bluuebunny/crossref_metadata_2025 huggingface dataset:
Development of an Instrument to Assess the Perceived Effectiveness of Academic Detailing
Authors: Smart Mary H. , Monteiro Andrea L. , Saffore Christopher D. , Ruseva Aleksandrina , Lee Todd A. , Fischer Michael A. , Pickard Alan Simon
Published: September 2020

Introduction:

Academic detailing (AD) is an effective, evidence-based education outreach method of promoting clinician behavior change. Detailer feedback is important for program evaluation but is rarely systematically collected. The study's objective was to develop a measure capturing the detailer's perception of the effectiveness of an AD program.

Methods:

A six-item measure with a five-level scale was initially developed from the literature review and expert panel consultation. Item constructs were usefulness, acceptability, feasibility, relevance, effectiveness of communication, and readiness to change. The measure was piloted, refined, and tested during an opioid-focused AD program that included two visits. The instrument structure was evaluated using exploratory factor analysis, measure reliability was assessed using item–item correlation (rho), corrected item–total correlation, Cronbach alpha (α), and item response theory.

Results:

The initial six-item instrument demonstrated unidimensionality. The Cronbach α for the measure was 0.74 (visit 1) and 0.79 (visit 2); one item (relevance) was redundant (α = 0.73 and 0.79 when deleted) and therefore dropped. Items related to usefulness, acceptability, and readiness to change displayed high item–item correlation (rho ≥ 0.50) and contributed the most information and seemed to operate as a single scale (ie, “likelihood to change”) based on item response theory analysis. Items related to feasibility and communication were slightly different constructs and should be reported separately.

Discussion:

The five-item detailer assessment of visit effectiveness (the “DAVE”) instrument provides a standardized approach to assess AD. Further study of its validity and broader use in other programs and educational outreach activities is encouraged.
The Role of Bias in Knowledge Translation: Lessons Learned from a Dissemination of Best Practices in Maternal Opioid Use
Authors: Nichols Tracy R. , Gringle Meredith R.
Published: September 2020

Introduction:

Increases in opioid use during pregnancy fueled concerns among reproductive health advocates, policy makers, and providers in North Carolina, United States. A stakeholder group designed a set of knowledge translation (KT) interventions to increase the use of evidence-based practices across relevant health care and social service arenas. Efforts to decrease stigma was included as a best practice. Understanding the process and the contexts in which KT intervention activities occur can help increase their effectiveness. Toward that end, this study examined how stigma was addressed and how audiences responded to evidence-based messages.

Methods:

Data were collected over a seven-year period and included observations of KT activities (conferences, workshops, and community meetings), focus groups and interviews conducted with providers, and a review of publicly available documents, including KT intervention materials. Clarke's situational mapping was initially applied, and stigma emerged as a critical contextual element. Data were then analyzed to identify how stigma was addressed and how evidence-based messages were received.

Results:

Despite direct stigma-reduction messages, biases against maternal drug use and ambivalence toward evidence-based recommendations of harm reduction principles were found in audience responses. Findings also revealed tensions around the interpretation of knowledge and the appropriate implementation of best practices between “experts” and among practitioners.

Discussion:

Stigma and professional biases may serve as significant barriers to KT activities. Results suggest that even under the best of circumstances, evidence-based practices for highly stigmatized and controversial issues are difficult to disseminate and may require unique approaches.
Structuring Mentoring in Medicine and Surgery. A Systematic Scoping Review of Mentoring Programs Between 2000 and 2019
Authors: Chua Wen Jie , Cheong Clarissa Wei Shuen , Lee Fion Qian Hui , Koh Eugene Yong Hian , Toh Ying Pin , Mason Stephen , Krishna Lalit Kumar Radha
Published: September 2020

Introduction:

Evidence of novice mentoring's successes in having senior clinicians support junior doctors and/or medical students in their clinical, academic, and research goals has spurred efforts to include mentoring in the core medical curriculum. However, lack of effective structuring threatens the viability of mentoring programs, precipitating ethical concerns about mentoring. This review aims to answer the question “what is known about mentoring structures in novice mentoring among medical students and junior doctors in medicine and surgery postings?,” which will guide the design of a consistent structure to novice mentoring.

