often prescribed when potentially not indicated (19%). Patients with high CKD stages were less likely to receive RAAS inhibitors but more likely to receive statins when indicated than stage 3 CKD patients. They also received more active vitamin D and erythropoietin-stimulating agents when potentially not indicated.

Conclusions

Priority areas for improvement of prescribing in CKD outpatients include potential underprescribing of RAAS inhibitors and statins, and potential overprescribing of active vitamin D. CKD stage should be taken into account when assessing prescribing quality.
Association between early-life exposure to the Great Chinese Famine and poor physical function later in life: a cross-sectional study
Authors: Tao Tao , Dai Lingyan , Ma JinXiang , Li Yusi , Guo Zhuoyuan
Published: July 2019

Objectives

This study aimed to evaluate the association between early-life exposure to the Great Chinese Famine (1959–1961) and the prevalence of poor physical function in midlife.

Design

A population-based historical prospective study was performed as part of a wider cross-sectional survey. Exposure to famine was defined by birthdate, and participants were divided into non-exposed group, fetal-exposed group and infant-exposed group.

Setting and participants

A total of 3595 subjects were enrolled into the study from the China Health and Retirement Longitudinal Study (CHARLS) 2015 based on random selection of households that had at least one member aged 45 years old and older in 28 provinces of mainland China.

Main outcome measures

Physical function status was assessed by a six-item self-report on the Barthel scale which rated basic activities of daily living (BADL).

Results

743 (20.7%) out of all participants were exposed to the Great Chinese Famine in their fetal periods, while 1550 (43.1%) participants were exposed at the age of an infant. The prevalence of poor physical function in the non-exposed group, fetal period-exposed group and infant period-exposed group were 12.3%, 15.5% and 17.0%, respectively. Among males, after stratification by gender and severity of famine, the prevalence of poor physical function in the fetal period was significantly higher (OR 2.40, 95% CI 1.18 to 4.89, p=0.015) than the non-exposed group in severely affected areas, even after adjusting for the number of chronic diseases, place of residence, smoking and alcohol drinking habits, marital status, educational level and body mass index. A similar connection between prenatal and early postnatal exposure to the Great Chinese Famine and the prevalence of poor physical function in midlife, however, was not observed from female adults.

Conclusions

Males who were exposed to the Great Chinese Famine (1959–1961) present considerably decreased physical function in their later life.
Retrospective cohort study of compliance with post-deployment screening in the Canadian Armed Forces
Authors: Beliveau Peter J H , Boulos David , Johnson Dylan
Published: July 2019

Objective

Canadian Armed Forces (CAF) personnel who return from certain international deployments are required to complete post-deployment screening (PDS) 90 to 180 days post-deployment; the primary goal of PDS is early detection of mental health problems that aims for reduced delays to care provision. We investigated service members’ compliance with the PDS completion requirement and the factors associated with this compliance; a secondary objective was to investigate completion timing.

Design

The study used a retrospective cohort of CAF personnel (n=28 460) who had deployments over 01 January 2009 to 31 December 2014; inferences were based on a probabilistic sample (n=3004).

Primary outcome

The primary outcome was PDS completion. We assessed the timing of PDS completion, comparing non-compliant (early, late or no completion) with compliant completions (90 to 180 days post-deployment) among deployments that required screening. Kaplan-Meier plots summarised time-to-completion and logistic regression assessed the covariate associations with compliant completion. Covariate-adjusted marginal compliance prevalence differences (MPD) were computed.

Results

67.3% (95% CI65.0 to 69.6) of deployments that required PDS had one completed; 43.3% (95%CI 40.6 to 46.0) were completed within the compliant period. Compliant completion was higher with lower ranks (MPD=10.6%, relative to officers), combat arms occupations (MPD=8.4%), Afghanistan deployments (MPD=19.2%), longer deployments (MPD=10.1%) and among those without a past mental health problem (MPD=9.7%).

