bluuebunny/crossref_metadata_2025 huggingface dataset:
Safety and Efficacy of a Topical Sodium Channel Inhibitor (TV-45070) in Patients With Postherpetic Neuralgia (PHN)
Authors: Price Nicola , Namdari Rostam , Neville Judith , Proctor Katie J.W. , Kaber Samer , Vest Jeffery , Fetell Michael , Malamut Richard , Sherrington Robin P. , Pimstone Simon N. , Goldberg Yigal P.
Published: July 2016

Objective:

The objective was to evaluate the safety and efficacy of TV-45070 ointment, as a treatment for postherpetic neuralgia, and to explore the response in patients with the Nav1.7 R1150W gain-of-function polymorphism.

Materials and Methods:

This was a randomized, placebo-controlled, 2-period, 2-treatment crossover trial. Patients with postherpetic neuralgia with moderate or greater pain received TV-45070 and placebo ointments, each applied twice daily for 3 weeks. The primary efficacy measure was the difference in change in mean daily pain score from baseline compared with the last week of placebo and active treatment. Secondary endpoints included responder rate analyses and a further exploratory analysis of response in carriers of the Nav1.7 R1150W polymorphism was conducted.

Results:

Seventy patients were enrolled and 54 completed the study. TV-45070 was safe and well tolerated. No statistical difference was observed between treatments for the primary endpoint. However, the proportion of patients with ≥50% reduction in mean pain scores at week 3 was greater on TV-45070 than on placebo (26.8% vs. 10.7%,P=0.0039). Similarly, a greater proportion of patients on TV-45070 had a ≥30% reduction in mean pain scores at week 3 (39.3% on TV-45070 vs. 23.2% on placebo,P=0.0784). Of note, 63% of patients with the R1150W polymorphism versus 35% of wild-type carriers had a ≥30% reduction in mean pain score on TV-45070 at week 3 (no inferential analysis performed).

Conclusions:

The 50% responder analysis suggests a subpopulation may exist with a more marked analgesic response to TV-45070.The trend toward a larger proportion of responders within Nav1.7 R1150W carriers warrants further investigation.
A Prospective Study of Predictors of Long-term Opioid Use Among Patients With Chronic Noncancer Pain
Authors: Thielke Stephen M. , Shortreed Susan M. , Saunders Kathleen , Turner Judith A. , LeResche Linda , Von Korff Michael
Published: July 2016

Background:

Chronic pain patients at increased risk of unfavorable pain and opioid misuse outcomes may be those most likely to use opioids long-term, but this has not been evaluated prospectively.

Objectives:

To ascertain whether pain prognostic risk, problem opioid use risk, and depression predict opioid use 1 year later among patients recently initiating opioid therapy with a moderate likelihood of long-term opioid use.

Materials and Methods:

Self-report and electronic health record data were collected from patients aged 45+ years who recently initiated opioid therapy (N=762), in an integrated health care system. Logistic regression models tested whether baseline patient chronic pain prognostic risk, problem opioid use risk, depression, and expectations concerning continued opioid use independently predicted continuing use at 1 year (≥30 d supply in the prior 4 mo).

Results:

At 1 year, 46% of participants continued to use opioids. Baseline problem opioid use risk score (adjusted odds ratio, 1.15; 95% confidence interval, 1.04-1.26) and expectations about continuing opioid use, but not pain prognostic risk score or depression, were significant predictors of 1-year opioid use. Compared with patients who thought continued opioid use unlikely, those who thought it was extremely or very likely had 4 times the odds of opioid use at 1 year (adjusted odds ratio, 4.05; 95% confidence interval, 2.59-6.31).

Discussion:

The strongest predictors of long-term opioid use were not patient-related or medication-related factors, but expectations about using opioids in the future. Asking about such expectations may be the easiest way to identify patients likely to continue opioid use long-term.
External Validation and Modification of a Predictive Model for Acute Postsurgical Pain at Home After Day Surgery
Authors: Stessel Björn , Fiddelers Audrey A.A. , Marcus Marco A. , van Kuijk Sander M.J. , Joosten Elbert A. , Peters Madelon L. , Buhre Wolfgang F.F.A. , Gramke Hans-Fritz
Published: July 2016

Objectives:

In 2009, Gramke and colleagues have described predictive factors to preoperatively detect those at risk for moderate to severe acute postsurgical pain (APSP) after day surgery. The aim of the present study is to externally validate this initial model and to improve and internally validate a modified version of this model.

Materials and Methods:

Elective patients scheduled for day surgery were prospectively enrolled from November 2008 to April 2010. Model discrimination was quantified using the area under the receiver operating characteristic curve (AUC). Model calibration was assessed by visual inspection of the calibration plot. Subsequently, we modified (different assignment of type of surgery, different cutoff for moderate to severe APSP, continuous of dichotomized variables and testing of additional variables) and internally validated this model by standard bootstrapping techniques.

Results:

A total of 1118 patients were included. The AUC for the original model was 0.81 in the derivation data set and 0.72 in our validation data set. The model showed poorly calibrated risk predictions. The AUC of the modified model was 0.82 (optimism-corrected AUC=0.78). This modified model showed good calibration.