Methods:

Levac (2010)'s framework was used to guide this systematic scoping review of mentoring programs in medicine and surgery published between 1 January 2000 and 31 December 2019 in PubMed, ScienceDirect, ERIC, Embase, Scopus, Mednar, and OpenGrey. A “split approach” involving concurrent independent use of a directed content analysis and thematic approach was used to analyze included articles.

Results:

Three thousand three hundred ninety-five abstracts were identified. There was concordance between the 3 themes and categories identified in analyzing the 71 included articles. These were the host organization, mentoring stages, and evaluations.

Conclusion:

The data reveal the need for balance between ensuring consistency and flexibility to meet the individual needs of stakeholders throughout the stages of the mentoring process. The Generic Mentoring Framework provides a structured approach to “balancing” flexibility and consistency in mentoring processes. The Generic Mentoring Framework is reliant upon appropriate, holistic, and longitudinal assessments of the mentoring process to guide adaptations to mentoring processes and ensure effective support and oversight of the program.
Health Professions Educators' System-Oriented Roles as Educational Advocate, Quality Improver, and Broker
Authors: Kumar Koshila , Schoo Adrian
Published: September 2020

Introduction:

Health professionals have many facets to their educational role. Although the teaching and student support dimensions of health professionals' educational role are highly visible in the literature, other nontraditional elements are not. This study presents a broader conceptualization of health professionals' educational role, with a focus on the strategic dimensions of their role.

Methods:

Participants were health professionals from different clinical backgrounds and teaching settings, with a formal role in education. Data were collected using a survey (n = 41) and interviews (n = 9), and this article focuses on reporting the qualitative findings of this study. Thematic analysis was used for data interpretation.

Results:

Health professionals have three strategic dimensions to their educational role. The first strategic dimension is educational advocacy, which is aimed at championing education at different levels and parts of the educational system and building educational capacity. The second strategic dimension is educational quality improvement which is focused on shifting narratives around education and educational change in health service settings and leveraging educational evidence. The final strategic dimension is educational brokerage which is oriented at connecting clinical and educational communities and building trust and consensus.

Discussion:

Beyond the microlevel of learning and teaching, health professionals engage in strategic work that is focused on the broader educational mission within health. Continuing professional development initiatives can empower health professionals to optimize these strategic and system-focused educational roles and responsibilities.
Definitions of Physician Certification Used in the North American Literature: A Scoping Review
Authors: Price David , Campbell Craig , Van Hoof Thomas J. , ElChamaa Rima , Jeong Dahn , Chappell Kathy , Moore Don , Olson Curtis , Danilovich Natalia , Kitto Simon
Published: September 2020

Introduction:

The authors sought to identify how physician specialty certification is defined in the North American literature.

Methods:

A rigorous, established six-stage scoping review framework was used to identify the North American certification literature published between January 2006 and May 2016 relating to physician specialty certification. Data were abstracted using a charting form developed by the study team. Quantitative summary data and qualitative thematic analysis of the purpose of certification were derived from the extracted data.

Results:

A two stage screening process identified 88 articles that met predefined criteria. Only 14 of the 88 articles (16%) contained a referenced purpose of certification. Eighteen definitions were identified from these articles. Definitional concepts included lifelong learning and continuous professional development, assessment of competence and performance, performance improvement, public accountability, and professional standing.