Conclusions

Our findings suggest that some selective processes may be occurring where those perceived to be at higher risk for post-deployment mental health problems are more compliant with PDS completion. However, PDS completion and compliant completion were lower than expected and this suggests a need to reinforce instruction on the guidelines and objectives of PDS among service members in the CAF.
Inequality in the distribution of ear, nose and throat specialists in 15 Latin American countries: an ecological study
Authors: Bright Tess , Mújica Oscar J , Ramke Jacqueline , Moreno Claudia M , Der Carolina , Melendez Amarilis , Lara Ovares Ericka , Sandoval Domingues Edgar Ivan , Santana Hernandez Diego Jose , Chadha Shelly , Silva Juan Carlos , Peñaranda Augusto
Published: July 2019

Objective

To explore sociogeographical inequalities in the availability and distribution of ear, nose and throat specialists (ENTs) in 15 Latin American (LA) countries.

Design

Ecological.

Setting

Spanish and Portuguese-speaking countries of LA.

The number of registered ENTs in 2017 was obtained from the National ENT Society in each country.

Outcome measures

The ENT rate/million population was calculated at the national and subnational (eg, state) level. Three measures were calculated to assess subnational distributive inequality of ENTs: (1) absolute and (2) relative index of dissimilarity; and (3) concentration index (using the Human Development Index as the equity stratifier). Finally, the ratio of ENTs/million population in the capital area compared with the rest of the country was calculated.

Results

There was more than a 30-fold difference in the number of ENTs/million population across the included countries—from 61.0 in Argentina (95% CI 58.7 to 63.4) to 2.8 in Guatemala (95% CI 2.1 to 3.8). In all countries, ENTs were more prevalent in advantaged areas and in capital areas. To attain distributive equality, Paraguay would need to redistribute the greatest proportion of its ENT workforce (67.3%; 95% CI 57.8% to 75.6%) and Brazil the least (18.5%; 95% CI 17.6% to 19.5%).

Conclusions

There is high inequality in the number and distribution of ENTs between and within the 15 studied countries in LA. This evidence can be used to inform policies that improve access to ear and hearing services in the region, such as scale-up of training of ENTs and incentives to distribute specialists equally. These actions to reduce inequities, alongside addressing the social determinants of ear and hearing health, are essential to realise Universal Health Coverage.
Implementation of a training program to increase knowledge, improve attitudes and reduce nursing care omissions towards patients with dementia in hospital settings: a mixed-method study protocol
Authors: Evripidou Melina , Merkouris Anastasios , Charalambous Andreas , Papastavrou Evridiki
Published: July 2019

Introduction

There is an evidence showing that when nurses have to allocate their time because of a lack of resources, older patients and especially those with dementia have a secondary care priority. The purpose of this study is to advance the level of knowledge, promote positive attitudes of nurses and reduce care deficits towards people with dementia through the implementation of a training programme. The programme will be enriched by an observational study of the care of patients with dementia to identify areas of missed care.

Method and analysis

This study will follow a mixed methodology consisting of three stages: (1) evaluation of the level of nurses’ knowledge and attitudes towards dementia care through the use of structured questionnaires, (2) observational study to evaluate nursing care in hospital settings, in order to detect any missed care and (3) quasi-experimental study, with a before-and-after design, through the implementation of the training programme in order to increase nurses’ knowledge, improve attitudes and consequently to promote care for patients with dementia. The data will be analysed with descriptive and inferential statistics with the use of the SPSS V.24.0 and with content analysis as regard to the observational data.

Ethics and dissemination

The protocol was approved by the National Bioethics committee and other local committees (ΕΕΒΚ: 2018.01.02). The participants will give their informed consent and the anonymity and confidentiality. Also, the protection of data will be respected. The results of the study will be disseminated in peer-reviewed international journals and conferences. If the intervention is successful, the training package will be given to the continuous education unit of the National Professional Association in order to be used on a regular basis.
Training surgeons and the informed consent discussion in paediatric patients: a qualitative study examining trainee participation disclosure
Authors: Bhanot Kunal , Chang Justin , Grant Samuel , Fecteau Annie , Camp Mark
Published: July 2019

Background

The process of obtaining informed consent is an important and complex pursuit, especially within a paediatric setting. Medical governing bodies have stated that the role of the trainee surgeon must be explained to patients and their families during the consent process. Despite this, attitudes and practices of surgeons and their trainees regarding disclosure of the trainee’s participation during the consent process has not been reported in the paediatric setting.

Methods

Nineteen face-to-face interviews were conducted with surgical trainees and staff surgeons at a tertiary-level paediatric hospital in Toronto, Canada. These were transcribed and subsequently thematically coded by three reviewers.