Conclusions:

The original prediction model of Gramke and colleagues performed insufficiently on our cohort of outpatients with respect to discrimination and calibration. Internal validation of a modified model shows promising results. In this model, preoperative pain, patient derived expected pain, and different types of surgery are the strongest predictors of moderate to severe APSP after day surgery.
Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU: A Single-Center, Randomized Controlled Trial*
Authors: Swan Joshua T. , Ashton Carol M. , Bui Lan N. , Pham Vy P. , Shirkey Beverly A. , Blackshear Jolene E. , Bersamin Jimmy B. , Pomer Rubie May L. , Johnson Michael L. , Magtoto Audrey D. , Butler Michelle O. , Tran Shirley K. , Sanchez Leah R. , Patel Jessica G. , Ochoa Robert A. , Hai Shaikh A. , Denison Karen I. , Graviss Edward A. , Wray Nelda P.
Published: July 2016

Objective:

To test the hypothesis that compared with daily soap and water bathing, 2% chlorhexidine gluconate bathing every other day for up to 28 days decreases the risk of hospital-acquired catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection in surgical ICU patients.

Design:

This was a single-center, pragmatic, randomized trial. Patients and clinicians were aware of treatment-group assignment; investigators who determined outcomes were blinded.

Setting:

Twenty-four–bed surgical ICU at a quaternary academic medical center.

Patients:

Adults admitted to the surgical ICU from July 2012 to May 2013 with an anticipated surgical ICU stay for 48 hours or more were included.

Interventions:

Patients were randomized to bathing with 2% chlorhexidine every other day alternating with soap and water every other day (treatment arm) or to bathing with soap and water daily (control arm).

Measurements and Main Results:

The primary endpoint was a composite outcome of catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection. Of 350 patients randomized, 24 were excluded due to prior enrollment in this trial and one withdrew consent. Therefore, 325 were analyzed (164 soap and water versus 161 chlorhexidine). Patients acquired 53 infections. Compared with soap and water bathing, chlorhexidine bathing every other day decreased the risk of acquiring infections (hazard ratio = 0.555; 95% CI, 0.309–0.997; p = 0.049). For patients bathed with soap and water versus chlorhexidine, counts of incident hospital-acquired infections were 14 versus 7 for catheter-associated urinary tract infection, 13 versus 8 for ventilator-associated pneumonia, 6 versus 3 for incisional surgical site infections, and 2 versus 0 for primary bloodstream infection; the effect was consistent across all infections. The absolute risk reduction for acquiring a hospital-acquired infection was 9.0% (95% CI, 1.5–16.4%; p = 0.019). Incidences of adverse skin occurrences were similar (18.9% soap and water vs 18.6% chlorhexidine; p = 0.95).

Conclusions:

Compared with soap and water, chlorhexidine bathing every other day decreased the risk of acquiring infections by 44.5% in surgical ICU patients.
ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research
Authors: Nates Joseph L. , Nunnally Mark , Kleinpell Ruth , Blosser Sandralee , Goldner Jonathan , Birriel Barbara , Fowler Clara S. , Byrum Diane , Miles William Scherer , Bailey Heatherlee , Sprung Charles L.
Published: July 2016

Objectives:

To update the Society of Critical Care Medicine’s guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research.

Design:

An appointed Task Force followed a standard, systematic, and evidence-based approach in reviewing the literature to develop these guidelines.

Measurements and Main Results:

The assessment of the evidence and recommendations was based on the principles of the Grading of Recommendations Assessment, Development and Evaluation system. The general subject was addressed in sections: admission criteria and benefits of different levels of care, triage, discharge timing and strategies, use of outreach programs to supplement ICU care, quality assurance/improvement and metrics, nonbeneficial treatment in the ICU, and rationing considerations. The literature searches yielded 2,404 articles published from January 1998 to October 2013 for review. Following the appraisal of the literature, discussion, and consensus, recommendations were written.

Conclusion:

Although these are administrative guidelines, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. A limited amount of high-quality evidence made it difficult to answer all the questions asked related to ICU admission, discharge, and triage. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing. We need to further develop preventive strategies to reduce the burden of critical illness, educate our noncritical care colleagues about these interventions, and improve our outreach, developing early identification and intervention systems.
Faecal immunochemical test in subjects not attending screening computed tomography colonography and colonoscopy in a randomized trial
Authors: Sali Lapo , Ventura Leonardo , Mascalchi Mario , Falchini Massimo , Mantellini Paola , Delsanto Silvia , Milani Stefano , Zappa Marco , Grazzini Grazia
Published: July 2016

The aim of this study was to evaluate the participation and yield of the faecal immunochemical test (FIT) in nonattendees for computed tomography colonography (CTC) or optical colonoscopy (OC) screening, in the setting of a randomized trial. In the SAVE trial, 16087 individuals were randomly assigned and invited to one of four interventions for colorectal cancer screening: (i) biennial FIT for three rounds; (ii) reduced-preparation CTC; (iii) full-preparation CTC; and (iv) OC. Nonattendees of reduced-preparation CTC, full-preparation CTC and OC groups were invited to FIT. Here, we analysed the participation rate and the detection rate for cancer or advanced adenoma (advanced neoplasia) of FIT among nonattendees for reduced-preparation CTC, full-preparation CTC and OC. Nonattendees were 1721 of 2395 (71.9%) eligible invitees in the reduced-preparation CTC group, 1818 of 2430 (74.8%) in the full-preparation CTC group and 883 of 1036 (85.2%) in the OC group. Participation rates for FIT were 20.2% (347/1721) in nonattendees for reduced-preparation CTC, 21.4% (389/1818) in nonattendees for full-preparation CTC and 25.8% (228/883) in nonattendees for OC. Differences between both CTC groups and the OC group were statistically significant (P≤0.01), whereas the difference between reduced-preparation and full-preparation CTC groups was not statistically significant (P=0.38). The detection rate of FIT was not statistically significantly different among nonattendees for reduced-preparation CTC (0.9%; 3/347), nonattendees for full-preparation CTC (1.8%; 7/389) and nonattendees for OC (1.3%; 3/228) (P>0.05). Offering FIT to nonattendees for CTC or OC increases the overall participation in colorectal cancer screening and enables the detection of additional advanced neoplasia.
Colposcopic patterns of vaginal intraepithelial neoplasia: a study from the Italian Society of Colposcopy and Cervico-Vaginal Pathology
Authors: Sopracordevole Francesco , Barbero Maggiorino , Clemente Nicolò , Fallani Maria G. , Cattani Paolo , Agarossi Alberto , de Piero Giovanni , Parin Alberto , Frega Antonio , Boselli Fausto , Mancioli Francesca , Buttignol Monica , Currado Francesca , Pieralli Annalisa , Ciavattini Andrea
Published: July 2016

The aim of this study was to evaluate the colposcopic patterns observed in women with a histopathological diagnosis of vaginal intraepithelial neoplasia (VaIN). The medical charts and the colposcopy records of women diagnosed with VaIN from January 1995 to December 2013 were analysed in a multicentre retrospective case series. The abnormal colposcopic patterns observed in women with VaIN1, VaIN2 and VaIN3 were compared. The vascular patterns and micropapillary pattern were considered separately. A grade II abnormal colposcopic pattern was more commonly observed in women with a biopsy diagnosis of VaIN3 rather than with VaIN1 or VaIN2 (P<0.001). Vascular patterns were also more common in women with VaIN3 rather than with VaIN1 or VaIN2 (P<0.001). Moreover, in women with grade I colposcopy, the rate of VaIN3 was significantly higher when a vascular pattern was observed (62.5 vs. 37.5%; P=0.04). The micropapillary pattern was more common in women with grade I colposcopy and it was more frequently observed in women with VaIN1 rather than in those with VaIN2 or VaIN3 (P<0.001). Grade II abnormal colposcopic pattern was more commonly observed in women with VaIN3. Moreover, the detection of vascular patterns appeared to be associated with more severe disease (VaIN3) even in women with grade I colposcopy, whereas the micropapillary pattern should be considered an expression of a less severe disease (VaIN1 and VaIN2).
Management of Attention-Deficit/Hyperactivity Disorder by Developmental-Behavioral Pediatricians: A DBPNet Study
Authors: Harstad Elizabeth , Blum Nathan , Gahman Amy , Shults Justine , Chan Eugenia , Barbaresi William ,   on behalf of the DBPNet Steering Committee
Published: July 2016

Objective:

To describe practice patterns for developmental-behavioral pediatricians (DBPs) practicing within Developmental-Behavioral Pediatrics Research Network (DBPNet) academic medical centers providing follow-up for children with attention-deficit/hyperactivity disorder (ADHD) and determine how well they adhere to American Academy of Pediatrics ADHD Clinical Practice Guidelines.

Methods:

Seventy-eight DBPs at 12 academic medical centers participating in the DBPNet were asked to complete follow-up encounter surveys for patients with ADHD or autism spectrum disorder seen from 12/2011 through 6/2012. Data regarding patient characteristics, comorbid conditions, and medication management were obtained at the time of each visit.

Results:

Fifty-seven DBPs completed 301 ADHD follow-up encounter surveys; 75.3% of patients were male with mean age 9.57 years (SD = 3.3). Race/ethnicity was primarily white/non-Hispanic with similar numbers on private insurance (41.5%) versus Medicaid (45.5%). DBPs identified comorbid learning disorders in 27.6% of children ≥6 years. Only 58.3% of children <6 years received counseling/behavioral therapy or had it recommended during the visit. DBPs primarily (90.6%) prescribed medications FDA-approved for ADHD treatment and growth was monitored for >98% of visits during which stimulants were prescribed. Parent- and teacher-completed rating scales were reviewed/completed during 43.9% and 37.8% of visits, respectively. There were no child or physician factors consistently associated with variation in practice patterns.

Conclusion:

Developmental-behavioral pediatricians practicing within DBPNet medical centers adhere to the recommended medication prescribing practices for ADHD, including use of FDA-approved medications and monitoring growth. However, DBPs within DBPNet do not consistently review ADHD rating scales or recommend behavioral counseling for children <6 years of age as recommended.
Repeated OnabotulinumtoxinA Treatment of Glabellar Lines at Rest Over Three Treatment Cycles
Authors: Carruthers Alastair , Carruthers Jean , Fagien Steven , Lei Xiaofang , Kolodziejczyk Julia , Brin Mitchell F.
Published: July 2016

BACKGROUND

OnabotulinumtoxinA has demonstrated the ability to eliminate mild glabellar lines at rest; however, less is known regarding the effect of repeat treatment on more severe lines at rest.

OBJECTIVE

To assess the effect of repeated onabotulinumtoxinA treatment for reduction of glabellar lines at rest.