Discussion:

Most articles identified in this scoping review did not define certification or describe its purpose or intent. Future studies should provide a definition of certification to further scholarly examination of its intent and effects and inform its further evolution.
Hereditary breast cancer: translation into clinical practice of recent American Society of Clinical Oncology, American Society of Radiation Oncology, and Society of Surgical Oncology recommendations
Authors: Corso Giovanni , Magnoni Francesca
Published: September 2020

Scientific acquisitions concerning the risk of breast cancer in the context of hereditary breast cancer syndrome are constantly evolving: alongside the BRCA1 and BRCA2 mutations, further ones have been identified, also associated with malignancies in different sites. Therefore, management of these clinical conditions requires a multidisciplinary and shared approach, based on constantly updated guidelines. The recent Expert Panel Consensus about management of hereditary breast cancer, chaired by the Society of Surgical Oncology with the American Society of Clinical Oncology and the American Society of Radiation Oncology, based on the evidences obtained by a systematic review of the literature, delineate accurate and novel directions towards an appropriate surgical, radiation, and systemic therapy management of breast cancer patients with specific germline mutations. These recent recommendations will provide to physicians an updated and useful tool in treatment decision making of these patients in daily practice.
Brain cancer incidence: a comparison of active-duty military and general populations
Authors: Bytnar Julie A. , Lin Jie , Eaglehouse Yvonne L. , Enewold Lindsey , Shriver Craig D. , Zhu Kangmin
Published: September 2020

Background

In the USA, brain cancer disproportionately affects young adults. The US military has a younger age structure than the general population and may have differential exposures related to brain cancer. This study aimed to compare the incidence rates of brain cancer in the active-duty military and general populations to provide clues for future etiologic research. The rates between military service branches were also compared.

Methods

The data for this study were from the Department of Defense’s Automated Central Tumor Registry (ACTUR) and the National Cancer Institute’s Surveillance, Epidemiology, and End Results 9 (SEER-9) registries. Age- and sex-adjusted incidence rates of malignant neuroepithelial brain cancer among adults 20–54 years of age from 1990–2013 were calculated and compared between the two populations, given as incidence rate ratios (IRRs) with 95% confidence intervals (CIs).

Results

The age and sex-adjusted incidence rate for malignant neuroepithelial brain cancer was significantly lower in the active-duty population than in the US general population (IRR = 0.62, 95% CI,  0.56–0.68). The reduced incidence rate in the active-duty population was observed in men, all races, individuals 20–44 of age, and for all histological subtypes and time periods assessed. There were no significant differences in rates between the military service branches.

Conclusion

The incidence rates of neuroepithelial brain cancer were lower in the active-duty military population than the US general population. This study highlights the need for more research to enhance our understanding of variations in brain cancer incidence between these two populations.
Caring for the Poor
Authors: Yuchs Kimi Collyer , Bonham C. Elizabeth
Published: September 2020

Living in a culture of poverty challenges people when they seek healthcare. Attitudes of healthcare workers caring for the poor can affect both return to care and subsequent health outcomes. This quality improvement project at a U.S. Midwestern hospital employed a quasi-experimental design to examine the effect of a voluntary educational intervention on nurses' attitudes toward the culture of poverty. Findings indicated a significant positive change in attitude dealing with stigmatizing statements about people living in the culture of poverty.
What Are the Long-term Results of Cemented Revision THA with Use of Both Acetabular and Femoral Impaction Bone Grafting in Patients Younger Than 55 Years?
Authors: Verspeek Jason , Nijenhuis Thijs A. , Kuijpers Martijn F. L. , Rijnen Wim H. C. , Schreurs B. Willem
Published: September 2020

Background

The increasing number of THAs in younger patients will inevitably result in an increase of revision procedures. However, there is little evidence about the outcome of revision procedures in this patient group. Therefore, we updated a previous study conducted 5 years ago about the outcome of revision procedures in patients younger than 55 years.

Questions/purposes

We sought to provide a concise update on the previously reported (1) long-term failure rate as defined by repeat revision, (2) clinical outcome as defined by the Oxford Hip score and the Harris Hip score, and (3) radiographic outcome of cemented revision THA performed with impaction bone grafting on both the acetabular and femoral sides in one surgery in patients younger than 55 years old.