Results

Five main themes were identified from the interviews. (1) Surgeons do not consistently disclose the role of surgical trainees to parents. (2) Surgical trainees are purposefully vague in disclosing their role during the consent discussion without being misleading. (3) Surgeons and surgical trainees believe parents do not fully understand the specific role of surgical trainees. (4) Graduated responsibility is an important aspect of training surgeons. (5) Surgeons feel a responsibility towards both their patients and their trainees. Surgeons do not explicitly inform patients about trainees, believing there is a lack of understanding of the training process. Trainees believe families likely underestimate their role and keep information purposely vague to reduce anxiety.

Conclusion

The majority of surgeons and surgical trainees do not voluntarily disclose the degree of trainee participation in surgery during the informed consent discussion with parents. An open and honest discussion should occur, allowing for parents to make an informed decision regarding their child’s care. Further patient education regarding trainees’ roles would help develop a more thorough and patient-centred informed consent process.
Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis
Authors: Schichtel Markus , Wee Bee , MacArtney John I , Collins Sarah
Published: July 2019

Background

Clinicians hesitate to engage with advance care planning (ACP) in heart failure. We aimed to identify the disease-specific barriers and facilitators for clinicians to engage with ACP.

Methods

We searched Medline, Embase, CINAHL, PubMed, Scopus, the British Nursing Index, the Cochrane Library, the EPOC register, ERIC, PsycINFO, the Science Citation Index and the Grey Literature from inception to July 2018. We conducted the review according to Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Two reviewers independently assessed original and empirical studies according to Critical Appraisal Skills Programme criteria. The SURE framework and thematic analysis were used to identify barriers and facilitators.

Results

Of 2308 articles screened, we reviewed the full text of 42 studies. Seventeen studies were included. The main barriers were lack of disease-specific knowledge about palliative care in heart failure, high emotional impact on clinicians when undertaking ACP and lack of multidisciplinary collaboration between healthcare professionals to reach consensus on when ACP is indicated. The main facilitators were being competent to provide holistic care when using ACP in heart failure, a patient taking the initiative of having an ACP conversation, and having the resources to deliver ACP at a time and place appropriate for the patient.

Conclusions

Training healthcare professionals in the delivery of ACP in heart failure might be as important as enabling patients to start an ACP conversation. This twofold approach may mitigate against the high emotional impact of ACP. Complex interventions are needed to support clinicians as well as patients to engage with ACP.
Evaluation of the criteria for trauma activation in the paediatric emergency department
Authors: Pek Jen Heng , Ong Yong-Kwang Gene , Quek En Ci Samuel , Feng Xun Yi Jasmine , Allen Jr John Carson , Chong Shu-Ling
Published: July 2019

Background

Trauma team activation criteria have a variable performance in the paediatric population. We aimed to identify predictors for high-level resource utilisation during trauma resuscitation in the ED.

Methods

A retrospective study was conducted in the ED of a tertiary paediatric hospital. Patient data were collected from trauma surveillance registry and analysis was performed to identify significant predictors. We then assessed the sensitivity and specificity of proposed models with respect to observed patient outcomes.

Results

Among 11 282 cases, the mean age was 6.1±4.9 (SD) years old. Fall was the most common mechanism of injury in 7364 (65.3%) patients. Eighty-eight (0.8%) patients required at least one high-level resource. Significant predictors for high-resource utilisation were overall GCS of <14 (relative risk (RR) 38.841, 95% CI 21.328 to 70.739, p<0.001), high-risk mechanisms of fall from height and motor vehicle collision (RR 7.863, 95% CI 4.687 to 13.192, p<0.001), as well as age-specific tachycardia (RR 1.796, 95% CI 1.145 to 2.817, p=0.0108). A model consisting of GCS and high-risk mechanism would under-triage 21 (0.2%) patients and over-triage 681 (6.0%) patients. When age-specific tachycardia was added, 8 (0.1%) less patients would be under-triaged but an additional 3251 (28.9%) patients would be over-triaged.

Conclusion

As utilisation of high-level resources in paediatric trauma was rare, it was difficult to find an appropriate balance between under-triage and over-triage. Between the two, minimising the proportion of under-triage is more important as patient safety is paramount in paediatric trauma care.
Location of arrest and effect of prehospital advanced airway management after emergency medical service-witnessed out-of-hospital cardiac arrest: nationwide observational study
Authors: Park Jeong Ho , Song Kyoung Jun , Shin Sang Do , Ro Young Sun , Hong Ki Jeong , Kong So Yeon
Published: July 2019

Objectives

To investigate the association of prehospital advanced airway management (AAM) on outcomes of emergency medical service (EMS)-witnessed out-of-hospital cardiac arrest (OHCA) according to the location of arrest.

