bluuebunny/crossref_metadata_2025 huggingface dataset:
Suppression of T Cell Autophagy Results in Decreased Viability and Function of T Cells Through Accelerated Apoptosis in a Murine Sepsis Model*
Authors: Oami Takehiko , Watanabe Eizo , Hatano Masahiko , Sunahara Satoshi , Fujimura Lisa , Sakamoto Akemi , Ito Chizuru , Toshimori Kiyotaka , Oda Shigeto
Published: September 2016

Objective:

While type 1 programmed cell death (apoptosis) of T cells leads to immunosuppression in sepsis, a crosstalk between apoptosis and autophagy (type 2 programmed cell death) has not been shown. The aim of this study is to elucidate the details of the interaction between autophagy and immunosuppression.

Design:

Laboratory investigation in the murine sepsis model.

Setting:

University laboratory.

Subjects:

Six- to 8-week-old male mice.

Interventions:

We investigated the kinetics of autophagy in T cells from spleen in a cecal ligation and puncture model with green fluorescent protein-microtubule-associated protein light chain 3 transgenic mice. We analyzed apoptosis, mitochondrial homeostasis and cytokine production in T cells, and survival rate after cecal ligation and puncture using T cell–specific autophagy-deficient mice.

Measurements and Main Results:

We observed an increase of autophagosomes, which was assessed by flow cytometry. However, an autophagy process in CD4+ T cells during sepsis was insufficient including the accumulation of p62. On the other hand, a blockade of autophagy accelerated T cell apoptosis compared with the control mice, augmenting the gene expression of Bcl-2-like 11 and programmed cell death 1. Furthermore, mitochondrial accumulation in T cells occurred via a blockade of autophagy during sepsis. In addition, interleukin-10 production in CD4+ T cells from the cecal ligation and puncture–operated knockout mice was markedly increased. Consequently, deficiency of autophagy in T cells significantly decreased the survival rate in the murine sepsis model.

Conclusions:

We demonstrated that blocking autophagy accelerated apoptosis and increased mortality in concordance with the insufficient autophagy process in CD4+ T cells in the murine sepsis model, suggesting that T cell autophagy plays a protective role against apoptosis and immunosuppression in sepsis.
Prognostic Factors for Long-Term Mortality in Critically Ill Patients Treated With Prolonged Mechanical Ventilation: A Systematic Review
Authors: Dettmer Matthew R. , Damuth Emily , Zarbiv Samson , Mitchell Jessica A. , Bartock Jason L. , Trzeciak Stephen
Published: September 2016

Objectives:

Long-term survival for patients treated with prolonged mechanical ventilation is generally poor; however, patient-level factors associated with long-term mortality are unclear. Our objective was to systematically review the biomedical literature and synthesize data for prognostic factors that predict long-term mortality in prolonged mechanical ventilation patients.

Data sources:

We searched PubMed, CINAHL, and Cochrane Library from 1988 to 2015 for studies on prolonged mechanical ventilation utilizing a comprehensive strategy without language restriction.

Study Selection:

We included studies of adults 1) receiving mechanical ventilation for more than or equal to 14 days, 2) admitted to a ventilator weaning unit, or 3) received a tracheostomy for acute respiratory failure. We analyzed articles that used a multivariate analysis to identify patient-level factors associated with long-term mortality (≥ 6 mo from when the patient met criteria for receiving prolonged mechanical ventilation).

Data Extraction:

We used a standardized data collection tool and assessed study quality with a customized Newcastle-Ottawa Scale. We abstracted the strength of association between each prognostic factor and long-term mortality. Individual prognostic factors were then designated as strong, moderate, weak, or inconclusive based on an a priori previously published schema.

Data Synthesis:

A total of 7,411 articles underwent relevance screening; 419 underwent full article review. We identified 14 articles that contained a multivariate analysis. We abstracted 19 patient-level factors that showed association with long-term mortality. Six factors demonstrated strong strength of evidence for association with the primary outcome: age, vasopressor requirement, thrombocytopenia, preexisting kidney disease, failed ventilator liberation, and acute kidney injury ± hemodialysis requirement. All factors, except preexisting kidney disease and failed ventilator liberation, were measured at the time the patients met criteria for prolonged mechanical ventilation.

Conclusions:

Despite the magnitude of the public health challenge posed by the prolonged mechanical ventilation population, only 14 articles in the biomedical literature have tested patient-level factors associated with long-term mortality. Further research is needed to inform optimal patient selection for prolonged mechanical ventilation.
Relative Bradycardia in Patients With Septic Shock Requiring Vasopressor Therapy
Authors: Beesley Sarah J. , Wilson Emily L. , Lanspa Michael J. , Grissom Colin K. , Shahul Sajid , Talmor Daniel , Brown Samuel M.
Published: September 2016

Objectives:

Tachycardia is common in septic shock, but many patients with septic shock are relatively bradycardic. The prevalence, determinants, and implications of relative bradycardia (heart rate, < 80 beats/min) in septic shock are unknown. To determine mortality associated with patients who are relatively bradycardic while in septic shock.

Design:

Retrospective study of patients admitted for septic shock to study ICUs during 2005–2013.

Setting:

One large academic referral hospital and two community hospitals.

Patients:

Adult patients with septic shock requiring vasopressors.

Intervention:

None.

Measurements:

Primary outcome was 28-day mortality. We used multivariate logistic regression to evaluate the association between relative bradycardia and mortality, controlling for confounding with inverse probability treatment weighting using a propensity score.

Results:

We identified 1,554 patients with septic shock, of whom 686 (44%) met criteria for relative bradycardia at some time. Twenty-eight-day mortality in this group was 21% compared to 34% in the never-bradycardic group (p< 0.001). Relatively bradycardic patients were older (65 vs 60 yr;p< 0.001) and had slightly lower illness severity (Sequential Organ Failure Assessment, 10 vs 11;p= 0.004; and Acute Physiology and Chronic Health Evaluation II, 27 vs 28;p= 0.008). After inverse probability treatment weighting, covariates were balanced, and the association between relative bradycardia and survival persisted (p< 0.001).

Conclusions:

Relative bradycardia in patients with septic shock is associated with lower mortality, even after adjustment for confounding. Our data support expanded investigation into whether inducing relative bradycardia will benefit patients with septic shock.
Long-Term Outcomes After ICU Admission Triage in Octogenarians
Authors: Andersen Finn H. , Flaatten Hans , Klepstad Pål , Follestad Turid , Strand Kristian , Krüger Andreas J. , Hahn Michael , Buskop Christian , Rime Anne-Karin , Kvåle Reidar
Published: September 2016

Objective:

To describe ICU admission triage and outcomes in octogenarians.

Design:

Multicenter prospective observational study.

Setting:

Three nonuniversity hospitals and three university hospitals in Norway.

Patients:

Patients 80 years old or older who were referred for ICU admission from November 2013 to October 2014.

Interventions:

None.

Measurements and Main Results:

Of the 355 included patients, 105 (29.6%) were refused ICU treatment. Risk factors for ICU refusal in patients considered “too ill/old” were advanced age and low functional status. Risk factors for ICU refusal in patients considered “too well” were advanced age, male sex, university hospital admission, comorbidity, and low Simplified Acute Physiology Score 3. Overall ICU survival was 71.6%. Hospital and 1-year survival were 56.0% and 40.0% in the ICU-admitted, 65.2% and 50.0% in the nonadmitted patients considered too well, and 32.7% and 11.5% in patients considered too ill/old, respectively. The adjusted Kaplan-Meier curves showed significantly lower survival for nonadmitted patients considered too ill/old than for ICU-admitted patients and nonadmitted patients considered too well. At follow-up, triage patients had lower health-related quality of life than an age- and sex-matched control group in the domains of self-care, usual care, and anxiety and depression, and a lower EuroQol visual analog scale scores.

Conclusions:

Overall, 29.6% of the patients were refused ICU treatment. The adjusted survival analyses showed a significantly higher survival for ICU-admitted octogenarians than for nonadmitted patients who were considered too ill/old, indicating a benefit of ICU admission. Overall, the follow-up of triage patients showed lower health-related quality of life than an age- and sex-matched control population.
Improving ICU-Based Palliative Care Delivery: A Multicenter, Multidisciplinary Survey of Critical Care Clinician Attitudes and Beliefs
Authors: Wysham Nicholas G. , Hua May , Hough Catherine L. , Gundel Stephanie , Docherty Sharron L. , Jones Derek M. , Reagan Owen , Goucher Haley , Mcfarlin Jessica , Cox Christopher E.
Published: September 2016

Objective:

Addressing the quality gap in ICU-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment.

Design:

Mixed-methods study.

Setting:

Medical and surgical ICUs at three large academic hospitals.

Participants:

Three hundred three nurses, intensivists, and advanced practice providers.

Measurements and Main Results:

Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts (triggers) for specialist consultation. Most (n = 225; 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n = 123; 41%); only 17 of them (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team–family relationships.

Conclusions:

Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting.
The RAD51C exonic splice-site mutations c.404G>C and c.404G>T are associated with familial breast and ovarian cancer
Authors: Neidhardt Guido , Becker Alexandra , Hauke Jan , Horváth Judit , Bogdanova Markov Nadja , Heilmann-Heimbach Stefanie , Hellebrand Heide , Thiele Holger , Altmüller Janine , Nürnberg Peter , Meindl Alfons , Rhiem Kerstin , Blümcke Britta , Wappenschmidt Barbara , Schmutzler Rita K. , Hahnen Eric
Published: September 2016