Methods

Between 1991 and 2007, we performed 86 complete THA revisions in patients younger than 55 years. In 38% (33 of 86) of revisions, bone impaction grafting was used on both the acetabular and femoral side because of acetabular and femoral bone stock loss. Mean age at time of revision was 46 ± 8 years. No patient was lost to follow-up, but six patients died during follow-up, including three since 2015. Still, the hips of all 33 patients were included in analysis at a mean of 17 ± 5 years. Failure was calculated using competing risk analysis. For clinical outcome, we assessed the Harris Hip score and the Oxford Hip score from our longitudinally maintained institutional database. Radiographic analysis was performed to evaluate radiographic loosening, defined as radiolucencies ≥ 2 mm in all zones or ≥ 5 mm migration for both components. The acetabular component was also considered loose with tilting ≥ 5°

Results

The 15-year failure rate of revision THA was 27% (95% CI 13 to 44) for re-revision of any component for any reason and 10% (95% CI 3 to 25) for re-revision of any component for aseptic loosening. The mean Harris Hip score increased from 55 ± 18 preoperatively to 74 ± 22 at latest follow-up. Eight cups were considered radiographically loose, seven of which were re-revised. No stems were considered radiographically loose. Failure rate with endpoint radiographic loosening at 15 years was 23% (95% CI 10 to 39).

Conclusion

We found that impaction bone grafting with a cemented cup and a cemented stem is a valuable biological revision technique that results in a stable and durable solution, after one or even multiple previous revision THAs. Although current implants may prove sufficient in most cases, they do not promote bone stock preservation. We believe that in young patients with bone stock loss, impaction bone grafting can be used as long as the defect can be contained adequately with a metal mesh and viable bone bed is available for revascularization.

Level of Evidence

Level IV, therapeutic study.
Semaglutide
Authors: Chan Mabel , Dimitriou Alexis , Lam Sum
Published: September 2020

Diabetes mellitus (DM) is a complex and chronic condition that requires continuous medical care. Uncontrolled hyperglycemia can lead to serious microvascular and macrovascular complications, such as coronary artery disease, peripheral arterial disease, and stroke. Type 2 DM occurs when the pancreas is unable to produce adequate insulin to regulate glucose levels and when there is a decrease in sensitivity to insulin in the body. Insufficient glucagon-like peptide (GLP-1), a normal body hormone, plays an important role in the pathophysiology of DM. The introduction of the GLP-1 receptor agonists expanded therapeutic options in achieving glycemic control in adult patients. In 2005, the US Food and Drug Administration approved exenatide as the first injectable formulation, which led to the advancement of other injectable formulations within the class of GLP-1 receptor agonists. In 2019, semaglutide was approved as the first oral GLP-1 receptor agonist addressing the unmet needs in patients who benefit from therapy with this therapeutic class yet are unwilling to use an injectable drug. This article will provide an overview of the GLP-1 receptor agonists, including the pharmacology of semaglutide, its clinical evidence and role in therapy in type 2 DM.
Attitudes on Prophylactic Antibiotic Use in Dermatologic Surgery: A Survey Study of American College of Mohs Surgery Members
Authors: Aizman Leora , Barbieri John S. , Lukowiak Tess M. , Perz Allison M. , Sobanko Joseph F. , Shin Thuzar M. , Higgins Harold William , Giordano Cerrene N. , Maher Ian A. , Golda Nicholas , Miller Christopher J. , Etzkorn Jeremy R.
Published: September 2020

BACKGROUND

Antibiotic prescriptions associated with dermatologic surgical visits are increasing and prescribing practices vary among surgeons.

OBJECTIVE

To describe dermatologic surgeons' attitudes and practices regarding prophylactic antibiotic use for surgical site infection (SSI), to compare current prescribing practices to those of a 2012 survey, and to determine surgeons' interest in clinical trial data on the utility of prophylactic antibiotics.

MATERIALS AND METHODS

This was a cross-sectional online survey of the American College of Mohs Surgery (ACMS) members. Survey items were adapted from a 2012 survey of ACMS members.

RESULTS

The survey was initiated by 101 ACMS members. 75.25% (76/101) of surgeons reported routinely prescribing prophylactic antibiotics to reduce SSI risk. The use of prophylactic antibiotics varied with clinical scenario. Most providers (84.21%, 64/76) prescribe postoperative antibiotics, with an average course of 6.56 days. 40.21% (39/97) of respondents were uncertain if prophylaxis prevents SSI, and up to 90.63% (87/96) indicated interest in clinical trial data evaluating the efficacy of oral antibiotics for SSI prevention.

CONCLUSION

Dermatologic surgeons continue to report varied attitudes and practices for SSI prophylaxis. Evidence from clinical trials is desired by surgeons to guide clinical practice.
Risk of Renal Cell Carcinoma Associated with Calcium Channel Blockers
Authors: Kristensen Kasper Bruun , Habel Laurel A. , Gagne Joshua J. , Friis Søren , Andersen Klaus Kaae , Hallas Jesper , Pottegård Anton
Published: September 2020

Background:

We examined whether the apparent association between renal cell carcinoma (RCC) and use of dihydropyridine calcium channel blockers (CCBs) was explained by confounding by indication since hypertension, the main indication for CCBs, is a risk factor for RCC.

Methods:

Using Danish health registries, we conducted a nested case-control study including 7315 RCC cases during 2000–2015. We matched each case with up to 20 controls on age and sex using risk-set sampling. We estimated odds ratios (ORs) for long-term CCB use associated with RCC using conditional logistic regression. We addressed confounding by indication by (1) adjusting for hypertension severity indicators; (2) evaluating dose-response patterns; (3) examining whether other first-line anti-hypertensives were associated with RCC; and (4) using an active comparator new user design by nesting the study in new users of CCBs or angiotensin-converting enzyme inhibitors (ACEIs).

Results:

The adjusted OR for RCC associated with long-term CCB use compared to non-use was 1.76 (1.63–1.90). After we additionally adjusted for hypertension severity indicators, the OR remained elevated (OR 1.37; confidence interval [CI] 1.25, 1.49) with evidence of a dose-response pattern. Other anti-hypertensives were also associated with RCC, for example, ACEIs (OR 1.27; 95% CI = 1.16, 1.39) and thiazides (OR 1.22; 95% CI = 1.12, 1.34). In the active comparator new user design, the OR was 1.21 (95% CI = 0.95, 1.53) for use of CCBs compared with ACEIs.

Conclusions:

In this population, confounding by indication appeared to explain at least part of the association between RCC and dihydropyridine CCBs.
Serotonergic antidepressants for sleep disturbances in perimenopausal and postmenopausal women: a systematic review and meta-analysis
Authors: Cheng Yu-Shian , Sun Cheuk-Kwan , Yeh Pin-Yang , Wu Ming-Kung , Hung Kuo-Chuan , Chiu Hsien-Jane
Published: September 2020

Importance:

Although previous meta-analyses mainly focused on the effects of hormonal treatment against menopausal sleep disturbances, the therapeutic role of antidepressants has not been systematically addressed.

Objective:

To study the therapeutic benefit and safety of antidepressants in menopausal sleep disturbances.

Evidence review:

Randomized controlled trials assessing the therapeutic effects of antidepressants against menopausal sleep problems were identified from the PubMed, Cochrane Library, and Science Direct databases from inception to March 1, 2020. Studies that were clinical trials with placebo controls were included. Subgroup analyses were conducted according to a random effects model.

Findings:

Analysis of seven eligible randomized controlled trials including a total of 1,949 perimenopausal and postmenopausal women showed the effectiveness of serotonergic antidepressants against sleep disturbances despite the small effect size (Hedge  g = 0.24, 95% CI = 0.11-0.38). The efficacy remained significantly better than that of placebo for postmenopausal women (Hedge  g = 0.25, 95% CI = 0.04-0.45), participants with hot flashes (Hedge g = 0.18, 95% CI = 0.02-0.34), and those without diagnosis of major depressive disorder (Hedge g = 0.23, 95% CI = 0.06-0.40). There was no difference in therapeutic benefit between sedating and nonsedating serotonergic antidepressants. Besides, the dropout rate did not differ between antidepressant and placebo groups.

Conclusions and Relevance:

Our results showed that serotonergic antidepressants were effective against sleep disturbances in perimenopausal and postmenopausal women. The efficacy remained significant for women without major depressive disorder. The dropout rates were also comparable between serotonergic antidepressants and placebo groups.
Behavioral and psychological health inequities in income disparate perimenopausal women: a brief report
Authors: Dickins Kirsten A. , Looby Sara E.
Published: September 2020

Objective:

To assess differences in behavioral and psychological health characteristics in perimenopausal women delineated by income disparity.

Methods:

A hypothesis generating secondary data analysis was conducted in 33 women, using public health insurance enrollment as a proxy for income. Sociodemographic characteristics were assessed. Study outcomes included behavioral health characteristics: current cigarette smoking, substance abuse history, current exercise, obesity (BMI ≥30); psychological health characteristics, and sleep: depressed mood (Center for Epidemiologic Studies Depression Scale [CES-D]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), and sleep (Insomnia Severity Index [ISI]). Group comparisons were assessed via the Student t test, Wilcoxon Rank-Sum test or Chi-square test, and multivariable models.

Results:

Forty-two percent (n = 14) were designated as income disparate, and sociodemographic characteristics were similar between groups; nearly half were Black/African American. More income disparate women reported current cigarette smoking [71% (10) vs 21%(4), P = 0.004] and substance abuse history [79%(11) vs 5%(1), P < 0.0001]. Fewer income disparate women reported current exercise [57%(8) vs 89%(17), P = 0.03] and more were obese [BMI ≥30; 50%(7) vs 11%(2), P = 0.01]. Income disparate women experienced significantly higher CES-D scores [13.5 (11.75, 23.75) vs 6 (0, 9), P < 0.0001], GAD-7 scores [5.5 (2, 8.75) vs 2 (0, 4), P = 0.04], and ISI scores [11 (5.55) vs 5 (4.36), P = 0.004].

Conclusions:

Findings from this preliminary analysis evidence inequities in behavioral, psychological, and sleep characteristics in perimenopausal women. Awareness of how the social determinants of health impact outcomes among vulnerable perimenopausal women is critical to developing equitable aging opportunities, including customized preventive health screenings and interventions that engage income disparate perimenopausal women.

Video Summary:

http://links.lww.com/MENO/A642.
Comparison of performance and health indicators between perimenopausal and postmenopausal obese women: the effect of high-intensity interval training (HIIT)
Authors: Jabbour Georges , Iancu Horia D.
Published: September 2020

Objective:

This study examined the effects of 6 weeks of high-intensity interval training (HIIT) on performance and health indicators in obese perimenopausal (PERIM) women and similarly aged and older postmenopausal women (POSTM1 and POSTM2, respectively).

Methods:

Sixteen PERIM women (average age 49.6 y), 21 POSTM1 women (average age 50.6 y), and 19 POSTM2 women (average age 69.6 y) completed a 6-week HIIT intervention. Anthropometric parameters, mechanical efficiency (ME in %), lipid oxidation (LO in %), and low and high spectral frequencies (LF[ms2] and HF[ms2]) were computed pre- and postintervention.

Results:

PERIM women showed a significantly higher VO2max preintervention compared to POSTM1 and 2 (P < 0.01). Moreover, HF, LF, and the LF/HF ratio differed significantly in PERIM women preintervention compared to POSTM1 and 2 (P < 0.01, respectively). After 6 weeks, a significant decrease in anthropometric variables was observed for all groups (P < 0.01). The VO2max in mL/kg/min increased for all groups (P < 0.01). Multiple linear regression analysis demonstrated that age contributed significantly to differences in VO2max values between groups preintervention (r = 0.72). This model accounted for 34% (r2 = 0.34) of the variation. On the other hand, menopause status was an independent predictor of LO, accounting for 38% of the variation, as well as of HF (33%), LF (29%), and the LF/HF ratio (24%). After HIIT, no age or menopause effect was detected for these independent variables.

Conclusions:

Maximal oxygen consumption, HF, LF, and the LF/HF ratio differ among women according to the menopausal status and age. A 6-week HIIT intervention improved many health and performance parameters and reduced the effects of menopause and age.
Pharmacologic therapy for pulmonary artery hypertension
Authors: Nair Ajith
Published: September 2020

Purpose of review

Pulmonary arterial hypertension (PAH) is a disease that carries a significant mortality left untreated. This article aims to review pharmacotherapeutics for PAH.

Recent findings

PAH-specific therapies have evolved over the last three decades and have expanded from one therapy in the 1990s to 14 FDA-approved medications. Current therapies are directed at restoring the imbalance of vasoactive mediators that include nitric oxide, endothelin and prostacyclin. Although these agents are effective as monotherapy, recent trials have promulgated the strategy of upfront combination therapy. The availability of oral prostacyclin agonists has also allowed for expanded treatment options. Risk assessment is vital in guiding therapy for PAH patients. There is ongoing focus on targeting pathological mechanisms of the disease via novel therapies and repurposing existing drugs.

There is an array of medications available for the treatment of PAH. Prudent combination of therapies to maximize treatment effect can improve morbidity and mortality. This article reviews the data supporting these therapies and attempts to outline an approach to patient management.
Low blood pressure and adverse outcomes in acute stroke: HeadPoST study explanations
Authors: Ouyang Menglu , Muñoz-Venturelli Paula , Billot Laurent , Wang Xia , Song Lili , Arima Hisatomi , Lavados Pablo M. , Hackett Maree L. , Olavarría Verónica V. , Brunser Alejandro , Middleton Sandy , Pontes-Neto Octavio M. , Lee Tsong-Hai , Watkins Caroline L. , Robinson Thompson , Anderson Craig S.
Published: September 2020

Objective:

As uncertainties exist over underlying causes, we aimed to define the characteristics and prognostic significance of low blood pressure (BP) early after the onset of acute stroke.

Methods:

Post hoc analyzes of the international Head Positioning in acute Stroke Trial (HeadPoST), a pragmatic cluster-crossover randomized trial of lying flat versus sitting up in stroke patients from nine countries during 2015–2016. Associations of baseline BP and death or dependency [modified Rankin scale (mRS) scores 3–6] and serious adverse events (SAEs) at 90 days were assessed in generalized linear mixed models with adjustment for multiple confounders. SBP and DBP was analysed as continuous measures fitted with a cubic spline, and as categorical measures with low (<10th percentile) and high (≥140 and ≥90 mmHg, respectively) levels compared with a normal range (≥10th percentile; 120–139 and 70–89 mmHg, respectively).

Results:

Among 11 083 patients (mean age 68 years, 39.9% women) with baseline BP values, 7.2 and 11.7% had low SBP (<120 mmHg) and DBP (<70 mmHg), respectively. Patients with low SBP were more likely to have preexisting cardiac and ischemic stroke and functional impairment, and to present earlier with more severe neurological impairment than other patients. Nonlinear ‘J-shaped’ relationships of BP and poor outcome were apparent: compared with normal SBP, those with low SBP had worse functional outcome (adjusted odds ratio 1.27, 95% confidence interval 1.02–1.58) and more SAEs, particularly cardiac events, with adjustment for potential confounders to minimize reverse causation. The findings were consistent for DBP and were stronger for ischemic rather than hemorrhagic stroke.

Conclusion:

The prognostic significance of low BP on poor outcomes in acute stroke was not explained by reverse causality from preexisting cardiovascular disease, and propensity towards greater neurological deficits and cardiac events. These findings provide support for the hypothesis that low BP exacerbates cardiac and cerebral ischemia in acute ischemic stroke.
Guidance Needed for Continued Employment of Long-term Contaminated Individuals
Authors: Paciello Lara R. , Owoc Julian J.
Published: September 2020

Operational practices in nuclear power utilities often restrict job assignments for workers with internal contamination due to the difficulty of monitoring for new intakes and strict radioactive material controls. However, restriction of job assignments for an extended period (i.e., months to years) may be too conservative. An industry consensus on guidance in these conditions would be helpful for Radiation Safety Officers (RSOs) to allow long term contaminated workers to have less work restrictions.
Attenuation of Gamma Radiation Using ClearView Radiation ShieldingTM in Nuclear Power Plants, Hospitals and Radiopharmacies
Authors: Bakshi Jayeesh , Chu Bae P.
Published: September 2020

Radiation protection materials, such as lead (Pb), water, concrete, steel, and aluminum, have been successfully used for decades. Although they are effective shields, these materials do have limitations. For example, lead is heavy and toxic, and water and concrete must be thick to provide significant shielding, all of which renders these materials prohibitive for certain applications. For example, the half-value layer for water to shield against 60Co is 30.48 cm (12”), which makes it an extremely bulky material. The development of ClearView Radiation Shielding™ addresses some of the limitations that are faced by traditional radiation protection shields. The product is a transparent liquid gamma radiation shield that can be fabricated in custom sizes and thicknesses. Here, we describe applications of ClearView Radiation Shielding in nuclear plants and hospitals. ClearView Radiation Shielding is used to shield nuclear power plant workers from 60Co in critical path and high dose in refueling outages to observe automated operations inside the containment, and operations such as cylindrical frisking stations and benchtop sampling. ClearView Radiation Shielding is designed as rolling shields and radionuclide containments in hospitals to protect staff and families during unsealed radionuclide treatment such as MIBG and Lutetium therapies. For successful implementation in hospitals, the product was tested against various radioisotopes, also described in this work. Operational uses of ClearView Radiation Shielding in commercial nuclear and medical industries allows staff working in radioactive environments visibility, better communication and similar levels of radiation protection compared with traditional shielding materials. The product helps improve workflows and reduced total dose received by workers. Additionally, attenuation measurements using ClearView Radiation Shielding against multiple isotopes was performed. With 1.25 cm (0.5”) ClearView Radiation Shielding thickness, the shield attenuated 1) 65% of the effective dose from 131I, 2) 35.15% of the effective dose from 137Cs, and 3) 22.5% of the effective dose from 60Co. Isotopes in the range of 35 keV to 1899 keV. 3.81 were attenuated greater than 90% with a ClearView Radiation Shielding shield thickness of 7.62 cm (3”). The half-value layer for 60Co with a ClearView Radiation Shielding thickness of 3.81 cm (1.5”) attenuated the effective dose of 18F gammas by 85.59%. With a density of 2.3 g cm−3, ClearView Radiation Shielding was measured to be half the weight of lead for equal shielding. ClearView Radiation Shielding is transparent, lightweight, and an alternative material to conventional radiation shields to reduce radiation exposure.
A Cyclotron Decommissioning Radiological Assessment Exercise Performed by Student Mentees Underrepresented in the Radiation Safety Profession
Authors: Zapata Jessie R. , Stewart Justice , Kelly Kalifa O. , Taylor Aaron R. , Martinez Erika I. , Amoako Kofi , Gutierrez Janet M. , Emery Robert J. , Cheng Sai Yan , Patlovich Scott J. , Harvey Mark C.
Published: September 2020

Cyclotrons used in nuclear medicine imaging accelerate protons, deuterons, and helium ions to bombard a target, which produces nuclear reactions that generate positron-emitting radionuclides. Secondary neutrons are nonuniformly emitted in these reactions and induce heterogeneous activation of the cyclotron components and concrete vault enclosure. This poses radioactive waste management complications when decommissioning a cyclotron facility, since the objective is to ensure that exposures are within regulatory limits and as low as reasonably achievable (ALARA). The McGovern Medical School in The University of Texas Health Science Center in Houston housed a Scanditronix MC40 cyclotron that produced short-lived radioisotopes for Positron Emission Tomography (PET) imaging from 1984 to 2001 until Tropical Storm Allison rendered it inoperable. The purpose of this study was to provide underrepresented Science, Technology, