bluuebunny/crossref_metadata_2025 huggingface dataset:
Factors that contribute to effective online nutrition education interventions: a systematic review
Authors: Murimi Mary W , Nguyen Bong , Moyeda-Carabaza Ana F , Lee Hyun-Jung , Park Oak-Hee
Published: May 2019

Context

The use of the internet and technology as a medium for delivering online nutrition education (ONE) has increased; however, evidence-based studies exploring factors that contribute to best practices in online interventions have not emerged.

Objective

The purpose of this systematic review was to identify factors that contributed to successful ONE interventions in relation to research studies published between 2009 and 2018.

Data sources

Following the PRISMA guidelines, relevant studies were identified through PubMed, Medline, Web of Science, Science Direct, and Education Resources Information Center (ERIC) databases.

Data extraction

Five authors screened and determined the quality of the studies using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and extracted the data from the articles.

Data analysis

Twenty-seven studies were included: 21 studies were website-based, 3 were delivered through smartphone application, 2 were delivered as online courses, and 1 used text messages. Tailored messages/feedback, interaction between participants and investigators, identification of specific behaviors, use theory, adequate duration, and alignment between stated objectives and activities were factors that contributed to successful online interventions, while comparison bias and the lack of specific details on duration and dosage, tracking system, objective outcome measurements, and follow-up were factors that may have interfered with successful ONE interventions.

Conclusions

The findings underscore the importance of developing ONE intervention designs that utilize factors unique to online platforms for effective interventions aimed at behavior change.
Role of berries in vascular function: a systematic review of human intervention studies
Authors: Martini Daniela , Marino Mirko , Angelino Donato , Del Bo’ Cristian , Del Rio Daniele , Riso Patrizia , Porrini Marisa
Published: May 2019

Context

Berries are a source of polyphenols with recognized health-promoting activities. Several studies suggest that consumption of berries may improve vascular function.

Objective

The aim of this systematic review is to provide evidence of short- and long-term benefits of berries on outcomes of vascular function.

Data Sources

Human intervention studies were collected from PubMed and Scopus databases.

Study Selection

Studies were eligible if they investigated the effects of acute or chronic berry consumption on one or more markers of vascular function in humans and provided a characterization of the berry polyphenolic content. Only randomized controlled trials were included, and studies were excluded if berries were combined with other foods.

Data Extraction

After selection, 22 randomized controlled trials were included and analyzed, most of which were performed in healthy individuals or patients with cardiovascular risk factors.

Results

The overall results seem to suggest a protective role of berries in vascular function, likely dependent on the time of exposure, the type and dose of berry, and the biomarkers analyzed. Flow-mediated dilation and reactive hyperemia index (markers of vascular reactivity) improved following short-term interventions, while pulse wave velocity and augmentation index (markers of arterial stiffness) improved only after medium- to long-term intervention.

Conclusions

Current evidence suggests that berries, at physiological relevant doses, may have a role in the modulation of vascular function and stiffness. High-quality human intervention trials are encouraged in order to strengthen these findings and to better elucidate the mechanisms involved in such modulation.
From Patient Zero to Public Health Emergency
Authors: Kennedy Maureen Shawn
Published: May 2019

The measles outbreaks may be a wake-up call to reinvigorate vaccination campaigns.
The Alarming Global Increase in Measles
Authors: Goldrick Barbara A.
Published: May 2019

Is the antivaccination movement causing a worldwide pandemic?
Volunteering in Two Border Communities
Authors: Kelly Patricia J.
Published: May 2019

Editor&s note: Patricia J. Kelly is a retired professor of nursing at the University of Missouri–Kansas City. In this report, she writes about her work and observations while volunteering at and visiting migrant shelters in Tucson, Arizona, where she lives, and San Diego, where she often travels to visit family.
New Drug Treats Rare Blood Clotting Disorder
Authors: Aschenbrenner Diane S.
Published: May 2019

Caplacizumab-yhdp (Cablivi) is the first drug specifically indicated for acquired thrombotic thrombocytopenic purpura, a rare and potentially life-threatening blood clotting disorder. It is prescribed in combination with plasmapheresis and immunosuppressive therapy.

The drug carries a warning that severe bleeding can occur with use, although the most common adverse effects are headache and minor bleeding from the nose or gums.

Caplacizumab-yhdp is given initially as an iv bolus and then as a subcutaneous injection along with plasmapheresis.
Original Research: Exploring Working Relationships Between National and Expatriate RNs on Humanitarian Aid Missions: The Perspectives of Liberian Nurses
Authors: Wilson Deborah , Jallah Darlington S.
Published: May 2019

Purpose: This qualitative study was conducted to explore the perceptions and concerns of Liberian RNs who work for international nongovernmental organizations (NGOs) in Liberia, and to elicit insights and suggestions about how to improve collaboration between national and expatriate nursing staff.

Methods: Five focus groups involving 19 nurses and an individual interview with one nurse were conducted. A semistructured interview guide was used to gather perspectives and garner suggestions. A phenomenological approach was used to identify emergent themes.

Results: Regarding positive experiences, participants from all 10 NGOs reported that working with expats gave them opportunities to be mentored, learn new skills, and try out new techniques and equipment. Negative experiences included problems with disrespect and expats’ lack of cultural competency. Participants spoke of adverse patient outcomes that resulted when expats made assumptions and wouldn't listen to national staff.

Conclusions: The findings indicate that changes are warranted in the current work culture between national and expatriate nursing staff. Improving collaboration between national and expatriate RNs could lead to higher-quality care and better patient outcomes. Predeployment training for expatriates that incorporates the voices of national staff is recommended; this would raise awareness of the realities of nursing in low-resource settings and promote respect for national staff.
Comprehensive EHR Associated with Higher Nurse Satisfaction
Authors: Rosenberg Karen
Published: May 2019

According to this study:

Adoption of a comprehensive EHR system is associated with greater nurse satisfaction with the system, more favorable reports of the system's usability, and higher quality of care. However, work environment affected all usability ratings.
Decolonization Reduces Risk of Postdischarge MRSA
Authors: Rosenberg Karen
Published: May 2019

According to this study:

Decolonization with chlorhexidine and mupirocin led to lower risks of postdischarge methicillin-resistant Staphylococcus aureus and readmission compared with hygiene education alone.
Epilepsy
Authors: Perkins Amanda
Published: May 2019

It's essential for nurses to understand this condition and know how to care for patients experiencing a seizure.
Discharge after stroke
Authors: Carrillo-Gutierrez Cristina , Jaime Frances , Smith Kim , Elsehety Marwah , Headley Janelle , Sostand Shanequa , Harrison Nicole , Strug Polina , Vu Kim , Savitz Sean , Sharrief Anjail
Published: May 2019

Stroke patients are at increased risk for cognitive impairments and physical limitations after discharge. Enhancing the discharge process can help drive improved outcomes.
Treatable traits in chronic rhinosinusitis with nasal polyps
Authors: Heffler Enrico , Malvezzi Luca , Pirola Francesca , Zięba Natalia , Paoletti Giovanni , Mercante Giuseppe , Spriano Giuseppe , Canonica Giorgio Walter
Published: May 2019

Purpose of review

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex inflammatory sinonasal disease that deserves a multidisciplinary precision medicine approach. In a precision medicine model, a more pragmatic approach taking in consideration disease features that are potentially treatable should be considered.

Recent findings

Several treatable traits in CRSwNP can be identified: from disease-related ones, to extra-ENT features, to behavioral and environmental factors. This review article summarizes primarily the recent findings of CRSwNP-related treatable traits and how they can be modified by given treatments.

The advent of biological agents acting directly to the endotype underlying CRSwNP pushes the scientific community to integrate clinical, surgical and immunological evaluations for each single patient; this naturally leads to the identification of specific treatable traits that can serve as possible outcomes for any single biological.
Cutaneous drug hypersensitivity: developments and controversies
Authors: Brockow Knut , Pfützner Wolfgang
Published: May 2019

Purpose of review

Cutaneous drug hypersensitivity reactions (CDHRs) are a complicated area with multiple clinical manifestations and differential diagnoses, requiring differentiated diagnostic measurements and optimized therapeutic management.

Recent findings

Disseminated CDHRs to classical drugs can be classified by a simple algorithm, whereas chemotherapeuticals or biopharmaceuticals may show drug-specific and atypical clinical presentations. Controversies in drug hypersensitivity diagnosis exist about the benefit and accuracy of in-vitro tests. Although skin tests are the best means of detecting sensitization to drugs, methods have not been sufficiently standardized. The necessity for skin tests before performing drug provocation test (DPT) and of prolonged DPTs is discussed in selected patients. If a suspicion has been documented, β-lactam allergy should be excluded. The standard allergy diagnosis is done by an allergist. In case of urgent need because of an infection and low risk according to history, faster delabeling pathways have been developed. There is weak evidence that patients with mastocytosis may have a slightly increased risk of developing immediate-type drug hypersensitivity; however, if considerations are taken, drugs do not have to be withheld for this patient group. There is particular need for improved diagnostic measurements in patients with drug-induced severe cutaneous adverse reactions (SCARs), both identifying the offending drug and detecting individuals at risk. Further challenges encompass appropriate treatments during the acute as well as chronic phase of SCARs.

Recent literature has contributed to our understanding of clinical manifestations and existing controversies and future needs in this area.
Critical Gaps in Understanding the Clinician–Scientist Workforce: Results of an International Expert Meeting
Authors: Weggemans Margot M. , Friesen Farah , Kluijtmans Manon , Prakken Berent , ten Cate Olle , Woods Nicole N. , Rosenblum Norman D.
Published: May 2019