METHODS

Subjects 18 to 75 years old with at least mild glabellar lines at rest, as assessed by the validated Facial Wrinkle Scale (FWS) with photonumeric guide (score ≥ 1), received 3 treatments of 20 U onabotulinumtoxinA 4 months apart (N = 225). “Response” was defined as elimination of glabellar lines at rest (FWS score = 0) at any time point (Days 7, 30, 60, 90, and 120). Effect of treatment cycle on response was analyzed using repeated measures logistic regressions (p < .05).

RESULTS

Most subjects were female (85%) and white (88%) (age range: 35–54 years). The likelihood of significant response was as follows: for all subjects combined (odds ratio [OR]: 1.31), for subjects with mild resting lines at baseline (OR: 1.49), and for older women (≥55 years) with mild resting lines at baseline (OR: 2.22). Of all subjects, 76% responded after 1 treatment, and 45% responded in all 3 cycles.

CONCLUSION

Subjects repeatedly treated with onabotulinumtoxinA showed progressive improvement in glabellar lines at rest.
Nasal Reconstruction: Extending the Limits
Authors: Rezaeian Farid , Corsten Marcus , Haack Sebastian , Gubisch Wolfgang M. , Fischer Helmut
Published: July 2016

Reconstructing the 3-dimensional structure of the nose requires the maintenance of its aesthetic form and function. Restoration of the correct dimension, projection, skin quality, symmetrical contour, and function remains problematic. Consequently, modern approaches of nasal reconstruction aim at rebuilding the units rather than just covering the defect. However, revising or redoing a failed or insufficient reconstruction remains very challenging and requires experience and creativity. Here, we present a very particular case with a male patient, who underwent 37 operations elsewhere and presented with a failed nasal reconstruction. We describe and illustrate the complex steps of the nasal rereconstruction, including the reconstruction of the forehead donor site, surgical delay procedures for lining, and the coverage with a third paramedian forehead flap.
Financial performance, employee well-being, and client well-being in for-profit and not-for-profit nursing homes: A systematic review
Authors: Bos Aline , Boselie Paul , Trappenburg Margo
Published: July 2016

Background:

Expanding the opportunities for for-profit nursing home care is a central theme in the debate on the sustainable organization of the growing nursing home sector in Western countries.

Purposes:

We conducted a systematic review of the literature over the last 10 years in order to determine the broad impact of nursing home ownership in the United States. Our review has two main goals: (a) to find outwhich topicshave been studied with regard to financial performance, employee well-being, and client well-being in relation to nursing home ownership and (b) to assessthe conclusions related to these topics. The review results in two propositions on the interactions between financial performance, employee well-being, and client well-being as they relate to nursing home ownership.

Methodology/Approach:

Five search strategies plus inclusion and quality assessment criteria were applied to identify and select eligible studies. As a result, 50 studies were included in the review. Relevant findings were categorized as related to financial performance (profit margins, efficiency), employee well-being (staffing levels, turnover rates, job satisfaction, job benefits), or client well-being (care quality, hospitalization rates, lawsuits/complaints) and then analyzed based on common characteristics.

Findings:

For-profit nursing homes tend to have better financial performance, but worse results with regard to employee well-being and client well-being, compared to not-for-profit sector homes. We argue that the better financial performance of for-profit nursing homes seems to be associated with worse employee and client well-being.

Practical Implications:

For policy makers considering the expansion of the for-profit sector in the nursing home industry, our findings suggest the need for a broad perspective, simultaneously weighing the potential benefits and drawbacks for the organization, its employees, and its clients.
Loss-of-function polymorphisms in the organic cation transporter OCT1 are associated with reduced postoperative tramadol consumption
Authors: Stamer Ulrike M. , Musshoff Frank , Stüber Frank , Brockmöller Jürgen , Steffens Michael , Tzvetkov Mladen V.
Published: July 2016

The organic cation transporter OCT1 (SLC22A1) mediates uptake and metabolism of the active tramadol metabolite (+)O-desmethyltramadol in the liver. In this study, the influence of OCT1 genetic polymorphisms on pharmacokinetics and analgesic efficacy of tramadol in patients recovering from surgery was analyzed in addition to the CYP2D6 genotype. Postoperative patients who received tramadol through patient-controlled analgesia were enrolled. Genotypes resulting in 0, 1, or 2 active OCT1 alleles were determined as well as CYP2D6 genotypes. The primary endpoint was the 24-hour postoperative tramadol consumption in patients with 0 vs at least 1 active OCT1 allele. Secondary endpoint was the OCT1-dependent plasma concentration (areas under the concentration–time curves) of the active tramadol metabolite (+)O-desmethyltramadol. Of 205 patients, 19, 82, and 104 carried 0, 1, and 2 active OCT1 alleles, respectively. Cumulative tramadol consumption through patient-controlled analgesia was lowest in patients with 0 active OCT1 allele compared with the group of patients with 1 or 2 active alleles (343 ± 235 vs 484 ± 276 mg; P = 0.03). Multiple regression revealed that the number of active OCT1 alleles (P = 0.014), CYP2D6 (P = 0.001), pain scores (P < 0.001), and the extent of surgery (0.034) had a significant influence on tramadol consumption. Plasma areas under the concentration–time curves of (+)O-desmethyltramadol were 111.8 (95% confidence interval: 63.4-160.1), 80.2 (65.1-95.3), and 64.5 (51.9-77.2) h·ng·mL−1 in carriers of 0, 1, or 2 active OCT1 alleles (P = 0.03). Loss of OCT1 function resulted in reduced tramadol consumption and increased plasma concentrations of (+)O-desmethyltramadol in patients recovering from surgery. Therefore, analyzing OCT1 next to CYP2D6 genotype might further improve future genotype-dependent dose recommendations for tramadol.
Genetic variants associated with thermal pain sensitivity in a paediatric population
Authors: Matic Maja , van den Bosch Gerbrich E. , de Wildt Saskia N. , Tibboel Dick , van Schaik Ron H.N.
Published: July 2016

Pain sensitivity is an inherited factor that varies strongly between individuals. We investigated whether genetic polymorphisms in the candidate genesCOMT,OPRM1,OPRD1,TAOK3,TRPA1,TRPV1, andSCN9Aare contributing to experimental pain variability between children. Our study included 136 children and adolescents (8-18 years). Cold and heat pain thresholds were determined with a Thermal Sensory Analyzer. Women and young children were significantly more sensitive to pain (P< 0.05). After correction for age, gender, reaction time, and correction for multiple testing,OPRM1118A>G G-allele carriers (AG and GG) rated the hot stimulus as significantly less painful than didOPRM1118A>G AA genotyped individuals (2[1-5] vs 7 [3-9], respectively;P= 0.00005). Additionally,OPRM1118G allele carriers reached more frequently the minimum temperature limit (44% vs 17%, respectively;P= 0.003) and maximum temperature limit (52% vs 24%, respectively;P= 0.0052), indicative for lower pain sensitivity. The combined genotype, based on expected pain sensitivity,OPRM1118AA/COMT472 GA or AA genotyped children, was associated with lower pain thresholds (ie, higher pain sensitivity) than were theOPRM1118GA or GG/COMT472GG genotyped children. This is the first study reporting on genetic variants and experimental thermal pain in children and adolescents.OPRM1rs1799971 and the combinedOPRM1/COMTgenotype could serve as biomarkers for pain sensitivity.
Young children's ability to report on past, future, and hypothetical pain states: a cognitive-developmental perspective
Authors: Jaaniste Tiina , Noel Melanie , von Baeyer Carl L.
Published: July 2016

Children are at times asked by clinicians or researchers to rate their pain associated with their past, future, or hypothetical experiences. However, little consideration is typically given to the cognitive-developmental requirements of such pain reports. Consequently, these pain assessment tasks may exceed the abilities of some children, potentially resulting in biased or random responses. This could lead to the over- or under-treatment of children's pain. This review provides an overview of factors, and specifically the cognitive-developmental prerequisites, that may affect a child's ability to report on nonpresent pain states, such as past, future, or hypothetical pain experiences. Children's ability to report on past pains may be influenced by developmental (age, cognitive ability), contextual (mood state, language used by significant others), affective and pain-related factors. The ability to mentally construct and report on future painful experiences may be shaped by memory of past experiences, information provision and learning, contextual factors, knowledge about oneself, cognitive coping style, and cognitive development. Hypothetical pain reports are sometimes used in the development and validation of pain assessment scales, as a tool in assessing cognitive-developmental and social-developmental aspects of children's reports of pain, and for the purposes of training children to use self-report scales. Rating pain associated with hypothetical pain scenarios requires the ability to recognize pain in another person and depends on the child's experience with pain. Enhanced understanding of cognitive-developmental requirements of young children's pain reports could lead to improved understanding, assessment, and treatment of pediatric pain.
Improving Care Transitions Across Healthcare Settings Through a Human Factors Approach
Authors: Werner Nicole E. , Gurses Ayse P. , Leff Bruce , Arbaje Alicia I.
Published: July 2016

After more than two decades of research focused on care transition improvement and intervention development, unfavorable outcome measures associated with care transitions across healthcare settings persist. Readmissions rates remain an important outcome to target for intervention, adverse events associated with care transitions continue to be an issue, and patients are often dissatisfied with the quality of their care. Currently, interventions to improve care transitions are disease specific, require substantial financial investments in training allied healthcare professionals, or focus primarily on hospital-based discharge planning with mixed results. This complex situation requires a method of evaluation that can provide a comprehensive, in-depth, and context-driven investigation of potential risks to safe care transitions across healthcare settings, which can lead to the creation of effective, usable, and sustainable interventions. A systems' approach known as Human Factors and Ergonomics (HFE) evaluates the factors in a system that affect human performance. This article describes how HFE can complement and further strengthen efforts to improve care transitions.
The Effect of an Interprofessional Heart Failure Education Program on Hospital Readmissions
Authors: Clarkson Julia N. , Schaffer Susan D. , Clarkson Joshua J.
Published: July 2016

Heart failure (HF) is an increasing concern to public health, affecting approximately 5.1 million Americans and costing the United States over $32 billion annually. Compounding the concern, research has exposed the significant problem of hospital readmissions for the HF population, with an estimated 25% of HF patients are rehospitalized within 30 days of discharge. This project focuses on an education-based strategy designed to decrease hospital readmissions for this at-risk population. In particular, an interprofessional outpatient educational program (Heart Failure University [HFU]) was initiated to reduce healthcare costs and increase the quality of care for HF patients at a large private hospital in Florida. A retrospective case–control study was conducted to compare 30-day hospital readmissions of patients who attended HFU to patients who received standard education. Results indicated a significant association between HFU attendance and reduced 30-day hospital readmissions (χ2 [1, N = 106] = 5.68, p = .02). Strengthening this effect, the results showed patients who attended HFU had a significantly greater functional disability than those who did not attend (t(104) = 2.40, p = .018). These findings corroborate with current research on transitional care interventions and emphasize the importance of interprofessional, educational-based disease management programs for the HF population.
Applying Lean Techniques to Reduce Intravenous Waste Through Premixed Solutions and Increasing Production Frequency
Authors: Lin Alex C. , Penm Jonathan , Ivey Marianne F. , Deng Yihong , Commins Monica
Published: July 2016

Background:

This study aims to use lean techniques and evaluate the impact of increasing the use of premixed IV solutions and increased IV production frequency on IV waste.

