bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of psoriasis severity on patient-reported clinical symptoms, health-related quality of life and work productivity among US patients: real-world data from the Corrona Psoriasis Registry
Authors: Strober Bruce , Greenberg Jeffrey D , Karki Chitra , Mason Marc , Guo Ning , Hur Peter , Zhao Yang , Herrera Vivian , Lin Feng , Lebwohl Mark
Published: April 2019

Objectives

This analysis examined the association between psoriasis severity, assessed by body surface area (BSA) and the Investigator’s Global Assessment (IGA; previously used only in clinical trials), and patient-reported outcomes (PROs) in a real-world setting.

Design

Cross-sectional analysis within the Corrona Psoriasis Registry, an independent, prospective registry.

Setting

70 dermatology practices in the USA.

Participants

1529 adult patients with psoriasis being treated with biological or non-biological systemic psoriasis treatment by 31 May 2016.

Primary and secondary outcome measures

Psoriasis severity was assessed by percentage of affected BSA (mild (0%–5%), moderate (>5%–10%), severe (>10%–15%), very severe (>15%)) and IGA scores (clear/almost clear (0–1), mild (2), moderate (3), severe (4)). PROs (pain, itch, fatigue; Dermatology Life Quality Index [DLQI]; EuroQoL Visual Analogue Scale [EQ-VAS]; Work Productivity and Activity Impairment [WPAI]) were compared across BSA and IGA levels using analysis of variance and X2tests. The association between psoriasis severity and PROs was examined using multivariable regression models.

Results

The mean age was 50.6 years and 47% of patients were female. Consistently with more severe psoriasis, symptoms worsened, DLQI scores increased (p<0.05 for each level of BSA and IGA), EQ-VAS decreased (p<0.05 for each level of BSA and IGA) and WPAI scores increased. By BSA score, moderate to very severe psoriasis was associated with poorer outcomes for the ‘impairment while working’ and ‘daily activities impaired’ WPAI domains (all p<0.05 vs mild psoriasis). Very severe psoriasis was associated with increased ‘work hours missed’ and ‘work hours affected’ (both p<0.05 vs mild psoriasis) Findings were similar by IGA. Results were confirmed by multivariable regression analyses.

Conclusions

In a real-world setting, more severe psoriasis, assessed by BSA and IGA, was consistently associated with worse PROs.
Fit for purpose? OrganisationaL prOdUctivity and woRkforce wellbeIng in workSpaces in Hospital (FLOURISH): a multimethod qualitative study protocol
Authors: Rapport Frances , Auton Emilie , Cartmill John , Braithwaite Jeffrey , Shih Patti , Hogden Anne , Clay-Williams Robyn
Published: April 2019

Introduction

Workspaces are socially constructed environments where social relationships are produced, reproduced, challenged and transformed. Their primary function is to support high-quality service delivery to the benefit of ‘patients’. They are also settings where employees can work effectively, in a safe and healthy environment, delivering a high-quality service according to a ‘Work-As-Done’ rather than a ‘Work-As-Imagined’ model. However, hospital design is currently based on a managerial understanding of work accomplishments, often falling short of understanding what is actually happening on the ground. Furthermore, the research landscape lacks rigorous assessment of these complex sociological and health research concepts, either within the Australian context where this protocol is set, or internationally.

This paper describes an innovative protocol aimed at examining healthcare employees’ and organisations’ concerns and beliefs in workspace design. It outlines research investigating the effect of workspace use on productivity, health and safety and worker satisfaction, to clarify Work-As-Done, while creating healthy and more fulfilling environments.

Methods

This is a proof-of-concept study, taking place between June 2018 and April 2019, employing a multimethod, qualitative approach for in-depth assessment of one Australian, private, university hospital environment, using as its ‘case’ the Gastroenterology Surgical Unit. It involves (1) observations and informal interviews (shadowing) with employees and patients as they traverse hospital spaces and (2) visual data of spatial use. Fieldnotes will be analysed thematically, and visual data analysed using a predefined schematic framework (a visual taxonomy). Overarching themes and categories will be considered corroboratively, mixing visual and textual data to build an iterative and dynamic picture.

Ethics and dissemination

Ethical considerations will be discussed, while approval has been granted by the University’s Human Research Ethics Committee (HREC/5201800282), along with Governance approved by the Health Clinical Research Executive (CRG2018005). Study results will be disseminated through publications, research conferences and public reports.
Description of the BRIGHTLIGHT cohort: the evaluation of teenage and young adult cancer services in England
Authors: Taylor Rachel M , Fern Lorna A , Barber Julie , Alvarez-Galvez Javier , Feltbower Richard , Morris Stephen , Hooker Louise , McCabe Martin G , Gibson Faith , Raine Rosalind , Stark Dan P , Whelan Jeremy S
Published: April 2019

Objective

International recognition of the unique needs of young people with cancer is growing. Many countries have developed specialist age-appropriate cancer services believing them to be of value. In England, 13 specialist principal treatment centres (PTCs) deliver cancer care to young people. Despite this expansion of specialist care, systematic investigation of associated outcomes and costs has, to date, been lacking. The aim of this paper is to describe recruitment and baseline characteristics of the BRIGHTLIGHT cohort and the development of the bespoke measures of levels of care and disease severity, which will inform the evaluation of cancer services in England.