Clinician–scientists—health care professionals expert in research and clinical practice—can play a vital role in translating research outcomes to clinical practice. Concerns about the sustainability of the clinician–scientist workforce have been expressed in the literature for decades. Although many have made recommendations to increase the clinician–scientist workforce, there has been no substantial change. Therefore, an international expert meeting was held in March 2017 in Utrecht, the Netherlands, with the goal of discovering unidentified gaps in our understanding of challenges to the sustainability of the clinician–scientist workforce. Nineteen individuals (steering committee members; representatives from the AAMC, AFMC, and RCPSC; and physician–scientists, nurse–scientists, education scientists, deans, vice deans, undergraduate and postgraduate program directors, and a medical student) from Canada, the Netherlands, the United States, and Singapore participated in the meeting. The meeting identified 3 critical questions to be addressed: (1) What is the particular nature of the clinician–scientist role? (2) How are clinician–scientists to be recognized within the health and health research ecosystem? and (3) How can the value that clinician–scientists add to translational medicine and research be clarified to stakeholders and the public? The meeting participants identified a 3-fold agenda to address these questions: articulating the value proposition of clinician–scientists, supporting professionalization and professional identity development, and integrating clinical and research training. Addressing the 3 critical questions will likely contribute to a wider recognition of the value of clinician–scientists and be a first step in advancing from recommendations toward system-level changes to reinvigorate the clinician–scientist workforce.
Building Provider–Caregiver Partnerships: Curricula for Medical Students and Residents
Authors: Blackie Michael , Baughman Kristin R. , Palmisano Barbara , Sanders Margaret , Sperling David , Scott Erin , Radwany Steven , Drost Jennifer , Thomas Jon
Published: May 2019

Problem

A disconnect exists between caregivers and health care providers, resulting in fragmented communication, which increases caregiver stress and compromises patient care. Although providers have a responsibility to recognize caregiver burden, they receive scant training on issues important to caregivers.

Approach

From 2014 to 2017, as part of the Building Caregiver Partnerships Through Interprofessional Education project—a collaborative effort between Northeast Ohio Medical University and Summa Health—the authors developed curricula to foster effective partnerships between health care providers and caregivers by exposing medical students and residents to highly personal caregiving narratives. The curricula center on a short film featuring 4 families representing diverse caregiving experiences. The authors crafted several discussion guides, case-based learning exercises, structured clinical encounters, team-based simulations, and clinical cases as companion educational tools for the film.

Outcomes

Medical students reported the educational tools piloted to be valuable in broadening their understanding of caregivers’ needs, while residents reported the educational tools piloted to also be valuable in improving their communication and building partnerships with caregivers. Undergraduate and graduate faculty reported finding the pilots valuable.

Next Steps

Future goals include conducting an outcome evaluation, based on ACGME milestones, to identify and examine clinical outcomes to determine whether communication increases and quality of care improves as a result of the project. The authors would also like to include caregivers in the evaluation. Finally, because caregiving is best addressed from a team approach, the authors plan to pilot the project at other health professions programs.
Building Social Capital to Foster Interprofessional Education: The Interprofessional Educator Academy
Authors: Lee Linda S. , O’Connor Grochowski Colleen , Valiga Theresa M. , von Isenburg Megan , Bures McNeill Diana
Published: May 2019

Interprofessional education (IPE) is promoted as a necessary precursor to the implementation of the collaborative practices in patient care thought to improve teamwork and communication among health care providers, patients, their families, and communities. Yet barriers to IPE persist, due largely to a lack of understanding on the part of health care team members about the norms and practices of health professions outside their own. A by-product of social interactions within groups and networks, social capital is a collective asset that contributes to the development of trust, innovation, and coordination of efforts toward mutual goals. Duke AHEAD (Academy for Health Professions Education and Academic Development), an interprofessional educator academy, is examined through the lens of social capital theory as a viable means of breaking down barriers to IPE, thereby improving patient care.
Defining a Taxonomy of Intracranial Hypertension
Authors: Kofke W. Andrew , Rajagopalan Swarna , Ayubcha Diana , Balu Ramani , Cruz-Navarro Jovany , Manatpon Panumart , Mahanna-Gabrielli Elizabeth
Published: May 2019

Intracranial pressure (ICP) monitoring and control is a cornerstone of neuroanesthesia and neurocritical care. However, because elevated ICP can be due to multiple pathophysiological processes, its interpretation is not straightforward. We propose a formal taxonomy of intracranial hypertension, which defines ICP elevations into 3 major pathophysiological subsets: increased cerebral blood volume, masses and edema, and hydrocephalus. (1) Increased cerebral blood volume increases ICP and arises secondary to arterial or venous hypervolemia. Arterial hypervolemia is produced by autoregulated or dysregulated vasodilation, both of which are importantly and disparately affected by systemic blood pressure. Dysregulated vasodilation tends to be worsened by arterial hypertension. In contrast, autoregulated vasodilation contributes to intracranial hypertension during decreases in cerebral perfusion pressure that occur within the normal range of cerebral autoregulation. Venous hypervolemia is produced by Starling resistor outflow obstruction, venous occlusion, and very high extracranial venous pressure. Starling resistor outflow obstruction tends to arise when cerebrospinal fluid pressure causes venous compression to thus increase tissue pressure and worsen tissue edema (and ICP elevation), producing a positive feedback ICP cycle. (2) Masses and edema are conditions that increase brain tissue volume and ICP, causing both vascular compression and decrease in cerebral perfusion pressure leading to oligemia. Brain edema is either vasogenic or cytotoxic, each with disparate causes and often linked to cerebral blood flow or blood volume abnormalities. Masses may arise from hematoma or neoplasia. (3) Hydrocephalus can also increase ICP, and is either communicating or noncommunicating. Further research is warranted to ascertain whether ICP therapy should be tailored to these physiological subsets of intracranial hypertension.
The dark side of Sjögren's syndrome: the possible pathogenic role of infections
Authors: Bartoloni Elena , Alunno Alessia , Gerli Roberto
Published: May 2019

Purpose of review

To highlight recent findings on pathogenic mechanisms and clinical associations which characterize the role of infectious agents as triggers for Sjögren's syndrome development.

Recent findings

Several candidate infectious agents have been identified to induce the autoimmune and inflammatory pathways leading to Sjögren's syndrome clinical appearance in the setting of a genetic background. This is reinforced by the demonstration that Sjögren's syndrome patients are characterized by higher prevalence of seropositivity to virus and bacterial agents in comparison with general population. Moreover, these agents may infect salivary gland epithelial cells. Stronger evidence confirmed the role of some viruses, like Epstein–Barr, as triggers of the disease and different mechanisms have been demonstrated to interplay. Recent experimental and clinical studies supported the adjunctive role of an altered buccal and intestinal microbial composition and chronic inflammatory response to Helicobacter pylori in disease induction. Finally, latent viral infections and immune system chronic stimulation induced by persistent infections may participate in disease lymphoproliferative evolution.

Different viral and bacterial agents have been identified as triggers in Sjögren's syndrome induction and contributors to the chronic immune system stimulation underlying lymphoproliferative complication. Deeper knowledge of involved microbial agents and pathogenic mechanisms linking Sjögren's syndrome and infections may help the identification of preventive therapeutic strategy.
A Systematic Review and Standardized Comparison of Available Evidence for Outcome Measures Used to Evaluate Proximal Humerus Fracture Patients
Authors: Nowak Lauren L. , Davis Aileen M. , Mamdani Muhammad , Beaton Dorcas , Kennedy Carol , Schemitsch Emil H.
Published: May 2019

Objectives:

To summarize and appraise any patient-reported or clinician-measured outcome measures based on their measurement properties in proximal humerus fracture patients.

Data Sources and Study Selection:

MEDLINE, EMBASE, and CINAHL were searched from January 2000 to August 2018 to identify all studies of proximal humerus fracture patients that reported a measurement property evaluation of an outcome measure.

Data Extraction and Synthesis:

Quality appraisal of each measure was completed using the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) tool. The EMPRO takes into account all studies of each measure, and the overall score is transformed linearly to a range of 0 (lowest) to 100 (best).

Results:

Eleven instruments were identified. Intended concepts of the instruments included clinician-measured shoulder function, patient-reported function or disability, and patient-reported general health state. Only the Disabilities of the Arm, Shoulder and Hand (DASH), Oxford Shoulder Score, Constant Score, University of California, Los Angeles Shoulder Score, and EuroQol 5 Dimension (EQ5D) were evaluated in more than 1 study. The Shoulder Function Index (SFINX), DASH, and EQ5D had the highest EMPRO scores (80, 66, and 58, respectively). The SFINX and DASH consistently scored among the top 3 instruments for each attribute.

Conclusions:

Evidence on the measurement properties of outcome measures for proximal humerus fracture patients is limited. With the available evidence, the SFINX is recommended as a clinician-measured functional outcome measure, the DASH as a patient-reported functional outcome measure, and the EQ5D as a general health status measure.
Ligamentous Lisfranc Injury: A Biomechanical Comparison of Dorsal Plate Fixation and Transarticular Screws
Authors: Bansal Ankit , Carlson Daniel A. , Owen John R. , Cheatham Seth A. , Williams D. S. Blaise , Kates Stephen L. , Wayne Jennifer S.
Published: May 2019

Objectives:

Optimal fixation technique after purely ligamentous Lisfranc injury remains controversial. This biomechanical study compares dorsal plate versus transarticular screw fixation by measuring dorsal and plantar joint diastasis. A unique protocol was developed, using reflective triad markers and positional cameras.

Methods:

Eleven cadaveric matched pairs were assigned to either transarticular screw or dorsal plate fixation. Two reflective triad markers were placed into the medial cuneiform (C1) and second metatarsal base (MT2). Three cameras recorded the 3-dimensional location of triads to quantify C1-MT2 diastasis in the following states: intact Lisfranc ligament (INTACT), cut ligament (CUT), fixed (SCREW or PLATE) joint, and fixed joint after 10,000 loaded cycles. On completion, the plantar Lisfranc ligament insertions were identified, and plantar diastasis was determined using additional reflective triads. Statistical post hoc pairwise comparisons assessed differences in diastasis.

Results:

C1-MT2 diastasis in the CUT state increased relative to INTACT (P < 0.001). SCREW fixation reduced C1-MT2 diastasis relative to CUT at dorsal (P < 0.007) and plantar (P = 0.015) locations after cycling. PLATE fixation significantly reduced dorsal diastasis relative to CUT (P < 0.001) but not for plantar diastasis (P > 0.99). PLATE plantar diastasis was numerically higher than INTACT but not significantly (P > 0.39). PLATE plantar diastasis tended to be greater than SCREW before cycling (P = 0.068) and after cycling (P = 0.080).

Conclusions:

Transection of the Lisfranc ligament complex yielded C1-MT2 diastasis. Both SCREW and PLATE fixation successfully reduced dorsal diastasis. However, upon load, the PLATE resulted in greater plantar diastasis, nearly statistically different relative to the SCREW. Cyclic loading at 343 N did not worsen diastasis.
Degenerative Disc Disease
Authors: Battié Michele C. , Joshi Anand B. , Gibbons Laura E.
Published: May 2019

Study Design.

A systematic search and review

Objective.

The aim of this study was to investigate the term, degenerative disc disease, to elucidate its current usage and inform clinical, research, and policy recommendations.

Summary of Background Data.

Degenerative disc disease has long been a dominant concept in common, painful spinal disorders. Yet, despite its pervasiveness and important clinical consequences and controversies, there has not been a systematic examination of its use and meaning in the scientific literature.

Methods.

We conducted a systematic search of publications using the term degenerative disc disease from 2007 through 2016 in Ovid MEDLINE (R), Embase, CINAHL, and Scopus. Two investigators independently reviewed all publications in the primary sample. Publication and author identifiers, and qualitative study descriptors were extracted. Finally, the definition of degenerative disc disease was placed in one of eight categories. Data were summarized using descriptive statistics.

Results.

Degenerative disc disease appeared in the titles of 402 publications in the primary sample and increased in frequency by 189% from the first to the last 3 years of the decade. No single definition was used in the majority of publications, and most frequently, the term was used without any definition provided (30.1%). In other cases, degenerative disc disease specifically included radiculopathy or myelopathy (14.4%), or only back or neck pain (5.5%), or was equated with disc degeneration regardless of the presence of symptoms (15.4%), or with discogenic pain or disc degeneration as a presumed cause of axial pain (12.7%). Another 7.2% comprised a mix of broad ranging findings and diagnoses. The most notable differences in definitions occurred between surgeons and other disciplines, and when applied to cervical versus lumbar regions.

Conclusion.

Despite longstanding use and important consequences, degenerative disc disease represents an underdeveloped concept, with greatly varying, disparate definitions documented. Such inconsistencies challenge clear, accurate communication in medicine and science, create confusion and misconceptions among clinicians, patients and others, and hinder the advancement of related knowledge.

Level of Evidence: 4
The Anterolateral Thigh-Medial Femoral Condyle Chimeric Flow-through Flap for Posttraumatic Wrist Arthrodesis
Authors: Kurlander David E. , Wu-Fienberg Yuewei , Long Tobias C. , Rowe David J. , Gatherwright James
Published: May 2019

Wrist arthrodesis in the setting of segmental bone loss can have high failure rates. Therefore, vascularized bone grafting has been advocated for select patients. Patients suffering concomitant large soft tissue loss present even greater challenge. To that end, we describe for the first time successful anterolateral thigh-medial femoral condyle chimeric flow-through flap for posttraumatic wrist arthrodesis and soft tissue coverage. This is a case report of a 19-year-old male laborer who suffered a large blast injury resulting in significant bone and soft tissue injury to the dominant right hand and wrist. After multiple debridements, there was a segmental bone defect from the distal radius and ulna to the metacarpal bases, as well as a 12×8 cm dorsal soft tissue defect. This was reconstructed with a anterolateral thigh-medial femoral condyle chimeric flow-through flap and concomitant wrist arthrodesis in a single stage. Besides a donor site thigh seroma, recovery was uneventful with clinical and radiographic evidence of fusion by >9 weeks postoperation.
Typologies of Decision-Makers in the ICU: A Qualitative Study of Patients With Acute Respiratory Distress Syndrome and Sepsis and Their Surrogates
Authors: Lava Michael S. , Dickert Neal W. , Frew Paula M. , Martin Gregory S. , Sevransky Jonathan E.
Published: May 2019

Objectives:

To develop hypotheses of patient and surrogate’s rationale for decision-making.

Design:

We pursued a qualitative study of patients with acute respiratory distress syndrome or sepsis and their surrogates. Fourteen patients and 28 surrogates were given semistructured interviews while in the ICU and again 30 days later. The interviews focused on goal outcomes for the ICU stay and why a patient or surrogate would want a specific intervention (e.g., intubation and cardiopulmonary resuscitation).

Setting:

ICU of tertiary care academic hospital.

Patients:

Fourteen acute respiratory distress syndrome or sepsis patients and 28 of their surrogates.

Interventions:

None.

Measurements and Main Results:

Interviews were analyzed using grounded theory and the constant comparative method on NVivo 10.0 (QSR International, Melbourne, Australia). We identified the following four typologies of decision-making rationale: 1) “Timers”—determined decisions based on the length of time on life support; 2) “Natural Livers”—rejected interventions using a “machine”; 3) “Deferrers”—relied on physician for decision-making and prognosis; and 4) “Believers”—relied on a higher power for guidance.

Conclusions:

Our hypothesized typologies need validation in a prospective observational trial. If validated, they may allow for better clinician communication.
Thrombomodulin, Plasminogen Activator Inhibitor-1 and Protein C Levels, and Organ Dysfunction in Sepsis
Authors: Katayama Shinshu , Koyama Kansuke , Shima Jun , Tonai Ken , Goto Yuya , Koinuma Toshitaka , Nunomiya Shin
Published: May 2019

Objectives:

Since endothelial function is closely related to organ dysfunction in sepsis and the relationship among endothelial injury, organ dysfunction, and other biomarkers remains unclear, we aimed to evaluate the correlation among endothelial injury, organ dysfunction, and several biomarkers in patients with sepsis.

Design:

This was a retrospective observational study.

Setting:

The study was conducted in a university hospital with 14 mixed ICU beds.

Patients:

ICU patients with sepsis from June 2011 to December 2017 were enrolled in this study.

Interventions:

Endothelial biomarkers (soluble thrombomodulin, plasminogen activator inhibitor-1, and protein C) and markers of inflammation and coagulation were evaluated during the ICU stay. Sequential Organ Failure Assessment scores were assessed for 7 days after ICU admission to determine organ dysfunction. Variables were compared among five stratified groups according to the Sequential Organ Failure Assessment score (0–2, 3–5, 6–8, 9–12, and 13–24). Regression analysis and 95% CIs were used to evaluate trends in biomarkers.

Measurements and Main Results:

The patients were divided into five stratified groups (Sequential Organ Failure Assessment 0–2, n = 159 [20.5%]; Sequential Organ Failure Assessment 3–5, n = 296 [38.2%]; Sequential Organ Failure Assessment 6–8, n = 182 [23.5%]; Sequential Organ Failure Assessment 9–12, n = 75 [9.7%]; Sequential Organ Failure Assessment 13–24, n = 31 [4.0%]). Protein C activity was significantly correlated with the severity of organ dysfunction. It was lower on day 1, increased upon successful treatment, and was significantly higher in groups with lower Sequential Organ Failure Assessment scores.

Conclusions:

Trends and activity of protein C were superior in predicting organ dysfunction compared with other endothelial biomarkers. Monitoring the level of protein C activity is an ideal tool to monitor organ dysfunctions in patients with sepsis.
Low ICU Burnout in a Safety Net Hospital
Authors: LeClaire Michele M. , Poplau Sara , Prasad Kriti , Audi Crystal , Freese Rebecca , Linzer Mark
Published: May 2019

Objectives:

Burnout tends to be high in ICU settings. Stressors include serious patient illness, round-the-clock acute events, and end-of-life (nonbeneficial) care. We report on an ICU with very low burnout scores. We sought to understand factors that might be responsible for these favorable outcomes.

Design:

We compared ICU scores on burnout and its predictors with scores in non-ICU providers, merging scores in four ICUs (burn, medical, surgical, and pediatrics). Analyses included descriptive statistics, as well as general estimating equations to assess odds of burnout in ICU clinicians versus non-ICU clinicians.

Setting:

Annual wellness survey performed in October 2017 at Hennepin Healthcare System, an integrated system of care that includes an urban safety net hospital in Minneapolis, MN.

Subjects:

Six-hundred seventy-nine providers (physicians and advanced practice providers).

Interventions:

None.

Measurements and Main Results:

Annual surveys are performed using the validated Mini-Z 10 item wellness instrument. The Mini-Z assesses stress, satisfaction, and burnout, as well as known predictors including work control, chaos, teamwork, values alignment, and electronic medical record-related stress. Response rate in ICUs was 70% (64% elsewhere). Ten percentage of ICU clinicians reported burnout versus 37% of other providers (p = 0.015). ICUs were characterized as having lower chaos, less stress, and very high teamwork and values alignment between clinicians and leaders. Odds of burnout were four times lower in ICU clinicians (odds ratio, 0.24; 95% CI, 0.06–0.96; p = 0.043). Of all Hennepin Healthcare System providers, those with values not aligned with leaders had 3.28 times the odds of burnout (95% CI, 1.92–5.59; p < 0.001).

Conclusions:

Low burnout can be present in a busy, safety net ICU. Explicitly aligning values between clinicians and leaders may hold promise as a remediable worklife factor for producing these favorable results.
Clinician Perception of a Machine Learning–Based Early Warning System Designed to Predict Severe Sepsis and Septic Shock*
Authors: Ginestra Jennifer C. , Giannini Heather M. , Schweickert William D. , Meadows Laurie , Lynch Michael J. , Pavan Kimberly , Chivers Corey J. , Draugelis Michael , Donnelly Patrick J. , Fuchs Barry D. , Umscheid Craig A.
Published: May 2019

Objective:

To assess clinician perceptions of a machine learning–based early warning system to predict severe sepsis and septic shock (Early Warning System 2.0).

Design:

Prospective observational study.

Setting:

Tertiary teaching hospital in Philadelphia, PA.

Patients:

Non-ICU admissions November–December 2016.

Interventions:

During a 6-week study period conducted 5 months after Early Warning System 2.0 alert implementation, nurses and providers were surveyed twice about their perceptions of the alert’s helpfulness and impact on care, first within 6 hours of the alert, and again 48 hours after the alert.

Measurements and Main Results:

For the 362 alerts triggered, 180 nurses (50% response rate) and 107 providers (30% response rate) completed the first survey. Of these, 43 nurses (24% response rate) and 44 providers (41% response rate) completed the second survey. Few (24% nurses, 13% providers) identified new clinical findings after responding to the alert. Perceptions of the presence of sepsis at the time of alert were discrepant between nurses (13%) and providers (40%). The majority of clinicians reported no change in perception of the patient’s risk for sepsis (55% nurses, 62% providers). A third of nurses (30%) but few providers (9%) reported the alert changed management. Almost half of nurses (42%) but less than a fifth of providers (16%) found the alert helpful at 6 hours.

Conclusions:

In general, clinical perceptions of Early Warning System 2.0 were poor. Nurses and providers differed in their perceptions of sepsis and alert benefits. These findings highlight the challenges of achieving acceptance of predictive and machine learning–based sepsis alerts.
Glomerular Hyper- and Hypofiltration During Acute Circulatory Failure: Iohexol-Based Gold-Standard Descriptive Study
Authors: Salmon Gandonnière Charlotte , Helms Julie , Le Tilly Olivier , Benz-de Bretagne Isabelle , Bretagnol Anne , Bodet-Contentin Laetitia , Mercier Emmanuelle , Halimi Jean-Michel , Benzékri-Lefèvre Dalila , Meziani Ferhat , Barin-Le Guellec Chantal , Ehrmann Stephan
Published: May 2019

Objective:

To assess glomerular filtration rate in the early phase of acute circulatory failure by measuring iohexol plasma clearance.

Design:

Interventional prospective multicentric study.

Setting:

Three French ICUs in tertiary teaching hospitals.

Patients:

Patients with acute circulatory failure within 12 hours after ICU admission.

Interventions:

IV administration of a nontoxic 5-mL dose of iohexol. Collection of nine arterial blood samples over 24 hours for iohexol plasma concentration measurements. Iohexol clearance calculation with a population pharmacokinetic model. Iohexol clearance was an estimation of the mean glomerular filtration rate over 24 hours.

Measurements and Main Results:

Among 99 included patients, we could calculate iohexol clearance for 85. The median iohexol clearance was 31 mL/min (interquartile range, 16–44). According to iohexol clearance, 41 patients (48%) had severe hypofiltration (clearance, < 30 mL/min), 29 (34%) had moderate hypofiltration, and 10 (12%) had mild hypofiltration (clearance, 30–60 and 60–90 mL/min, respectively). Four patients (5%) had normal glomerular filtration rate, and only one (1%) showed hyperfiltration (clearance, > 130 mL/min). Urinary creatinine clearance underestimated renal impairment in one patient out of two; the bias of iohexol clearance toward 24-hour urinary creatinine clearance over the same period was –18.1 mL/min (limits of agreement, –73.5 to 37.4).

Conclusions:

We demonstrated the feasibility of iohexol clearance measurement in unstable critically ill patients. Normal kidney function is exceptional during the early phase of acute circulatory failure. Glomerular filtration rate estimation by urinary creatinine clearance frequently fails to detect renal impairment. Hyperfiltration is very infrequent.
Intra-Abdominal Hypertension Is Responsible for False Negatives to the Passive Leg Raising Test
Authors: Beurton Alexandra , Teboul Jean-Louis , Girotto Valentina , Galarza Laura , Anguel Nadia , Richard Christian , Monnet Xavier
Published: May 2019

Objectives:

To compare the passive leg raising test ability to predict fluid responsiveness in patients with and without intra-abdominal hypertension.

Design:

Observational study.

Setting:

Medical ICU.

Patients:

Mechanically ventilated patients monitored with a PiCCO2 device (Pulsion Medical Systems, Feldkirchen, Germany) in whom fluid expansion was planned, with (intra-abdominal hypertension+) and without (intra-abdominal hypertension–) intra-abdominal hypertension, defined by an intra-abdominal pressure greater than or equal to 12 mm Hg (bladder pressure).

Interventions:

We measured the changes in cardiac index during passive leg raising and after volume expansion. The passive leg raising test was defined as positive if it increased cardiac index greater than or equal to 10%. Fluid responsiveness was defined by a fluid-induced increase in cardiac index greater than or equal to 15%.

Measurements and Main Results:

We included 60 patients, 30 without intra-abdominal hypertension (15 fluid responders and 15 fluid nonresponders) and 30 with intra-abdominal hypertension (21 fluid responders and nine fluid nonresponders). The intra-abdominal pressure at baseline was 4 ± 3 mm Hg in intra-abdominal hypertension– and 20 ± 6 mm Hg in intra-abdominal hypertension+ patients (p < 0.01). In intra-abdominal hypertension– patients with fluid responsiveness, cardiac index increased by 25% ± 19% during passive leg raising and by 35% ± 14% after volume expansion. The passive leg raising test was positive in 14 patients. The passive leg raising test was negative in all intra-abdominal hypertension– patients without fluid responsiveness. In intra-abdominal hypertension+ patients with fluid responsiveness, cardiac index increased by 10% ± 14% during passive leg raising (p = 0.01 vs intra-abdominal hypertension– patients) and by 32% ± 18% during volume expansion (p = 0.72 vs intra-abdominal hypertension– patients). Among these patients, the passive leg raising test was negative in 15 patients (false negatives) and positive in six patients (true positives). Among the nine intra-abdominal hypertension+ patients without fluid responsiveness, the passive leg raising test was negative in all but one patient. The area under the receiver operating characteristic curve of the passive leg raising test for detecting fluid responsiveness was 0.98 ± 0.02 (p < 0.001 vs 0.5) in intra-abdominal hypertension– patients and 0.60 ± 0.11 in intra-abdominal hypertension+ patients (p = 0.37 vs 0.5).

Conclusions:

Intra-abdominal hypertension is responsible for some false negatives to the passive leg raising test.
Mitochondrial DNA Haplogroups and Delirium During Sepsis
Authors: Samuels David C. , Hulgan Todd , Fessel Joshua P. , Billings Frederic T. , Thompson Jennifer L. , Chandrasekhar Rameela , Girard Timothy D.
Published: May 2019

Objectives:

Studies suggest that mitochondrial dysfunction underlies some forms of sepsis-induced organ failure. We sought to test the hypothesis that variations in mitochondrial DNA haplogroup affect susceptibility to sepsis-associated delirium, a common manifestation of acute brain dysfunction during sepsis.

Design:

Retrospective cohort study.

Setting:

Medical and surgical ICUs at a large tertiary care center.

Patients:

Caucasian and African American adults with sepsis.

Measurements and Main Results:

We determined each patient’s mitochondrial DNA haplogroup using single-nucleotide polymorphisms genotyping data in a DNA databank and extracted outcomes from linked electronic medical records. We then used zero-inflated negative binomial regression to analyze age-adjusted associations between mitochondrial DNA haplogroups and duration of delirium, identified using the Confusion Assessment Method for the ICU. Eight-hundred ten patients accounted for 958 sepsis admissions, with 802 (84%) by Caucasians and 156 (16%) by African Americans. In total, 795 patient admissions (83%) involved one or more days of delirium. The 7% of Caucasians belonging to mitochondrial DNA haplogroup clade IWX experienced more delirium than the 49% in haplogroup H, the most common Caucasian haplogroup (age-adjusted rate ratio for delirium 1.36; 95% CI, 1.13–1.64; p = 0.001). Alternatively, among African Americans the 24% in haplogroup L2 experienced less delirium than those in haplogroup L3, the most common African haplogroup (adjusted rate ratio for delirium 0.60; 95% CI, 0.38–0.94; p = 0.03).

Conclusions:

Variations in mitochondrial DNA are associated with development of and protection from delirium in Caucasians and African Americans during sepsis. Future studies are now required to determine whether mitochondrial DNA and mitochondrial dysfunction contribute to the pathogenesis of delirium during sepsis so that targeted treatments can be developed.
Assessing Competence in Central Venous Catheter Placement by Pediatric Critical Care Fellows: A National Survey Study*
Authors: Boyer Donald L. , Zurca Adrian D. , Mason Katherine , Mink Richard , Petrillo Toni , Schuette Jennifer , Tcharmtchi M. Hossein , Winkler Margaret , Fleming Geoffrey M. , Turner David A.
Published: May 2019

Objectives:

To describe the current approach to initial training, ongoing skill maintenance, and assessment of competence in central venous catheter placement by pediatric critical care medicine fellows, a subset of trainees in whom this skill is required.

Design:

Cross-sectional internet-based survey with deliberate sampling.

Setting:

United States pediatric critical care medicine fellowship programs.

Subjects:

Pediatric critical care medicine program directors of Accreditation Council for Graduate Medical Education-accredited fellowship programs.

Interventions:

None.

Measurements and Main Results:

A working group of the Education in Pediatric Intensive Care Investigators research collaborative conducted a national study to assess the degree of standardization of training and competence assessment of central venous catheter placement across pediatric critical care medicine fellowship programs. After piloting, the survey was sent to all program directors (n = 67) of Accreditation Council for Graduate Medical Education-accredited pediatric critical care medicine programs between July 2017 and September 2017. The response rate was 85% (57/67). Although 98% of programs provide formalized central venous catheter placement training for first-year fellows, only 42% of programs provide ongoing maintenance training as part of fellowship. Over half (55%) of programs use a global assessment tool and 33% use a checklist-based tool when evaluating fellow central venous catheter placement competence under direct supervision. Only two programs (4%) currently use an assessment tool previously published and validated by the Education in Pediatric Intensive Care group. A majority (82%) of responding program directors believe that a standardized approach to assessment of central venous catheter competency across programs is important.

Conclusions:

Despite national mandates for skill competence by many accrediting bodies, no standardized system currently exists across programs for assessing central venous catheter placement. Most pediatric critical care medicine programs use a global assessment and decisions around the ability of a fellow to place a central venous catheter under indirect supervision are largely based upon subjective assessment of performance. Further investigation is needed to determine if this finding is consistent in other specialties/subspecialties, if utilization of standardized assessment methods can improve program directors’ abilities to ensure trainee competence in central venous catheter insertion in the setting of variable training approaches, and if these findings are consistent with other procedures across critical care medicine training programs, adult and pediatric.