Methods

We evaluated a Korean national OHCA database from 2012 to 2016. Adults with EMS-witnessed, non-traumatic OHCA were included. Patients were categorised into four groups according to whether prehospital AAM was conducted (yes/no) and location of arrest (‘at scene’ or ‘in the ambulance’). The primary outcome was discharge with good neurological recovery (cerebral performance category 1 or 2). Multivariable logistic regression analysis was conducted to evaluate the association between AAM and outcome according to the location of arrest.

Results

Among 6620 cases, 1425 (21.5%) cases of arrest occurred ‘at the scene’, and 5195 (78.5%) cases of arrest occurred ‘in an ambulance’. Prehospital AAM was performed in 272 (19.1%) OHCAs occurring ‘at the scene’ and 645 (12.4%) OHCAs occurring ‘in an ambulance’. Patients with OHCA in the ambulance who had prehospital AAM showed the lowest good neurological recovery rate (6.0%) compared with OHCAs in the ambulance with no AAM (8.9%), OHCA at scene with AAM (10.7%) and OHCA at scene with no AAM (7.7%). For OHCAs occurring in the ambulance, the use of AAM had an adjusted OR of 0.67 (95% CI 0.45 to 0.98) for good neurological recovery.

Conclusion

Our data show no benefit of AAM in patients with EMS-witnessed OHCA. For patients with OHCA occurring in the ambulance, AAM was associated with worse clinical outcome.
Adapting the Canadian CT head rule age criteria for mild traumatic brain injury
Authors: Fournier Nicolas , Gariepy Charles , Prévost Jean-François , Belhumeur Vincent , Fortier Émile , Carmichael Pierre-Hugues , Gariepy Jean-Luc , Le Sage Natalie , Émond Marcel
Published: July 2019

Objective

With the ageing population, the prevalence of mild traumatic brain injury (mTBI) among older patients is increasing, and the age criteria of the Canadian CT head rule (CCHR) is challenged by many emergency physicians. We modified the age criteria of the CCHR to evaluate its predictive capacity.

Methods

We conducted a retrospective cohort study at a level 1 trauma centre ED of all mTBI patients 65 years old and over with an mTBI between 2010 and 2014. Main outcome was a clinically important brain injury (CIBI) reported on CT. The clinical and radiological data collection was standardised. Univariate analyses were performed to measure the predictive capacities of different age cut-offs at 70, 75 and 80 years old.

Results

104 confirmed mTBI were included; CT scan identified 32 (30.8%) CIBI. Sensitivity and specificity (95% CI) of the CCHR were 100% (89.1 to 100) and 4.2% (0.9 to 11.7) for a modified criteria of 70 years old; 100% (89.1 to 100) and 13.9% (6.9 to 24.1) for 75 years old; and 90.6% (75.0 to 98.0) and 23.6% (14.4 to 35.1) for 80 years old. Furthermore, modifying the age criteria to 75 years old showed a reduction of CT up to 25% (n=10/41) among the individuals aged 65–74 without missing CIBI.

Conclusion

Adjusting the age criteria of the Canadian CT head rule to 75 years old could be safe while reducing radiation and ED resources. A future prospective study is suggested to confirm the proposed modification.
Expansion of disability across successive Mexican birth cohorts: a longitudinal modelling analysis of birth cohorts born 10 years apart
Authors: Payne Collin F , Wong Rebeca
Published: July 2019

Background

Life expectancy (LE) in Mexico has risen rapidly since the 1950s. In high-income contexts, these increases have coincided with a compression of disability to later ages. However, little evidence on trends in disability-free LE (DFLE) exist from Mexico or elsewhere in Latin America.

Methods

Using data from the Mexican Health and Aging Study, we compare changes in LE and DFLE in ages 50–59, 60–69 and 70–79 using birth-cohort-specific multistate lifetable models across successive 10-year birth cohorts. Disability was measured using the Katz activities of daily living (ADL) index, and limitation was measured using a seven-item questionnaire on physical functioning.

Results

Overall, Mexican adults born in 1953–1962 lived 0.87 (p<0.001) fewer active years between ages 50 and 59 than individuals born in 1942–1951, a difference comprised of a 0.54-year (p<0.001) increase in physically limited LE and a 0.27-year (p<0.001) increase in ADL-disabled LE. Active LE declined by 1.13 (p<0.001) years in ages 60–69, and by 0.93 (p<0.001) years in ages 70–79, across successive 10-year birth cohorts. No substantial changes in total LE were seen in any age group, and the magnitude of the expansion of disability was larger in females than in males.

Conclusions

Our results indicate that more recently born cohorts of Mexican adults are spending more years of life with physical limitations and disabilities. These results foreshadow a need to closely monitor adult health in middle-income contexts, as the epidemiological conditions under which disability has expanded in Mexico are similar to those seen in many other countries.
Obesity and cardiovascular outcomes: Another look at a meta-analysis of Mendelian randomization studies
Authors: Kelley George A , Kelley Kristi S , Stauffer Brian L
Published: July 2019

This study used the inverse variance heterogeneity (IVhet) model to conduct a reanalysis of a recent meta-analysis that reported a positive association, based on the random-effects (RE) model, between obesity and the incidence of type 2 diabetes and coronary heart disease, but not all-cause stroke, in adults. Data emanated from a recent meta-analysis of five Mendelian randomization studies representing 881,692 adults. Results were pooled using the IVhet model and reported as OR's and 95% CI. Small-study effects were examined using the Doi plot and Luis Furuya-Kanamori (LFK) index. Influence analysis was also conducted. The association between obesity and type 2 diabetes, coronary heart disease, and all-cause stroke was, respectively, 1.38 (95% CI 1.00 to 1.90, p=0.05, I2=93%), 1.10 (95% CI 0.90 to 1.35, p=0.35, I2=87%), and 1.02 (95% CI 0.95 to 1.09, p=0.64, I2=0%). Compared with the original RE model, results were similar for all-cause stroke, but point estimates for type 2 diabetes and coronary heart disease were smaller (29.3% and 9.8%) with wider (7.0% and 14.7%), overlapping CI. Major asymmetry suggestive of small-study effects was observed (LFK=3.59). With the exception of one study for type 2 diabetes, results remained uncertain (overlapping 95% CI) when each study was deleted from the model once. A lack of certainty exists regarding the association between obesity and the incidence of type 2 diabetes, coronary heart disease, and all-cause stroke in adults.
Enablers and barriers to clinical leadership in the labour ward of district hospitals in KwaZulu-Natal, South Africa
Authors: Mianda Solange , Voce Anna Silvia
Published: July 2019

Introduction and background

Like many health systems in low-income and middle-income countries, the South African health system has failed to decrease both maternal and perinatal mortality significantly, especially in district hospitals. Inappropriately trained healthcare providers and poor clinical leadership are repeatedly linked to healthcare providers’ preventable factors contributing to most maternal and perinatal deaths. Clinical skills of healthcare providers have been largely addressed, while clinical leadership remained neglected. One strategy implemented recently to support clinical leadership is the introduction of District Clinical Specialist Teams (DCSTs). Clinical leadership in the labour ward of district hospitals in KwaZulu-Natal (KZN) is conceptualised as an emergent phenomenon arising from dynamic interactions in the labour ward and the broader health system, converging to attain optimal patient care.

Aim

To evaluate the enablers and barriers to clinical leadership in the labour ward of district hospitals.

Method

Iterative data collection and analysis, following the Corbin and Strauss grounded theory approach, was applied. In-depth interviews were carried out with the midwifery members of the DCSTs in KZN. The emergent enablers and barriers to clinical leadership were presented and discussed at a workshop with broader midwifery representation, leading to a final classification of enablers and barriers to clinical leadership.

Results and conclusion

Enablers and barriers to clinical leadership arise as a result of emergent dynamic interactions within the labour ward and the broader health system, located at policy, organisational, team and individual healthcare provider levels, with the policy context as the overriding factor framing the implementation of clinical leadership.
Bronchoalveolar cell differential count and the number of asbestos bodies correlate with survival in patients with asbestosis
Authors: Keskitalo Eerika , Varis Laura , Bloigu Risto , Kaarteenaho Riitta
Published: July 2019

Objectives

To determine cell differential counts and the number of asbestos bodies (ABs) in bronchoalveolar lavage (BAL) fluid obtained from patients with asbestosis, and to correlate the results with their survival.