Design

Prospective, longitudinal, observational study.

Setting

Ninety-seven National Health Service hospitals in England.

Participants

A total of 1114 participants were recruited and diagnosed between July 2012 and December 2014: 55% (n=618) were men, mean age was 20.1 years (SD=3.3), most (86%) were white and most common diagnoses were lymphoma (31%), germ cell tumour (19%) and leukaemia (13%).

Results

At diagnosis, median quality of life score was significantly lower than a published control threshold (69.7 points); 40% had borderline to severe anxiety, and 21% had borderline to severe depression. There was minimal variation in other patient-reported outcomes according to age, diagnosis or severity of illness. Survival was lower in the cohort than for young people diagnosed during the same period who were not recruited (cumulative survival probability 4 years after diagnosis: 88% vs 92%).

Conclusions

Data collection was completed in March 2018. Longitudinal comparisons will determine outcomes and costs associated with access/exposure to PTCs. Findings will inform international intervention and policy initiatives to improve outcomes for young people with cancer.
Screening and treatment to reduce severe hyperbilirubinaemia in infants in primary care (STARSHIP): a factorial stepped-wedge cluster randomised controlled trial protocol
Authors: van der Geest Berthe A M , de Graaf Johanna P , Bertens Loes C M , Poley Marten J , Ista Erwin , Kornelisse René F , Reiss Irwin K M , Steegers Eric A P , Been Jasper V
Published: April 2019

Introduction

Jaundice caused by hyperbilirubinaemia is a physiological phenomenon in the neonatal period. However, severe hyperbilirubinaemia, when left untreated, may cause kernicterus, a severe condition resulting in lifelong neurological disabilities. Although commonly applied, visual inspection is ineffective in identifying severe hyperbilirubinaemia. We aim to investigate whether among babies cared for in primary care: (1) transcutaneous bilirubin (TcB) screening can help reduce severe hyperbilirubinaemia and (2) primary care-based (versus hospital-based) phototherapy can help reduce hospital admissions.

Methods and analysis

A factorial stepped-wedge cluster randomised controlled trial will be conducted in seven Dutch primary care birth centres (PCBC). Neonates born after 35 weeks of gestation and cared for at a participating PCBC for at least 2 days within the first week of life are eligible, provided they have not received phototherapy before. According to the stepped-wedge design, following a phase of ‘usual care’ (visual assessment and selective total serum bilirubin (TSB) quantification), either daily TcB measurement or, if indicated, phototherapy in the PCBC will be implemented (phase II). In phase III, both interventions will be evaluated in each PCBC. We aim to include 5500 neonates over 3 years.

Primary outcomes are assessed at 14 days of life: (1) the proportion of neonates having experienced severe hyperbilirubinaemia (for the TcB screening intervention), defined as a TSB above the mean of the phototherapy and the exchange transfusion threshold and (2) the proportion of neonates having required hospital admission for hyperbilirubinaemia treatment (for the phototherapy intervention in primary care).

Ethics and dissemination

This study has been approved by the Medical Research Ethics Committee of the Erasmus MC Rotterdam, the Netherlands (MEC-2017-473). Written parental informed consent will be obtained. Results from this study will be published in peer-reviewed journals and presented at (inter)national meetings.

Trial registration number

NTR7187.
Could implementation of mifepristone address Canada’s urban–rural abortion access disparity: a mixed-methods implementation study protocol
Authors: Norman Wendy V , Munro Sarah , Brooks Melissa , Devane Courtney , Guilbert Edith , Renner Regina , Kendall Tamil , Soon Judith A , Waddington Ashley , Wagner Marie-Soleil , Dunn Sheila
Published: April 2019

Introduction

In January 2017, mifepristone-induced medical abortion was made available in Canada. In this study, we will seek to (1) understand facilitators and barriers to the implementation of mifepristone across Canada, (2) assess the impact of a ‘community of practice’ clinical and health service support platform and (3) engage in and assess the impact of integrated knowledge translation (iKT) activities aimed to improve health policy, systems and service delivery issues to enhance patient access to mifepristone.

Methods and analysis

This prospective mixed-methods implementation study will involve a national sample of physicians and pharmacists recruited via an online training programme, professional networks and a purpose-built community of practice website. Surveys that explore constructs related to diffusion of innovation and Godin’s behaviour change frameworks will be conducted at baseline and at 6 months, and qualitative data will be collected from electronic interactions on the website. Survey participants and a purposeful sample of decision-makers will be invited to participate in in-depth interviews. Descriptive analyses will be conducted for quantitative data. Thematic analysis guided by the theoretical frameworks will guide interpretation of qualitative data. We will conduct and assess iKT activities involving Canada’s leading health system and health professional leaders, including evidence briefs, Geographical Information System (GIS)maps, face-to-face meetings and regular electronic exchanges. Findings will contribute to understanding the mechanisms of iKT relationships and activities that have a meaningful effect on uptake of evidence into policy and practice.