Whereas RAD51C mutations increase the relative risk for ovarian cancer (OC) to 5.88 (95% confidence interval=2.91–11.88, P=7.65×10–7), the associated risks for breast cancer (BC) remain largely unknown, as deleterious RAD51C alterations are extremely rare in BC-only families. Here, we report the results of a RAD51C mutational screening in a large series of German familial index patients negative for pathogenic BRCA1/2 mutations and the in-vitro characterization of two novel exonic RAD51C splice-site mutations. A total of 610 index cases derived from BC/OC (n=587) or OC-only families (n=23) were screened for potentially deleterious germline mutations in RAD51C. The frequencies of two splice-site mutations were assessed by single-nucleotide polymorphism genotyping in 1410 additional cases not enriched for OC family history. In three independent families, we identified novel splice-site mutations affecting the last nucleotide of exon 2 (c.404G>C, c.404G>T). Both mutations disrupt proper RAD51C pre-mRNA processing and cause a missense substitution immediately followed by a stop codon (p.Cys135Serfs*2; p.Cys135Leufs*2). Even though both mutations have similar effects on the protein level, they are associated with either BC/OC, OC-only, or BC-only family histories. The rare finding of a clearly truncating RAD51C mutation in an early-onset BC patient with a BC-only family history supports the notion that compromised RAD51C function may result in both BC and OC. Large international collaborative studies are needed to quantify the relative risk of RAD51C alterations for BC and to unravel the genetic modifying factors that determine phenotypic variability with respect to cancer site.
Design and Development of a Proactive Rapid Response System
Authors: Heal Michelle , Silvest-Guerrero Sarah , Kohtz Cindy
Published: September 2016

Timely identification of patient deterioration can prompt intervention and prevent the escalation of care and unplanned intensive care admissions. However, both personal experience and professional literature reveals that staff nurses in the acute care setting may not notice subtle signs of patient deterioration or may be reluctant to activate the rapid response system. To overcome these barriers, a proactive rapid response system with early warning signs was created and studied. Using a quasi-experimental design, data were collected from two medical-surgical nursing units at one large tertiary medical center over a 6-month period. One unit used the new rapid response system and early warning sign criteria with real-time data entry and trigger activation. A second unit served as the control and relied on the nurse for rapid response system activation. Findings revealed that the use of the newly developed rapid response system demonstrated significantly greater sensitivity to subtle signs of patient deterioration and prompted early evaluation and intervention.
Nurses' Satisfaction With Using Nursing Information Systems From Technology Acceptance Model and Information Systems Success Model Perspectives
Authors: Lin Hsien-Cheng
Published: September 2016

Nursing information systems can enhance nursing practice and the efficiency and quality of administrative affairs within the nursing department and thus have been widely considered for implementation. Close alignment of human-computer interaction can advance optimal clinical performance with the use of information systems. However, a lack of introduction of the concept of alignment between users' perceptions and technological functionality has caused dissatisfaction, as shown in the existing literature. This study provides insight into the alignment between nurses' perceptions and how technological functionality affects their satisfaction with Nursing Information System use through a reductionist perspective of alignment. This cross-sectional study collected data from 531 registered nurses in Taiwan. The results indicated that “perceived usefulness in system quality alignment,” “perceived usefulness in information quality alignment,” “perceived ease of use in system quality alignment,” “perceived ease of use in information quality alignment,” and “perceived ease of use in service quality alignment” have significantly affected nurses' satisfaction with Nursing Information System use. However, “perceived usefulness in service quality alignment” had no significant effect on nurses' satisfaction. This study also provides some meaningful implications for theoretical and practical aspects of design.
Autologous Fat Transfer for Breast Augmentation: A Review
Authors: Al Sufyani Mohammed A. , Al Hargan Abdullah H. , Al Shammari Nayf A. , Al Sufyani Mohannad A.
Published: September 2016

BACKGROUND

The use of autologous fat transfer for breast augmentation is still controversial due to ongoing concerns regarding its efficacy and safety, most notably, concerns about breast cancer risk and detection.

OBJECTIVE

To summarize the current knowledge on the safety and efficacy of autologous fat transfer for breast augmentation with focus on clinical techniques, outcome, and complications.

METHODS

A thorough search of the literature was conducted using the terms autologous fat transfer, autologous fat grafting, and breast augmentation in the Medline and Embase databases, and relevant English and German language articles were included.

RESULTS

Findings were categorized in a step-by-step approach to the fat grafting procedure divided into technique (harvesting, processing, and injection), postoperative care, graft viability enhancement, outcome, complications, and breast cancer risk.

CONCLUSION

Autologous fat transfer for breast augmentation is not yet standardized. Therefore, outcomes vary widely depending on the surgeon's expertise. The majority of reported complications are of low morbidity, and based on available data, the procedure has a good long-term safety profile. Although there is no evidence that fat grafting increases breast malignancy risk, long-term follow-up is required.
The Efficacy of Massage in Reducing Nodule Formation After Poly-l-Lactic Acid Administration for Facial Volume Loss: A Randomized, Evaluator-Blinded Clinical Trial
Authors: Wu Douglas C. , Goldman Mitchel P.
Published: September 2016

BACKGROUND

The risk of nodule formation following poly-l-lactic acid (PLLA) injections for facial volume loss is well known. Traditionally, post-treatment massage according to the 5-5-5 rule (5 times per day for 5 minutes for 5 days) has been applied to mitigate this risk. However, such a regimen may be onerous for patient compliance. Using currently accepted injection technique and product dilution, the efficacy of massage for nodule prevention has never been formally evaluated.

OBJECTIVE

To evaluate the efficacy of massage in reducing the incidence of nodule formation post-PLLA injection.