Methods:

Study was conducted at a tertiary hospital pharmacy department in three phases. Phase I included evaluation of IV waste when IV production occurred three times a day and eight premixed IV products were used. Phase II increased the number of premixed IV products to 16. Phase III then increased IV production to five times a day.

Results:

During Phase I, an estimate of 2,673 IV doses were wasted monthly, accounting for 6.14% of overall IV doses. This accounted for 688 L that cost $60,135. During Phase II, the average monthly IV wastage reduced significantly to 1,069 doses (2.84%), accounting for 447 L and $34,003. During Phase III, the average monthly IV wastage was further decreased to 675 doses (1.69%), accounting for 78 L and $3,431. Hence, a potential annual saving of $449,208 could result from these changes.

Conclusion:

IV waste was reduced through the increased use of premixed solutions and increasing IV production frequency.
Cutaneous Cytomegalovirus Growth Around a Gastrostomy Button
Authors: Riley Robin M. , Thompson Nancy M.
Published: July 2016

A 3-year-old boy with history of gastrostomy tube placement and cadaveric cytomegalovirus (CMV)-positive, renal transplant, into a CMV-negative recipient, presents because of rapidly growing hypertrophic epithelialized granulation tissue around the gastrostomy tube. The growth around the gastrostomy tube was resected and confirmed by pathology to be CMV. This case is of interest because all reported cases of cutaneous CMV have presented as ulcerations. CMV growth should be considered in the differential in a patient postrenal transplant.
Creation of a Pediatric Burn Clinic
Authors: Quilty Jennifer
Published: July 2016

Pediatric burns are a major source of morbidity and healthcare expenditure in the United States. Options and availability for outpatient pediatric burn treatment can be limited, potentially leading to high medical costs and delay in proper treatment. In our local community, there was no adequate, cost-effective outpatient treatment for patients with pediatric burn. In 2007, clinicians who specialize in pediatric burn care developed an outpatient pediatric burn clinic. The treatment team consisted of a pediatric nurse practitioner and four pediatric surgeons from the local children's hospital. Since opening, over 1,200 patients have been treated on a strictly outpatient basis. Kurt Lewin's three-stage model of change provided a conceptual model. The constructs include unfreeze the model pattern of burn referrals, change the pattern, and then work through a refreezing process. The burn clinic filled a need in the community by providing cost-effective outpatient specialty treatment for patients with pediatric burns. The future includes continuing ongoing marketing to the referring pediatric groups and outlying emergency department providers, expansion of staff to meet the growing needs of the community, and burn prevention community outreach.
Silver Sulfadiazine or Biobrane Dressings
Authors: Hodnett Carly W.
Published: July 2016

Background

In the treatment of partial thickness burns in pediatrics, silver sulfadiazine (SSD) has been widely used. Biobrane, a biosynthetic dressing, has gained popularity for treatment as well for its promotion of epithelial growth. Nonetheless, there is limited information on the comparison of SSD and Biobrane for the treatment of partial-thickness burns in children. This literature review aimed to provide objective data on increased epithelial growth and decreased infection risk of SSD and Biobrane.

Purpose

The aim of this study was to conduct a literature review to examine the use of Biobrane dressings in comparison with SSD for the treatment of partial-thickness burns in children to improve epithelial growth and decrease risk of infection as compared with SSD.

Results

Seven systemic reviews were included in the literature review. Evidence showed that there was limited high-quality evidence to confirm the effectiveness of Biobrane compared with SSD in the pediatric population with partial thickness burns in regard to fewer dressing changes, improved healing time, and reduced wound infections. Some evidence exists showing Biobrane's ease in use and improved healing time when compared with SSD.

Recommendations for Practice

Future research is necessary to investigate Biobrane and SSD within large pediatric burn populations to establish its effectiveness and provide high-quality evidence for the treatment of pediatric partial-thickness burns.
Corticosteroids Versus Pentoxifylline for Severe Alcoholic Hepatitis
Authors: Njei Basile , Do Albert , McCarty Thomas R. , Fortune Brett E.
Published: July 2016

Introduction:

Despite the significant morbidity and mortality associated with alcoholic hepatitis, a consensus or generally accepted therapeutic strategy has not yet been reached. The purpose of this analysis was to evaluate the effects of corticosteroids and pentoxifylline on short-term mortality, incidence of hepatorenal syndrome, and sepsis in patients with severe alcoholic hepatitis.

Materials and Methods:

We conducted a comprehensive search of the Cochrane library, PUBMED, Scopus, EMBASE, and published proceedings from major hepatology and gastrointestinal meetings from January 1970 to June 2015. All relevant articles irrespective of language, year of publication, type of publication, or publication status were included. Two independent reviewers extracted data and scored publications; a third investigator adjudicated discrepancies. The κ scores were measured to assess the agreement between the 2 initial reviewers. The review and meta-analyses were performed following the recommendations of The Cochrane Collaboration. Conventional meta-analysis and Trial sequential analysis were performed. GRADEpro version 3.6 was used to appraise the quality of epidemiologic evidence.

Results:

A total of 14 studies satisfied inclusion criteria comparing corticosteroids, pentoxifylline, or placebo. Compared with placebo, corticosteroids reduced 28-day mortality (RR=0.53; 95% CI, 0.33-0.84; P=0.006). There was no statistically significant difference in short-term mortality between pentoxifylline and placebo (RR=0.74; 95% CI, 0.46-1.18; P=0.21). Neither corticosteroids nor pentoxifylline impacted the incidence of hepatorenal syndrome or sepsis. Trial sequential analysis confirmed the results of our conventional meta-analysis.

Conclusions and Relevance:

Corticosteroids demonstrated a decrease in 28-day mortality in patients with severe alcoholic hepatitis. The evidence from this study is insufficient to support any recommendations regarding the mortality benefit of pentoxifylline in severe alcoholic hepatitis.
Small-bowel Surveillance in Patients With Peutz-Jeghers Syndrome
Authors: Goverde Anne , Korsse Susanne E. , Wagner Anja , van Leerdam Monique E. , Krak Nanda C. , Stoker Jaap , van Buuren Henk R. , Hofstra Robert M.W. , Bruno Marco J. , Dewint Pieter , Dekker Evelien , Spaander Manon C.W.
Published: July 2016

Background and Study Aims:

Small-bowel surveillance with polypectomy of polyps ≥15 mm prevents complications in patients with Peutz-Jeghers syndrome (PJS). We aimed to compare magnetic resonance enteroclysis (MRE) and double balloon enteroscopy (DBE) for diagnostic yield of these polyps and for patient preference.

Materials and Methods:

PJS patients prospectively underwent MRE followed by proximal DBE within 20 weeks. Endoscopists were blinded to the MRE results. We compared number of polyps ≥15 mm detected by MRE and DBE. Patients’ perceptions of both procedures were assessed using questionnaires.

Results:

Fifteen PJS patients (67% males, median age 47 y) underwent both MRE and DBE. Polyps ≥15 mm were identified by MRE and/or DBE in 12/15 (80%) patients. There was no significant difference in the detection of polyps ≥15 mm (38 by MRE vs. 50 by DBE, P=0.37). Sensitivity for these polyps was 62% (38/61) for MRE and 82% (50/61) for DBE. Patients’ perceived shame and burden did not differ significantly between MRE and DBE. Patients reported significantly more pain during preparation for MRE than for DBE (moderate vs. no pain, P=0.02), although perceived pain during the procedures was comparable (both mild, P=0.89). For future small-bowel surveillance 10/13 (77%) patients preferred DBE over MRE (P=0.09).

Conclusions:

Our results suggest that MRE and DBE have a comparable diagnostic yield of polyps ≥15 mm. However, DBE allows for direct intervention and was preferred over MRE by most patients in this series. Larger cohorts of PJS patients are needed to fully evaluate the diagnostic yield of DBE compared with other modalities.
Use of Reticulocyte Hemoglobin Content in the Assessment of Iron Deficiency in Children With Inflammatory Bowel Disease
Authors: Syed Sana , Kugathasan Subra , Kumar Archana , Prince Jarod , Schoen Bess T. , McCracken Courtney , Ziegler Thomas R. , Suchdev Parminder S.
Published: July 2016

Background:

Iron deficiency and anemia affect up to 50% to 75% of patients with inflammatory bowel disease (IBD). Iron deficiency in IBD may be difficult to diagnose because of the effect of inflammation on iron status biomarkers. Thus, there is a need for better methods to accurately determine iron status in IBD.

Objective:

The aim of the study was to investigate the association of inflammation with hemoglobin content of reticulocytes (CHr) and the utility of CHr in comparison to standard iron biomarkers.

Methods:

We conducted a cross‐sectional study of children with IBD. Iron biomarkers (CHr, ferritin, soluble transferrin receptor [sTfR], hepcidin, hemoglobin) were measured along with systemic biomarkers of inflammation (C‐reactive protein, α1‐acid glycoprotein]. Spearman correlations were used to evaluate the relation of inflammation and iron biomarkers. The criterion standard for iron deficiency was defined as inflammation‐corrected ferritin <15 μg/L or sTfR >8.3 mg/L. Receiver operating characteristic curves were used to estimate the prognostic values of all iron biomarkers to identify patients with iron deficiency.

Results:

We analyzed data in 62 children ages 5 to 18 years. Sixty‐nine percent of our subjects had Crohn disease and 31% had ulcerative colitis, of which 42% were girls and 53% African American. The prevalence of anemia was 32%, of iron deficiency was 52% using ferritin <15 μg/L or sTfR >8.3 mg/L, 39% using red blood cell distribution width of >14.5%, 26% using body iron stores of <0 mg/kg body weight, 25% using CHr of <28 pg, and 11% using mean corpuscular volume of <75 fL/cell. The prevalence of elevated CRP or AGP was 48%. After correcting ferritin and sTfR levels for inflammation, the prevalence of iron deficiency was 68%. CHr was correlated with C‐reactive protein (rs −0.44, P < 0.001) and α1‐acid glycoprotein (rs −0.37, P < 0.05). The optimal prognostic value for inflammation‐adjusted CHr to predict iron deficiency was 34 pg (area under the receiver operating characteristic of 0.70), with 88% sensitivity and 30% specificity.

Conclusions:

Iron deficiency and anemia are common in this pediatric IBD cohort. All explored iron biomarkers, including CHr, were affected by inflammation and should be adjusted. A single iron biomarker is unlikely to best predict iron deficiency in pediatric IBD. Iron intervention studies are needed to examine the response of iron biomarkers to iron supplementation in the setting of inflammation.
Tacrolimus Exerts Only a Transient Effectiveness in Refractory Pediatric Crohn Disease
Authors: Truffinet Oriane , Martinez‐Vinson Christine , Guerriero Emilie , Hugot Jean‐Pierre , Viala Jérôme
Published: July 2016

Objectives:

Tacrolimus is an immunosuppressive agent that has been proposed in the treatment of severe ulcerative colitis. The present study examined the effectiveness and safety of tacrolimus in treating refractory Crohn disease (CD) colitis in children.

Methods:

All children treated by oral tacrolimus for CD colitis at a tertiary pediatric center were included in the study. All patients were refractory to steroids and infliximab. Clinical response (decreased pediatric CD activity index [PCDAI] >15 and PCDAI <30) and remission (PCDAI <10) were monitored at 2, 4, 6, 12, and 24 months after induction. Tacrolimus blood levels and adverse effects were also noted.

Results:

Among 220 patients with CD, 8 children (including 3 girls, median age 14 [9.5–18] years) were registered with a median PCDAI of 58.7 (32.5–65) before tacrolimus initiation. In patients treated with tacrolimus, the overall clinical response rates were 6/8, 3/8, 2/8, 2/8, and 1/8 with a remission rate of 4/8, 0/8, 0/8, 2/8, and 0/8 at 2, 4, 6, 12, and 24 months, respectively. At 2 months, the PCDAI scores were lower than those at induction (median 11.2; P = 0.004) with the mean whole plasma level of tacrolimus being 8.75 ng/mL (5.9–10 ng/mL). Adverse events occurred in 6 of 8 patients, including renal dysfunction, insulin‐dependent diabetes, paresthesia, and tremor. Tacrolimus interruption was required in 2 cases.

Conclusions:

Tacrolimus could be considered to transiently treat refractory CD colitis. Tacrolimus could be used as a “bridge” toward another medical option in pediatric CD, although its adverse events are frequent.
Planning, Designing, Building, and Moving a Large Volume Maternity Service to a New Labor and Birth Unit
Authors: Thompson Heather , Legorreta Kimberly , Maher Mary Ann , Lavin Melanie M.
Published: July 2016

Background:

Our health system recognized the need to update facility space and associated technology for the labor and birth unit within our large volume perinatal service to improve the patient experience, and enhance safety, quality of care, and staff satisfaction. When an organization decides to invest $30 million dollars in a construction project such as a new labor and birth unit, many factors and considerations are involved. Financial support, planning, design, and construction phases of building a new unit are complex and therefore require strong interdisciplinary collaboration, leadership, and project management.

Methods:

The new labor and birth unit required nearly 3 years of planning, designing, and construction. Patient and family preferences were elicited through consumer focus groups. Multiple meetings with the administrative and nursing leadership teams, staff nurses, nurse midwives, and physicians were held to generate ideas for improvement in the new space. Involving frontline clinicians and childbearing women in the process was critical to success. The labor and birth unit moved to a new patient tower in a space that was doubled in square footage and geographically now on three separate floors. In the 6 months prior to the move, many efforts were made in our community to share our new space. The marketing strategy was very detailed and creative with ongoing input from the nursing leadership team. The nursing staff was involved in every step along the way. It was critical to have champions as workflow teams emerged. We hosted simulation drills and tested scenarios with new workflows. Move day was rehearsed with representatives of all members of the perinatal team participating.

Results:

These efforts ultimately resulted in a move time of ~5 hours. Birth volumes increased 7% within the first 6 months. After 3 years in our new space, our birth volumes have risen nearly 15% and are still growing.

Clinical Implications:

Key processes and roles responsible for a successful build, efficient and safe move day, and optimal operational utility, as anticipated, of a new labor and birth unit in a large volume perinatal service are detailed.
Influence of External Visual Focus on Gait in Children With Bilateral Cerebral Palsy
Authors: Bartonek Asa , Lidbeck Cecilia M. , Gutierrez-Farewik Elena M.
Published: July 2016

Purpose:

To explore whether focusing a target influenced gait in children with cerebral palsy (CP) and typical development (TD).

Methods:

Thirty children with bilateral CP (Gross Motor Function Classification System [GMFCS] I-III) and 22 with TD looked at a light at walkway end (Gaze Target) while walking and returned (No Target).

Results:

During Gaze versus No Target, children with TD reduced temporal-spatial parameters and movements in the sagittal (SPM) and transverse planes. In comparison, during Gaze Target, children in CP1 (GMFCS I) had larger trunk SPM, children in CP2 (GMFCS II) larger neck (SPM), and children in CP3 (GMFCS III) greater head and neck frontal plane movements, and reduced cadence and single support.

Conclusions:

Focusing a target altered gait in children with CP. Children in CP1 reduced movements similar to children with TD, children in CP2 behaved nearly unchanged, whereas children in CP3 reduced movements and temporal-spatial parameters, potentially as a consequence of lack of sensory information from lower limbs.