Ethics and dissemination

Ethical approval was received from the University of British Columbia Children’s and Women’s Hospital Ethics Review Board (H16-01006). Full publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to research participants through newsletters and media interviews, and to policy-makers through invited evidence briefs and face-to-face presentations.
Effect of metformin on the size of the HIV reservoir in non-diabetic ART-treated individuals: single-arm non-randomised Lilac pilot study protocol
Authors: Routy Jean-Pierre , Isnard Stéphane , Mehraj Vikram , Ostrowski Mario , Chomont Nicolas , Ancuta Petronela , Ponte Rosalie , Planas Delphine , Dupuy Franck P , Angel Jonathan B
Published: April 2019

Introduction

People living with HIV (PLWH) on antiretroviral therapy (ART) do not progress to AIDS. However, they still suffer from an increased risk of inflammation-associated complications. HIV persists in long-lived CD4+ T cells, which form the major viral reservoir. The persistence of this reservoir despite long-term ART is the major hurdle to curing HIV. Importantly, the size of the HIV reservoir is larger in individuals who start ART late in the course of infection and have a low CD4+/CD8+ ratio. HIV reservoir size is also linked to the levels of persistent inflammation on ART. Thus, novel strategies to reduce immune inflammation and improve the host response to control the HIV reservoir would be a valuable addition to current ART. Among the different strategies under investigation is metformin, a widely used antidiabetic drug that was recently shown to modulate T-cell activation and inflammation. Treatment of non-diabetic individuals with metformin controls inflammation by improving glucose metabolism and by regulating intracellular immunometabolic checkpoints such as the adenosin 5 monophosphate activated protein kinase and mammalian target of rapamycin, in association with microbiota modification.

Methods and analysis

22 PLWH on ART for more than 3 years, at high risk of inflammation or the development of non-AIDS events (low CD4+/CD8+ ratio) will be recruited in a clinical single-arm pilot study. We will test whether supplementing ART with metformin in non-diabetic HIV-infected individuals can reduce the size of the HIV reservoir as determined by various virological assays. The expected outcome of this study is a reduction in both the size of the HIV reservoir and inflammation following the addition of metformin to ART, thus paving the way towards HIV eradication.

Ethics and dissemination

Ethical approval: McGill university Health Centre committee number MP-37-2016-2456. Canadian Canadian Institutes of Health Research/Canadian HIV Trials Network (CTN) protocol CTNPT027. Results will be made available through publication in peer-reviewed journals and through the CTN website.

Trial registration number

NCT02659306
A theory-based, task-oriented, outdoor walking programme for older adults with difficulty walking outdoors: protocol for the Getting Older Adults Outdoors (GO-OUT) randomised controlled trial
Authors: Salbach Nancy M , Barclay Ruth , Webber Sandra C , Jones C A , Mayo Nancy E , Lix Lisa M , Ripat Jacquie , Grant Theresa , van Ineveld Cornelia , Chilibeck Philip D
Published: April 2019

Introduction

A theory-based, task-oriented, community walking programme can increase outdoor walking activity among older adults to optimise functional independence, social participation and well-being. The study objective is to determine if there is a difference in the change in outdoor walking activity from baseline to 10 weeks, 5.5 months and 12 months after receiving a 1-day interactive workshop and outdoor walking programme (Getting Older Adults Outdoors (GO-OUT)) compared with the workshop and weekly reminders (WR) in older adults with difficulty walking outdoors.

Methods and analysis

A randomised controlled trial is being conducted in four urban Canadian communities. We will stratify 240 individuals by site and participant type (ie, individual vs spousal/friend pair) and randomise to either the GO-OUT or WR intervention. The GO-OUT intervention involves a 1-day workshop, where participants complete eight interactive stations to build knowledge and skills to walk outside, followed by a 10-week group outdoor walking programme (two 1-hour sessions/week) led by a physiotherapist or kinesiologist in parks. The WR intervention consists of the same workshop and 10 weekly telephone reminders to facilitate outdoor walking. The primary outcome measure is mean outdoor walking time in minutes/week derived from accelerometry and global positioning system data. GO-OUT is powered to detect an effect size of 0.4, given α=0.05, β=0.20, equal number of participants/group and a 20% attrition rate. Secondary outcomes include physical activity, lifespace mobility, participation, health-related quality of life, balance, leg strength, walking self-efficacy, walking speed, walking distance/endurance and mood.

Ethics and dissemination

GO-OUT has received ethics approval at all sites. A Data Safety Monitoring Board will monitor adverse events. We will disseminate findings through lay summaries, conference presentations and journal articles.

Trial registration number

NCT03292510(Pre-results).
Next-generation sequencing for the detection of microorganisms present in human donor corneal preservation medium
Authors: Parekh Mohit , Borroni Davide , Romano Vito , Kaye Stephen B , Camposampiero Davide , Ponzin Diego , Ferrari Stefano
Published: April 2019

Objective

To detect the presence of microorganisms in the storage media of human donor corneas using next-generation sequencing method.

Methods

Seven samples from organ culture (OC) group (Cornea Max, Eurobio, Les Ulis, France) with one control (sterile media without any cornea) and seven samples from hypothermic storage group (Cornea Cold, Eurobio) with one control were used for this study. The corneas were placed in the respective storage media for 14 days before collecting the samples. Storage media (2 mL) from each sample were collected in RNAase-free tubes and shipped for ribosomal RNA sequencing of 16 S and 18 S. Simultaneously, another 1 mL of media sample was used for conventional diagnostic method (CDM) using Bactec instruments.

Results

In both, OC and hypothermic storage and control samples, the most abundant genera werePseudomonas, Comamonas, Stenotrophomonas, Alcanivorax, BrevundimonasandNitrobacter. Acidovorax, AcetobacterandHydrogenophiluswere detected mostly in the hypothermic storage group. The most abundant fungal pathogen detected belonged to the genusMalassezia,which was found in both the storage conditions. CDM was negative for microorganisms in all the samples.

Conclusion

Metagenomics provides full taxonomic profiling of the detected genomic material of the organisms and thus has the potential to deliver a much wider microbiological diagnostic approach than CDM. The costs and turn-around time need to be reduced, and; the detection of viable organisms would help this technology to be introduced into routine clinical practice.
Deep continuous patient-requested sedation until death: a multicentric study
Authors: Serey Adrien , Tricou Colombe , Phan-Hoang Nicolas , Legenne Myriam , Perceau-Chambard Élise , Filbet Marilene
Published: April 2019

Objectives

In 2016, a new law was adopted in France granting patients the right, under specific conditions, to continuous deep sedation until death (CDSUD). The goal of this study was to measure the frequency of requests for CDSUD from patients in palliative care.

Methods

The data collected from the medical records of patients in palliative care units (PCU) or followed by palliative care support teams (PCST) in the Rhône-Alpes area, who died after CDSUD, focused on the patient’s characteristics, the drugs used (and compliance with regulatory processes).

Results

All 12 PCU and 12 of the 24 PCST were included. Among the 8500 patients followed, 42 (0.5%) requested CDSUD until death. The patients were: 65.7 (SD=13.7) years old, highly educated (69%), had cancer (81%), refractory symptoms (98%) and mostly psychoexistential distress (69%). The request was rejected for 2 (5%) patients and delayed for 31 (74%) patients. After a delay of a mean 8 days, 13 (31%) patients were granted CDSUD. The drug used was midazolam at 115 mg/24 hours (15–480), during a mean of 3 days. PCUs used lower dosages than PCSTs (83 vs 147), with significantly lower initial doses (39 mg vs 132 mg, p=0.01). A life-threatening condition was recorded in 13 cases (31%) and a collegial decision was taken in 25 cases (60%).

Conclusion

This study highlights the low rate of request and the even lower rate of CDSUD in specialised palliative care. However, the sedation for psychoexistential distress and the lack of procedure records raise ethical questions.
Prevalence of excessive internet use and its correlation with associated psychopathology in 11th and 12th grade students
Authors: Kumar Nitin , Kumar Arvind , Mahto Subodh Kumar , Kandpal Manish , Deshpande Smita Neelkanth , Tanwar Parul
Published: April 2019

Background

Globally, the number of internet users has crossed the three-billion mark, while in India users grew over 17% in the first 6 months of 2015 to 354 million. This study presented a background on internet use and the existence of excessive internet use.

Aim

To study the extent of internet use in 11th and 12 grade students and the psychopathology, if any, associated with excessive internet use.

Methods

426 students who met the inclusion criteria were recruited from 11th and 12th grade classes from Kendriya Vidyalaya, New Delhi, India, and were assessed by Young’s Internet Addiction Test and the Strength and Difficulties Questionnaire.

Results

Among the 426 students, the mean internet addiction total score was 36.63 (20.78), which indicated mild level of internet addiction. 1.41% (six students) was diagnosed as excessive internet users, while 30.28% and 23.94% were classified as moderate and mild internet users, respectively. The prevalence of internet addiction between gender was 58.22% in males and 41.78% in females. While both positive (prosocial) and negative (hyperactivity, emotional, conduct and peer problem) impacts of internet use were reported by students, in the current study excessive use of internet had a negative impact on students’ lives as compared with positive impact, which was statistically significant (p<0.0001).

Conclusion

Excessive internet use led to abnormal behaviours which cause negative consequences to users. Early diagnosis of risk factors related to excessive internet use, provides education about responsible use and supervision of students by family members.
Impact of heart failure on stroke mortality and recurrence
Authors: Pana Tiberiu A , Wood Adrian D , Perdomo-Lampignano Jesus A , Tiamkao Somsak , Clark Allan B , Kongbunkiat Kannikar , Bettencourt-Silva Joao H , Sawanyawisuth Kittisak , Kasemsap Narongrit , Mamas Mamas A , Myint Phyo K
Published: April 2019

Objective

We aimed to examine the impact of heart failure (HF) on stroke mortality (in-hospital and postdischarge) and recurrence in a national stroke cohort from Thailand.

Methods

We used a large, insurance-based database including all stroke admissions in the public health sector in Thailand between 2004 and 2015. Logistic and Royston-Parmar regressions were used to quantify the effect of HF on in-hospital and long-term outcomes, respectively. All models were adjusted for age, sex and comorbidities and stratified by stroke type: acute ischaemic stroke (AIS) or intracerebral haemorrhage (ICH). Multistate models were constructed using flexible survival techniques to predict the impact of HF on the disease course of a patient with stroke (baseline-[recurrence]-death). Only first-ever cases of AIS or ICH were included in the multistate analysis.

Results

608 890 patients (mean age 64.29±13.72 years, 55.07% men) were hospitalised (370 527 AIS, 173 236 ICH and 65 127 undetermined pathology). There were 398 663 patients with first-ever AIS and ICH. Patients were followed up for a median (95% CI) of 4.47 years (4.45 to 4.49). HF was associated with an increase in postdischarge mortality in AIS (HR [99% CI] 1.69 [1.64 to 1.74]) and ICH (2.59 [2.07 to 3.26]). HF was not associated with AIS recurrence, while ICH recurrence was only significantly increased within the first 3 years after discharge (1.79 [1.18 to 2.73]).

Conclusions

HF increases the risk of mortality in both AIS and ICH. We are the first to report on high-risk periods of stroke recurrence in patients with HF with ICH. Specific targeted risk reduction strategies may have significant clinical impact for mortality and recurrence in stroke.
Combat medic course: evaluation of trainees’ perception of learning and academic-self perception
Authors: Çiçek Ahmet , Çetin M
Published: April 2019

Introduction

In response to the Syrian Civil War, the Turkish Armed Forces has focused its attention on internal security and border operations, thereby cushioning against both the threat of terrorist activities and supporting international peace efforts. This study was performed to evaluate the level of knowledge, skills and any behavioural changes after the combat medic course to enhance future courses.

Methods

A cross-sectional descriptive study was conducted between 25 December 2017 and 22 March 2018 using 40 combatant personnel undertaking the combat medic training course. Attendants’ perception of self- sufficiency was assessed using a specifically designed questionnaire using a 5-point Likert-type scale.

Results 

Trainee perception of self-confidence had the highest mean increase post course (4.1±0.7). Trainee academic self-perception demonstrated the lowest mean post course score in the domain of “using of the tactical emergency medications and liquids” (3.80±1.02). The highest mean was in the domain of bleeding control (4.63±0.49).

Conclusions

Improvements to specific components of the course have been identified and implemented to ensure greater success in the operational field environment. In particular, the total course hours will be increased and simulation encouraged using the most recent equipment used in the field.
Clinical activity at the UK military level 2 hospital in Bentiu, South Sudan during Op TRENTON from June to September 2017
Authors: Bailey Mark S , Gurney I , Lentaigne J , Biswas J S , Hill N E
Published: April 2019

Introduction

Diseases and non-battle injuries (DNBIs) are common on UK military deployments, but the collection and analysis of clinically useful data on these remain a challenge. Standard medical returns do not provide adequate clinical information, and clinician-led approaches have been laudable, but not integrated nor standardised nor used long-term. Op TRENTON is a novel UK military humanitarian operation in support of the United Nations Mission in South Sudan, which included the deployment of UK military level 1 and level 2 medical treatment facilities at Bentiu to provide healthcare for UK and United Nations (UN) personnel.

Methods

A service evaluation of patient consultations and admissions at the UK military level 2 hospital was performed using two data sets collected by the emergency department (ED) and medicine (MED) teams.

Results

Over a three-month (13-week) period, 286 cases were seen, of which 51% were UK troops, 29% were UN civilians and 20% were UN troops. The ED team saw 175 cases (61%) and provided definitive care for 113 (40%), whereas the MED team saw and provided definitive care for 128 cases (45%). Overall, there were 75% with diseases and 25% with non-battle injuries. The most common diagnoses seen by the ED team were musculoskeletal injuries (17%), unidentified non-malarial undifferentiated febrile illness (UNMUFI) (17%), malaria (13%), chemical pneumonitis (13%) and wounds (8%). The most common diagnoses seen by the MED team were acute gastroenteritis (AGE) (56%), UNMUFI (12%) and malaria (9%). AGE was due to viruses (31%), diarrhoeagenicEscherichia coli(32%), other bacteria (6%) and protozoa (12%).

Conclusion

Data collection on DNBIs during the initial phase of this deployment was clinically useful and integrated between different departments. However, a standardised, long-term solution that is embedded into deployed healthcare is required. The clinical activity recorded here should be used for planning, training, service development and targeted research.
Medical services policy in respect of detainees: evolution and outstanding issues
Authors: Lillywhite Louis
Published: April 2019

Alleged and confirmed abuse of civilians arrested or detained by the UK Armed Forces has been the subject of four formal enquiries, and all have used medical evidence and/or addressed medical issues. After the first three, robust policies were put in place to ensure that all those arrested had appropriate medical examinations and that healthcare personnel acted appropriately. However, by the time of the Second Gulf War, the training and medical processes had lapsed and were found to be a contributory factor in not preventing abuse. The fourth enquiry has endorsed most of the lapsed policies but is ambiguous in two areas—on medical certification of fitness for interrogation and the timing to the first medical examination. This article summarises the medical aspects of the four enquiries and discusses the two ambiguous areas, arguing that to diverge from the policies eventually put in place in Northern Ireland is a retrograde step. It also discusses how training put in place to avoid the very events which occurred in the Second Gulf was discontinued.
Comparative evaluation of the efficacy of using monocular, binocular and panoramic night vision goggles in successful venous access in darkness
Authors: Bilge Sedat , Aydin A , Yakut U
Published: April 2019

Introduction

The use of night vision goggles (NVGs) by medical staff operating in active combat areas may present a tactical advantage in maintaining unit concealment. This study seeks to assess the degree to which NVG use improves speed and ease of intravenous access in comparison to no NVG use, and which NVG system (monocular, binocular or panoramic) provides the best conditions for the clinician.

Methods

Cannulation was carried out using both eyes open (BEO) and one eye open (OEO) in well-lit conditions to establish a baseline measurement. The same procedure was then performed with a variety of NVGs, with and without infrared (IR) light sources in a dark room, and the degree of difficulty, time to procedural completion and success rate were compared.

Results

NVG use improved procedure speed in comparison to the BEO method in the dark. Among the NVG methods trialled, binocular NVG (BNVG) methods outperformed panoramic NVG (PNVG) and monocular NVG in terms of success rate.

Conclusions

Use of BNVG resulted with a better success rate in our study. We would like to emphasise that although combatant units prefer PNVGs for the wider temporal vision they provide, it must be kept in mind that this may pose a disadvantage in peripheral vascular access procedures while providing first aid to the casualty at close distances.
Evolution of military medicine literature: a scientometric study of global publications on military medicine between 1978 and 2017
Authors: Şenel Engin
Published: April 2019

Objectives

Scientometrics is a popular statistical discipline providing data relevant to publication patterns and trends in a certain academic field. There are no scientometric analyses of publications produced in military medicine literature. The present study aims to perform a holistic analysis of military medicine literature.

Methods

All data of this study were collected from theWeb of Science Core Collection. All indexed documents between 1978 and 2017 were included. Countries, authors, institutions, citations and keywords relevant to the military medicine literature were comprehensively analysed. An infomap revealing global productivity and infographics of scientometric networks were generated.

Results

A total of 48 240 published items were found, 82.29% of which were original articles. USA, covering 56.66% of all literature dominated the military medicine field followed by the UK, China, Canada and Israel. We found that 18 of 20 most productive institutions in the world were from USA and the US Department of Defense was the most contributing institution in the literature with 9664 documents. The most used keywords over a 40-year period were ‘military’, ‘veterans’, ‘posttraumatic stress disorder’ and ‘military personnel’. A scientometric network of keywords showed a complicated ‘starburst pattern’.

Conclusion

All most contributing countries except Turkey, China and Israel were developed nations. Only one institution (Tel Aviv University) from developing countries was noted in the list of 20 most productive institutions. The researchers from developing and the least developed countries should be encouraged and supported to carry out novel studies on military medicine.
Repatriation for diseases or non-battle injuries (DNBI): long-term impact on quality of life
Authors: Huizinga Eelco , Idenburg F J , van Dongen T T C F , Hoencamp R
Published: April 2019

Introduction

Throughout history, diseases and non-battle injuries (DNBI) have threatened deployed forces more than battlefield injuries. During the Dutch involvement in Afghanistan, the amount of DNBI that needed medical evacuation out of theatre (60%) exceeded the number of battle injuries (40%). The aim of this study is to explore the long-term quality of life (QoL) of Dutch service members that acquired a DNBI, warranting repatriation during their deployment to Afghanistan between 2003 and 2014.

Methods

Observational cross-sectional cohort study in a selected group of Dutch service members who deployed to Afghanistan 2003–2014 and were repatriated due to DNBI. Using the 36-item Short Form, EuroQol-6D, Symptom Checklist 90 and Post Deployment Reintegration Scale questionnaires, their outcomes were compared with a control group of deployed service members who did not sustain injuries or illnesses.

Results

Groups were comparable in age, rank, number of deployments and social status. There were significant differences found in terms of physical functioning, pain and health perspective. No differences were seen in emotional or psychological outcomes.

Conclusion

The amount of military service members who contract a DNBI is significant and imposes a burden on the capacity of the medical support, readiness of deployed units and sustainability of ongoing operations. However, regarding QoL, being forced to leave their units and to be repatriated to their home country due to a DNBI seems to have no significant impact on reported psychological symptoms of distress and reintegration experiences. Future research should focus on more in-depth registration of illnesses and not combat related diseases and injuries and even longer-term outcomes.
Assessing the utility of ultrasound in the role 2 hospital setting
Authors: Sellon Edward , Durdle S , Bailey D
Published: April 2019

Introduction

The usefulness of departmental diagnostic ultrasound in the role 2 setting has not been previously evaluated. This is because role 2 hospital manning does not traditionally include a diagnostic radiologist. This study aims to evaluate the usefulness of this added capability in the deployed role 2 hospital setting.

Methods

Prospective data were collected using a questionnaire alongside each scan request during the Op TRENTON 3 operational period. This included details of clinical indication and presumptive diagnosis. Scans were acquired and reported as part of routine care. The postscan clinical diagnosis and effect on management plan were determined by the treating clinician and recorded on the questionnaire. Point-of-care and focused assessment with sonography in trauma scans were excluded, as were ultrasound-guided interventional procedures.

Results

41 diagnostic departmental scans were included over the six-month period. 68% (28/41) of the scans increased clinical confidence in the management plan, while 29% (12/41) led to an alteration in the management plan. Only one examination (3%) was deemed to have had no clinical impact. Overall, the musculoskeletal scans had the greatest impact on patient management.

Conclusions

Constraints of manoeuvrability at role 2 currently preclude the availability of body CT and shift the demand for diagnostic soft tissue imaging to ultrasound. This capability is only possible with the deployment of suitably trained individuals. This study highlights the utility of this capability at role 2. Musculoskeletal ultrasound skills were of particular value, and training should be encouraged among physiotherapists and radiographers in lieu of, where necessary, a suitably trained deployable radiologist.
How leadership training saves money ‘service line leadership’ at Nottingham University Hospitals
Authors: Orme Duncan , Campbell Colin
Published: April 2019

New findings

The evidence presented demonstrates that this leadership programme improved financial performance through increased participant confidence, leading to improved individual and team performance. Observations confirm that margins were maximised by clinicians when provided with granular understanding of costs and training in leadership. Limitations of the study and methodology are discussed.

Background/aim

The ‘Service Line Leadership’ programme was developed at Nottingham University Hospitals National Health Service Trust to support financial recovery, through leadership skills and improved understanding of cost. Over 3 years, the programme attracted 425 participants (69 consultants). This retrospective study quantifies the impact of the programme and how it influenced leaders.

Methods

The five measures used were: (1) evaluation of the financial return on investment, (2) analysis of the mean differences between 360° psychometric assessment scores before and after the programme, (3) a survey utilising a focused interview and a follow-up questionnaire, (4) a post-programme questionnaire examining skills acquired and (5) a workshop evaluation using a net promoter score.

Results

Savings of £3.3 million were identified through the delivery of 11 separate initiatives. Quality improvements were observed. Participants were found to have changed their leadership behaviours through improved communication of trust, leading to empowerment, confidence to challenge perceptions and being mindful of others. New techniques were acquired giving rise to increased confidence in personal leadership.

Conclusion

The return on investment based on projects of leaders employing the techniques from the programme, demonstrated a positive impact on the business model of the hospital.
Ethics of crisis sedation: questions of performance and consent
Authors: Emmerich Nathan , Gordijn Bert
Published: April 2019

This paper focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term ‘crisis sedation.’ We first present a confabulated case that illustrates the kind of events we have in mind, before offering a more detailed account of the practice. We then comment on some of the ethical issues that crisis sedation might raise. We identify the primary value of crisis sedation as allowing healthcare professionals to provide some degree of reassurance to patients, their families and the professionals who are caring for them. Next we focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated.
Predictive value of platelet reactivity unit (PRU) value for thrombotic and hemorrhagic events during flow diversion procedures: a meta-analysis
Authors: Ajadi Ebunoluwa , Kabir Shaowli , Cook Aaron , Grupke Stephen , Alhajeri Abdulnasser , Fraser Justin F
Published: April 2019

Background and purpose

Platelet function testing prior to flow diversion procedures, although initially heavily debated, has seen a substantial increase in its adoption to assess the risk of operative and perioperative thrombotic and hemorrhagic events. This meta-analysis was conducted to assess platelet function testing, particularly the VerifyNow Platelet Reactivity Unit (PRU) assay, for a relationship between the reported assay PRU value and thrombotic and hemorrhagic events.

Materials and methods

The currently available literature (2013–2018) was surveyed with PubMed and Google Scholar searches. Included studies were those for which there were at least 30 cases during the study period, for which VerifyNow platelet reactivity unit values were obtained prior to the procedures and for which intraoperative and perioperative adverse events were noted. PRU value cut-offs ranging from >200 to >240 comprised the hyporesponse group while values ranging from <60 to <70 comprised the hyper-response group. The data were subject to statistical analysis to assess the relationship between PRU values and thrombotic and hemorrhagic events. The collected data were subsequently statistically analyzed to assess for publication bias.

Results

The searches yielded 27 studies, of which 12 met the inclusion criteria for the meta-analysis. The meta-analysis included data from 1464 reported Pipeline cases. The study included 273 men and 1177 women with a mean age across the analyzed procedures of 58 years (range 25–85). After loading with antiplatelet medications, preprocedural platelet hyper-responsiveness was associated with a greater incidence of hemorrhagic events with an increased absolute risk of 12%, but showed no relationship with thrombotic events. Preprocedural platelet hyporesponsiveness was associated with a greater incidence of thrombotic events with an absolute risk of 15%, but showed no relationship with hemorrhagic events.

Conclusions

VerifyNow PRU values that correspond to platelet hyporesponse or hyper-response to dual antiplatelet therapy are associated with a higher risk of thrombotic and hemorrhagic events, respectively. Thus, the PRU value may offer some predictive value for these events.
Novel clinical scores for occupational asthma due to exposure to high-molecular-weight agents
Authors: Taghiakbari Mahsa , Pralong Jacques-André , Lemière Catherine , Moullec Gregory , Saha-Chaudhuri Paramita , Cartier André , Castano Roberto , Suarthana Eva
Published: April 2019

Objective

Specific inhalation challenge (SIC) as the reference diagnostic test for occupational asthma (OA) is not widely available worldwide. We aimed to develop non-SIC-based models for OA.

Methods

Of 427 workers who were exposed to high-molecular-weight agents and referred to OA clinic at Montréal Sacré-Cœur Hospital between 1983 and 2016, we analysed 160 workers who completed non-specific bronchial hyper-responsiveness (NSBHR) tests and still worked 1 month before SIC. OA was defined as positive SIC. Logistic regression models were developed. The accuracy of the models was quantified using calibration and discrimination measures. Their internal validity was evaluated with bootstrapping procedures. The final models were translated into clinical scores and stratified into probability groups.

Results

The final model, which included age ≤40 years, rhinoconjunctivitis, inhaled corticosteroid use, agent type, NSBHR, and work-specific sensitisation had a reasonable internal validity. The area under the receiver operating characteristics curve (AUC) was 0.91 (95% CI 0.86 to 0.95), statistically significantly higher than the combination of positive NSBHR and work-specific sensitisation (AUC=0.84). The top 70% of the clinical scores (ie, the high probability group) showed a significantly higher sensitivity (96.4%vs86.9%) and negative predictive value (93.6%vs84.1%) than the combination of positive NSBHR and work-specific sensitisation (p value <0.001).

Conclusions

We developed novel scores for OA induced by high-molecular-weight agents with excellent discrimination. It could be helpful for secondary-care physicians who have access to pulmonary function test and allergy testing in identifying subjects at a high risk of having OA and in deciding on appropriate referral to a tertiary centre.
High-sensitive cardiac troponin T as a predictor of efficacy and safety after pulmonary vein isolation using focal radiofrequency, multielectrode radiofrequency and cryoballoon ablation catheter
Authors: Zeljkovic Ivan , Knecht Sven , Pavlovic Nikola , Celikyrut Umut , Spies Florian , Burri Sarah , Mannhart Dominik , Peterhans Loris , Reichlin Tobias , Schaer Beat , Osswald Stefan , Sticherling Christian , Kuhne Michael
Published: April 2019

Introduction

Myocardial injury markers such as high-sensitive cardiac troponin T (hs-cTnT) and creatine kinase MB (CK-MB) reflects the amount of myocardial injury with ablation. The aim of the study was to identify the value of myocardial injury markers to predict outcomes after pulmonary vein isolation (PVI) using three different ablation technologies.

Methods

Consecutive patients undergoing PVI using a standard 3.5 mm irrigated-tip radiofrequency catheter (RF-group), an irrigated multielectrode radiofrequency catheter (IMEA-group) and a second-generation cryoballoon (CB-group) were analysed. Blood samples to measure injury markers were taken before and 18–24 hours after the ablation. Procedural complications were collected and standardised follow-up was performed. Logistic regression was used to identify predictors of recurrence and complications.

Results

96 patients (RF group: n=40, IMEA-group: n=17, CB-group: n=39) undergoing PVI only were analysed (82% male, age 59±10 years). After a follow-up of 12 months, atrial fibrillation (AF) recurred in 45% in the RF-group, 29% in the IMEA-group and 36% in the CB-group (p=0.492). Symptomatic pericarditis was observed in 20% of patients in the RF-group, 15% in the IMEA-group and 5% in the CB-group (p=0.131). None of the injury markers was predictive of AF recurrence or PV reconnection after a single procedure. However, hs-cTnT was identified as a predictor of symptomatic pericarditis (OR: 1.003 [1.001 to 1.005], p=0.015).

Conclusion

Hs-cTnT and CK-MB were significantly elevated after PVI, irrespective of the ablation technology used. None of the myocardial injury markers were predictive for AF recurrence or PV reconnection, but hs-cTnT release predicts the occurrence of symptomatic pericarditis after PVI.
Cardiorespiratory fitness in patients with rheumatoid arthritis is associated with the patient global assessment but not with objective measurements of disease activity
Authors: Liff Marthe Halsan , Hoff Mari , Fremo Thomas , Wisløff Ulrik , Thomas Ranjeny , Videm Vibeke
Published: April 2019

Objective

Patients with rheumatoid arthritis (RA) suffer from more cardiovascular disease (CVD), and develop cardiovascular risk factors at an earlier age than the general population. Cardiorespiratory fitness (CRF) is an important predictor of cardiovascular health. There are few data regarding CRF of RA patients, measured as peak oxygen uptake (VO2peak) by the gold standard method; cardiopulmonary exercise testing. We compared CRF in RA patients to those from a healthy population, and investigated if risk factors for CVD and RA-specific variables including subjective and objective disease activity measures were associated with CRF in RA patients.

Methods

VO2peaktests of RA patients (n=93) were compared to those of an age-matched and gender-matched healthy population (n=4631) from the Nord-Trøndelag Health Study. Predictors of VO2peakwere found using Lasso (least absolute shrinkage and selection operator) regression, followed by standardised multiple linear regression.

Results

Women with RA ≥40 years and men with RA aged 40–49 years or 60–69 years had up to 20% lower CRF than the healthy population in the same age groups. By relative importance, body mass index (standardised coefficient=−0.25, p<0.001), physical activity level (coefficient=0.21, p<0.001), patient global assessment (PGA; coefficient=−0.14, p=0.006), systolic blood pressure (coefficient=−0.12, p=0.016), resting heart rate (coefficient=−0.11, p=0.032) and smoking (coefficient=−0.10, p=0.046) were significant predictors of CRF (R2=0.82, gender-adjusted and age-adjusted).

Conclusion

CRF in RA patients was lower than in a healthy population. CRF was associated with common risk factors for CVD and the PGA score. Focusing on fitness in RA patients may improve cardiovascular health.