MATERIALS AND METHODS

After obtaining informed consent, 20 subjects with facial lipoatrophy were enrolled in this randomized, evaluator-blinded clinical trial. Each subject was treated with 1 vial of PLLA each month for 3 months. Vials were diluted with 1 mL of 1% lidocaine and 7 ml of bacteriostatic water, shaken with a vortex and refrigerated for 24 to 48 hours before injection. Ten subjects were instructed to massage the treated areas according to the 5-5-5 rule and 10 subjects did not perform any massage post-treatment. Six-month follow-up data were collected for treatment efficacy and adverse events.

RESULTS

No nodules were reported by subjects or detected by the blinded evaluator regardless of massage status. Significant improvements in facial lipoatrophy were detected 1, 3, and 6 months after the final treatment session and were not statistically different between the 2 groups.

CONCLUSION

Using currently recommended guidelines for product preparation and injection, the application of massage post-PLLA facial treatment does not have a significant impact on nodule formation or treatment efficacy.
Is There Inequity in Hospital Care Among Patients With Acute Coronary Syndrome Who Are Proficient and Not Proficient in English Language?
Authors: Hyun Karice K. , Redfern Julie , Woodward Mark , Briffa Tom , Chew Derek P. , Ellis Chris , French John , Astley Carolyn , Gamble Greg , Nallaiah Kellie , Howell Tegwen , Lintern Karen , Clark Robyn , Wechkunanukul Kannikar , Brieger David
Published: September 2016

Background:

The provision of equitable acute coronary syndrome (ACS) care in Australia and New Zealand requires an understanding of the sources of variation in the provision of this care.

Objective:

The aim of this study was to compare the variation in care and outcomes between ACS patients with limited English proficiency (LEP) and English proficiency (EP) admitted to Australian and NZ hospitals.

Methods:

Data were collected from 4387 suspected/confirmed ACS patients from 286 hospitals between May 14 and 27, 2012, who were followed for 18 months. We compared hospital care and outcomes according to the proficiency of English using logistic regressions.

Results:

The 294 LEP patients were older (70.9 vs 66.3 years; P < .001) and had higher prevalence of hypertension (71.1% vs 62.8%; P = .004), diabetes (40.5% vs 24.3%; P < .001), and renal impairment (16.3% vs 11.1%; P = .007) compared with the 4093 EP patients. Once in hospital, there was no difference in receipt of percutaneous coronary intervention (57.0% vs 55.4%; P = .78) or coronary artery bypass graft surgery (10.5% vs 11.5%; P = .98). After adjustment for medical history, there were no significant differences (P > .05) between the 2 groups in the risk of major adverse cardiovascular events and/or all-cause death during the index admission and from index admission to 18 months.

Conclusions:

These results suggest that LEP patients admitted to Australian or New Zealand hospitals with suspected ACS may not experience inequity in hospital care and outcomes.
Psychometrics of the Zarit Burden Interview in Caregivers of Patients With Heart Failure
Authors: Al-Rawashdeh Sami Y. , Lennie Terry A. , Chung Misook L.
Published: September 2016

Background:

Identification of family caregivers who are burdened by the caregiving experience is vital to prevention of poor outcomes associated with caregiving. The Zarit Burden Interview (ZBI), a well-known measure of caregiving burden in caregivers of patients with dementia, has been used without being validated in caregivers of patients with heart failure (HF).

Purpose:

The purpose of this study is to examine the reliability and validity of the ZBI in caregivers of patients with HF.

Methods:

A total of 124 primary caregivers of patients with HF completed survey questionnaires. Caregiving burden was measured by the ZBI. Reliability was examined using Cronbach’s α and item-total/item-item correlations. Convergent validity was examined using correlations with the Oberst Caregiving Burden Scale. Construct validity was demonstrated by exploratory factor analysis and known hypothesis testing (ie, the hypothesis of the association between caregiving burden and depressive symptoms).

Results:

Cronbach’s α for the ZBI was .921. The ZBI had good item-total (r = 0.395–0.764) and item-item (mean r = 0.365) correlations. Significant correlations between the ZBI and the Oberst Caregiving Burden Scale (r = 0.466 for the caregiving time subscale and 0.583 for the caregiving task difficulty subscale; P < .001 for both) supported convergent validity. Four factors were identified (ie, consequences of caregiving, patient’s dependence, exhaustion with caregiving and uncertainty, and guilt and fear for the patient’s future) using factor analysis, which are consistent with previous studies. Caregivers with high burden scores had significantly higher depressive symptoms than did caregivers with lower burden scores (7.0 ± 6.8 vs 3.1 ± 4.3; P < .01).

Conclusion:

The findings provide evidence that the ZBI is a reliable and valid measure for assessing burden in caregivers of patients with HF.
Perceptions and Acceptability of Receiving SMS Self-care Messages in Chinese Patients With Heart Failure
Authors: Li Xiao , Chen Chen , Qu Mo-Ying , Li Zhi , Xu Ying , Duan Xue-Fei , Chen Xi , Zhang Qing , You Gui-Ying
Published: September 2016

Background:

Self-care is critical for postdischarge heart failure (HF) patients. Short message service (SMS) is a promising way to promote HF self-care.

Objective:

The aim of this study is to investigate knowledge status in Chinese HF patients, as well as the acceptance of SMS as a way to improve self-care.

Methods:

A survey using a self-developed questionnaire was conducted in patients with decompensated HF 2 days before discharge.

Results:

A total of 540 patients completed the survey. Among them, only 69.8% and 63.3% of patients were aware of their HF status and medication regimen, respectively. A total of 95.6% patients were willing to receive SMS. Patient himself/herself, caregiver, or both patient and caregiver were almost equally selected as the preferred receiver of SMS. Educational and/or reminder SMS was considered “very helpful” by 50.2% of the patients as a way of promoting self-care, similar to that of telephone education and brochure education. “Take your medicine”, “avoid getting flu,” and “keep follow-up” were regarded as the most important self-care contents, whereas “weigh yourself every day” and “restrict fluid intake” were considered the least important.

Conclusion:

As a way of promoting HF self-care, SMS intervention combining educational and reminder function might be well accepted by HF patients in China. The status of HF, medication, weight control, and fluid restriction should be emphasized during the practice. Caution should be drawn as the survey was not tested elsewhere. Further clinical trials would be conducted to examine the effect of SMS intervention on self-care behaviors and outcomes of HF patients.
Underreporting of Concussions and Concussion-Like Symptoms in Female High School Athletes
Authors: McDonald Tracy , Burghart Mark A. , Nazir Niaman
Published: September 2016

Underreporting of concussions and concussion-like symptoms in athletes continues to be a serious medical concern and research focus. Despite mounting worry, little evidence exists examining incidence of underreporting and documenting characteristics of head injury in female athletes participating in high school sports. This study examined the self-reporting behaviors of female high school athletes. Seventy-seven athletes participated, representing 14 high school sports. Nearly half of the athletes (31 participants) reported a suspected concussion, with 10 of the 31 athletes refraining from reporting symptoms to training staff after injury. Only 66% reported receiving concussion education. Concussion education appeared to have no relationship with diagnosed concussion rates in athletes, removing athletes from play, or follow-up medical care after injury. In conclusion, female high school athletes underreport signs and symptoms of concussions. Concussion education should occur at higher rates among female athletes to influence reporting behaviors.
Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010–2013
Authors: Blackman Virginia Schmied , Cooper Bruce A. , Puntillo Kathleen , Franck Linda S.
Published: September 2016

Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.

Pain scores were documented in 60.5% (n= 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60–100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).

Pain severity scores ranged from 0 to 10; mean = 5.5 (SD= 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.

Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.
Utility of Repeat Head Computed Tomography for Intracranial Hemorrhage After Trauma and Importance of Direct Patient Care
Authors: Zimmermann Mary Ellen , Brown Zachary , Matemavi Praise , Melnic Gloria , Sample Jason
Published: September 2016

At many institutions, it is common practice for trauma patients with traumatic intracranial hemorrhage (ICH) to receive routine repeat head computed tomographic (CT) scans after the initial CT scan, regardless of symptoms, to evaluate progression of the injury. The purpose of this study was to assess quantifiable risk factors (age, anticoagulation, gender) that could place patients at greater risk for progression of injury, thus requiring surgical intervention (craniotomy, craniectomy) for which serial CT scanning would be useful. From January 2014 to June 2015, a total of 211 patients presented with traumatic ICH and 198 were eligible for inclusion. Twenty-six patients required operative intervention for ICH. One of 26 patients went to the operating room as a result of repeat head CT scans without associated mental status change, change in neurological examination, or associated symptoms such as nausea or vomiting. Significant changes in patient management due to routine repeat CT scans were not observed. There were no statistically significant risk factors identified to place patients at higher risk for progression of disease. The data from this analysis emphasized the importance of nursing care in identifying and relaying changes in patient condition to the trauma team.
Risk Factors for Complications of Traumatic Injuries
Authors: de Aguiar Júnior Wagner , Saleh Carmen Mohamad Rida , Whitaker Iveth Yamaguchi
Published: September 2016

Complications in hospitalized trauma patients are major causes of morbidity and mortality. The aims of this study were to identify the in-hospital trauma patients' complications and identify the risk factors for complications in this population. A retrospective analysis was conducted in a sample from a Brazilian hospital. The sample consisted of 407 patients, 194 (47.66%) of whom had records of complications. The most common complications were infections (41.80%). The risk factors related to the complications were age, length of hospital stay, external causes, and injury severity. The complications were frequent in this sample, and the risk for complications was characterized by multiple factors.
Progressive Mobility Protocol Reduces Venous Thromboembolism Rate in Trauma Intensive Care Patients: A Quality Improvement Project
Authors: Booth Kathryn , Rivet Josh , Flici Richelle , Harvey Ellen , Hamill Mark , Hundley Douglas , Holland Katelyn , Hubbard Sandra , Trivedi Apurva , Collier Bryan
Published: September 2016

The intensive care unit (ICU) trauma population is at high risk for complications associated with immobility. The purpose of this project was to compare ICU trauma patient outcomes before and after implementation of a structured progressive mobility (PM) protocol. Outcomes included hospital and ICU stays, ventilator days, falls, respiratory failure, pneumonia, or venous thromboembolism (VTE). In the preintervention cohort, physical therapy (PT) consults were placed 53% of the time. This rose to more than 90% during the postintervention period. PT consults seen within 24 hr rose from a baseline 23% pre- to 74%–94% in the 2 highest compliance postintervention months. On average, 40% of patients were daily determined to be too unstable for mobility per protocol guidelines—most often owing to elevated intracranial pressure. During PM sessions, there were no adverse events (i.e., extubation, hypoxia, fall). There were no significant differences in clinical outcomes between the 2 cohorts regarding hospital and ICU stays, average ventilator days, mortality, falls, respiratory failure, or pneumonia overall or within ventilated patients specifically. There was, however, a difference in the incidence of VTE between the preintervention cohort (21%) and postintervention cohort (7.5%) (p = .0004). A PM protocol for ICU trauma patients is safe and may reduce patient deconditioning and VTE complications in this high-risk population. Multidisciplinary commitment, daily protocol reinforcement, and active engagement of patients/families are the cornerstones to success in this ICU PM program.
One Rural Hospital's Experience Implementing the Society for Healthcare Epidemiology of America Guidelines to Decrease Central Line Infections
Authors: Curlej Maria H. , Katrancha Elizabeth
Published: September 2016

In an effort to take advantage of the Highmark Quality Blue Initiative (N. D. Bastian, H. Kang, H. B. Nembhard, A. Bloschichak, P. M. Griffin, 2016) requiring information from hospitals detailing their central line-associated blood stream infections (CLABSIs) surveillance system, quality improvement program, and statistics regarding the CLABSI events, this institution investigated the latest evidence-based recommendations to reduce CLABSIs. Recognizing the baseline rate of 2.4 CLABSIs per 1,000 central line days and its effect on patient outcomes and medical costs, this hospital made a commitment to improve their CLABSI outcomes. As a result, the facility adopted the Society for Healthcare Epidemiology of America (SHEA) guidelines. The purpose of this article is to review the CLABSI rates and examine the prevention strategies following implementation of the SHEA guidelines. A quantitative, descriptive retrospective program evaluation examined the hospital's pre- and post-SHEA implementation methods of decreasing CLABSIs and the subsequent CLABSI rates over 3 time periods. Any patient with a CLABSI infection admitted to this hospital July 2007 to June 2010 (N = 78). CLABSI rates decreased from 1.9 to 1.3 over the study period. Compliance with specific SHEA guidelines was evaluated and measures were put into place to increase compliance where necessary. CLABSI rates at this facility remain below the baseline of 2.4 for calendar year 2013 (0.79), 2014 (0.07), and 2015 (0.33).
Implementation and Evaluation of a Team Simulation Training Program
Authors: Rice Yvonne , DeLetter Mary , Fryman Lisa , Parrish Evelyn , Velotta Cathie , Talley Cynthia
Published: September 2016

Background:

Care of the trauma patient requires a well-coordinated intensive effort during the golden hour to optimize survival.

Purpose:

We hypothesized that this program would improve knowledge, satisfaction, self-confidence, and simulated team performance.

Methods:

A pre-, post-test design with N = 7 BSN nurses, 21 years of age, less than 2 years of intensive care unit and nursing experience.

Setting:

Trauma intensive care unit, single-center academic Level 1 trauma center.

Results:

Improvement was shown in perception of team structure (paired t test 13.71–12.57; p = .0001) and communication (paired t test 14.85–12.14; p = .009). Improvement was shown in observed situation monitoring (paired t test 17.42–25.28; p = .000), mutual support (paired t test 12.57–18.57; p = .000), and communication (paired t test 15.42–25.00; p = .001). A decrease was shown in attitudes of mutual support (paired t test 25.85–19.71; p = .04) and communication (paired t test 26.14–23.00; p = .001). Mean satisfaction scores were 21.5 of a possible 25 points. Mean self-confidence scores were 38.83 out of a possible 40 points.

Discussion:

Simulation-based team training improved teamwork attitudes, perceptions, and performance. Team communication demonstrated significant improvement in 2 of the 3 instruments. Most participants agreed or strongly agreed that they were satisfied with simulation and had gained self-confidence.
Intractable Pneumothorax Treated With Endobronchial Watanabe Spigots
Authors: Okui Masayuki , Kohno Mitsutomo , Hasegawa Naoki , Kamiyama Ikuo , Ohtsuka Takashi
Published: September 2016

Pneumothorax secondary to nontuberculous mycobacterial lung disease is often intractable and associated with high mortality. An endobronchial Watanabe spigot (EWS) is a silicon plug developed for bronchoscopic bronchial occlusion. Here we report a case of intractable pneumothorax secondary to nontuberculous mycobacterial lung disease successfully treated using EWSs. Occlusion of the multiple ectatic bronchi connected to the bronchopleural fistula was essential for optimal effect of the EWSs.
Congestive Adenopathy
Authors: Shweihat Yousef R. , Perry James , Etman Yasser , Gabi Ala , Hattab Yousef , Al-Ourani Mohammad , Santhanam Prasanna , Bartter Thaddeus
Published: September 2016

Background:

Endosonography has improved our ability to reach thoracic lymph nodes and to diagnose pathologic conditions with nodal involvement and has lowered the threshold for biopsy. The purpose of this study was to avoid unnecessary procedures, it is important to recognize benign adenopathy. Congestive heart failure (CHF) is both common and a common cause of adenopathy. The purpose of this study was to study the association between CHF and adenopathy and to describe the typical presentation of congestive adenopathy.

Methods:

We performed a retrospective correlation of computed tomographic (CT) and laboratory findings for patients admitted to hospital with a diagnosis of CHF.

Results:

Of 500 patients admitted with a diagnosis of CHF, 215 appeared to have CT scans of the chest, and not to have a potentially confounding etiology of adenopathy. The incidence of adenopathy in this study group was 68%. Pulmonary edema on CT and pleural effusion were both significantly associated with adenopathy (P<0.01 for both). The pattern of congestive adenopathy was one of enlargement of several mediastinal nodes and less likely to involve hilar nodes and single stations in isolation.

Conclusion:

Congestive adenopathy is common in patients with evidence for acute volume overload. The pattern of presentation should allow clinicians to recognize congestive adenopathy and to separate it from other adenopathy for which biopsy might be appropriate.
Diagnostic Yield of Electromagnetic Navigation Bronchoscopy Using a Curved-tip Catheter to Aid in the Diagnosis of Pulmonary Lesions
Authors: Mukherjee Sumit , Chacey Michael
Published: September 2016

Background:

Electromagnetic navigation bronchoscopy (ENB) may aid in the diagnosis of solitary pulmonary lesions with a lower complication rate than conventional diagnostic modalities. A curved-tip catheter is now available for use with ENB; however, the diagnostic yield of this device has not been previously reported.

Methods:

A single-center, single-operator retrospective chart review was performed on patients who underwent ENB for the diagnosis of pulmonary lesions. A curved-tip catheter was used in all procedures; angle options were chosen depending on lesion location. After navigation to the target lesion, fine-needle aspiration, brushings, biopsies, and bronchoalveolar lavage were performed in all patients. Correct localization was confirmed with fluoroscopy.

Results:

Thirty-one consecutive patients underwent ENB between February and October 2014. The mean lesion size was 1.8 cm (range, 0.4 to 4.0 cm) and 35% were in the right upper lobe. The probe tip was navigated to the target lesion in all cases. A diagnosis was obtained in 30/31 patients (96.8%). Twenty-two (71%) had a definitive histologic diagnosis of malignancy. One case was nondiagnostic requiring a repeat fine-needle aspiration. The remaining 8 nonmalignant cases were followed radiologically and demonstrated no progression of lesion size through at least 1 year. Fiducials were placed in 48% of cases. There were 2 pneumothoraces (6.5%), one of which required chest tube placement (3.2%).

Conclusions:

This study suggests that the curved-tip catheter is a useful modality for diagnosing peripheral pulmonary lesions with ENB. The diagnostic yield of ENB using this catheter was superior to that reported in other studies utilizing straight catheters.
Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma: age is not a problem
Authors: Ziogas Dimitrios C. , Papadatos-Pastos Dionysios , Thillai Kiruthikah , Korantzis Ippokratis , Chowdhury Ruhe , Suddle Abid , O’Grady John , Al-Khadimi Gillian , Allen Natalie , Heaton Nigel , Ross Paul J. , Sarker Debashis
Published: September 2016

Objective

Sorafenib is the standard of care for patients with advanced hepatocellular carcinoma (HCC), but data on its use in the elderly are inconclusive.

Methods

All consecutive HCC patients who were treated in our institution with sorafenib since its licensing were included in the analysis. Patients were divided into two groups: (A) up to 75 and (B) older than 75 years old. Our endpoints were overall survival (OS) and time to treatment failure (TTF) because of disease progression or toxicity. Safety parameters and the prognostic effect of HCC characteristics were also investigated.

Results

Data from 190 patients (157 men), median age 66 (26–87) years, were studied (A=151 and B=39). No significant difference in OS and TTF was detected between the two groups [7.1 (5.5–8.7) vs. 10.4 (6.5–14.3) months, P=0.360 and 4.2 (2.3–6.2) vs. 5.6 (3.1–8.1) months, P=0.369, respectively]. Incidence of toxicities at all grades and dose reductions were comparable between groups A and B. In a multivariate setting, patients with Child–Pugh B score at baseline were associated with a higher risk of death (adjusted hazard ratio=2.17, 95% confidence interval:1.24–3.79, P=0.007) and treatment failure (adjusted hazard ratio=4.64, 95% confidence interval: 2.55–8.42, P=0.001) and had shorter OS and TTF compared with patients with a Child–Pugh A (P=0.004 and P<0.001, respectively).

Conclusion

Elderly patients with advanced HCC, when treated with sorafenib, have an equivalent clinical outcome with similar toxicity rates as their younger counterparts. Age alone should not be a discriminating factor for the management of advanced HCC with sorafenib.
Improving Discharge Instructions in a Pediatric Emergency Department
Authors: Akinsola Bolanle , Cheng John , Zmitrovich April , Khan Naghma , Jain Shabnam
Published: September 2016

Background

Effective communication between physician and patient is essential to optimize care after discharge from the emergency department (ED). Written discharge care instructions (DCI) complement verbal instructions and have been shown to improve communication and patient management. In 2012, Centers for Medicare and Medicaid Services proposed a quality measure (OP-19) that assesses compliance with key elements considered essential for high-quality written DCI.

Objective

To evaluate the impact of a QI intervention on improving quality of written DCI in a pediatric emergency department (PED).

Methods

A QI initiative was conducted at a tertiary PED with greater than 60,000 annual visits. Based on Centers for Medicare and Medicaid Services OP-19 measure and group consensus, 8 elements were defined a priori as requisites for good quality DCI. These elements are:

Providers reviewed a random sample of DCI of patients. Proportion of DCI that had each element documented was compared between preintervention phase (PRE) and postintervention phase (POST).

Results

Three hundred twenty-nine DCI (PRE) and 1434 DCI (POST) were reviewed. The POST DCI showed statistically significant improvement for each of the 8 elements. The bundle measure (proportion containing all 8 elements) increased from 23% (PRE) to 79% (POST) (P < 0.001).

Conclusions

The ED DCI improved in all 8 elements after a QI intervention. A detailed DCI at ED discharge enhances the patient's ability to comply with postdischarge treatment plan. Further studies are needed to evaluate the impact of improving DCI on ED return rates and other outcomes.
Epidemiology of Pediatric Traumatic Brain Injury in a Dense Urban Area Served by a Helicopter Trauma Service
Authors: Hill Ciaran S. , McLean Aaron L. , Wilson Mark H.
Published: September 2016

Objective

Pediatric traumatic brain injury is the most common cause of death and a major cause of morbidity in children and young adults worldwide. Despite this, our understanding of epidemiological factors relating to this type of injury is incomplete. The objective of this study was to explore a variety of factors relating to these injuries including mechanism, timing of emergency response, prehospital management, radiological diagnosis, neurosurgical care, and final outcomes.

Methods

A retrospective review of all pediatric traumas attending a single large, densely populated urban area within a 2-year period was undertaken, and all cases with significant pediatric traumatic brain injury, as defined by a computed tomography scan showing an intracranial injury, were included for further analysis. Various epidemiological and treatment factors were explored.

Results

One hundred sixteen patients fulfilled the inclusion criteria, and their injuries and management were explored further. A variety of key trends were identified. The most common mechanism of injury was pedestrian struck by car followed by falls from height. Males were injured 5 times more frequently than girls. A helicopter emergency trauma team attended 22% of the patients and intubated 11 in total. The most common intracranial injuries were skull fractures followed by contusions. Nineteen neurosurgical interventions were undertaken. Overall mortality in all patients was 8%.

Conclusions

An improved understanding of the epidemiology of pediatric brain injury will provide baselines for future outcome measurement and comparative analysis. This may improve service organization and delivery.
A National Analysis of Pediatric Trauma Care Utilization and Outcomes in the United States
Authors: Myers Sage R. , Branas Charles C. , French Benjamin , Nance Michael L. , Carr Brendan G.
Published: September 2016

Objectives

More childhood deaths are attributed to trauma than all other causes combined. Our objectives were to provide the first national description of the proportion of injured children treated at pediatric trauma centers (TCs), and to provide clarity to the presumed benefit of pediatric TC verification by comparing injury mortality across hospital types.

Methods

We performed a population-based cohort study using the 2006 Healthcare Cost and Utilization Project Kids Inpatient Database combined with national TC inventories. We included pediatric discharges (≤16 y) with the International Classification of Diseases, Ninth Revision code(s) for injury. Descriptive analyses were performed evaluating proportions of injured children cared for by TC level. Multivariable logistic regression models were used to estimate differences in in-hospital mortality by TC type (among level-1 TCs only). Analyses were survey-weighted using Healthcare Cost and Utilization Project sampling weights.

Results

Of 153,380 injured children, 22.3% were admitted to pediatric TCs, 45.2% to general TCs, and 32.6% to non-TCs. Overall mortality was 0.9%. Among level-1 TCs, raw mortality was 1.0% pediatric TC, 1.4% dual TC, and 2.1% general TC. In adjusted analyses, treatment at level-1 pediatric TCs was associated with a significant mortality decrease compared to level-1 general TCs (adjusted odds ratio, 0.6; 95% confidence intervals, 0.4–0.9).

Conclusions

Our results provide the first national evidence that treatment at verified pediatric TCs may improve outcomes, supporting a survival benefit with pediatric trauma verification. Given lack of similar survival advantage found for level-1 dual TCs (both general/pediatric verified), we highlight the need for further investigation to understand factors responsible for the survival advantage at pediatric-only TCs, refine pediatric accreditation guidelines, and disseminate best practices.