Methods

The BAL cell differential counts and ABs from 91 patients with asbestosis were determined. The BAL cell differential counts were analysed in relation to smoking status. BAL cell differential counts and the number of ABs were correlated with the patients’ survivals.

Results

A neutrophilic cell pattern was observed independently of smoking habits with both Papanicolau (8.4%) and May-Grunwald-Giemsa (6.5%) staining. Smoking and a high number of ABs (>2 AB/mL) were associated with high total cell counts and high macrophage and low lymphocyte differential counts. The median survival of the patients was 131.8 months. Shortened survival was associated with high numbers of ABs (78 vs 165 months; p=0.042) and low lymphocyte (77 vs 179 months; p=0.005), high neutrophil (102 vs 180 months; p=0.016) and high eosinophil (104 vs170 months; p=0.007) differential counts.

Conclusion

A neutrophilic cell pattern was evident in BAL from patients with asbestosis. Smoking and ABs both affected the total cell count and the macrophage and lymphocyte differential counts. Several BAL parameters associated with patient survival, suggesting that BAL cell count analyses could be used in the estimation of the prognosis of patients with asbestosis.
Waterpipe device cleaning practices and disposal of waste associated with waterpipe tobacco smoking in homes in the USA
Authors: Kassem Nada OF , Kassem Noura O , Liles Sandy , Reilly Erin , Kas-Petrus Flora , Posis Alexander Ivan B , Hovell Melbourne F
Published: July 2019

Objectives

To quantify postsmoking waterpipe tobacco (WPT) waste and describe postsmoking waterpipe (WP) device cleaning practices and disposal of associated waste in home settings.

Methods

We analysed data from a US convenience sample of 50 exclusive WPT smokers, mean age 25.3 years. Data were collected at a home visit during which participants smoked one WPT head and completed a self-administered questionnaire on WP cleaning practices and disposal of waste associated with WPT use. Research assistants provided and prepared a WP for participants by weighing and loading 10 g of WPT in the WP head and placing 470 mL of water in the WP bowl. At the completion of the smoking session, research assistants measured the remaining WPT and water. Descriptive analyses were performed.

Results

Of the 10 g of fresh WPT used for each smoking session, 70.1% (mean=7.01 g) was discarded postsmoking as waste; for each 470 mL of water used in the WP bowl, 94.3% (mean=443 mL) was discarded. WP device cleaning practices ranged from never cleaning the device to cleaning it after each smoking session. Respondents reported discarding smoked WPT residue in the trash (81.6%) or the kitchen sink (14.3%) and discarding postsmoking charcoal in the trash (57.6%), the kitchen sink (27.3%) or backyard soil (9.1%). Respondents reported discarding smoked WP water in the kitchen sink (76.5%), bathroom sink (14.7%), toilet (2.9%) and backyard soil (5.9%).

Conclusions

Interventions and regulations are needed to inform proper WP device cleaning practices and disposal of waste associated with WPT use.

Trial registration number

NCT03253653.
Mismatches in spatial scale of supply and demand and their consequences for local welfare in Scottish aquaculture
Authors: O’Higgins Tim , Alexander Karen , Graziano Marcello
Published: July 2019

Mismatches in spatial scales, or spatial disconnections between causes and effects of ecosystem degradation, can reduce resilience in social–ecological systems. These mismatches can be particularly disruptive in coastal and marine areas, where multiple social and ecological systems are multi-layered. Scotland’s Western Isles have a history of local resource exploitation to meet extra-regional, larger-scale demands, which has resulted in a long process of socio-demographic decline. Salmon aquaculture is a major and expanding industry in the area, often linked to “Blue Growth”. The expansion of this industry operates within and contributes to create several scale mismatches. Combining a systems approach across nested scales with a classification of scale mismatches, this work analyses the characteristics of the Western Isles salmon aquaculture industry, and it explores effects on social–ecological resilience. An extent scale mismatch between the global stocks offish-meal species and the local capacity to respond to fluctuations is identified. The implications for this mismatch for the Western Isles are discussed. Some potential policy arrangements for incorporating matched spatial scales are considered.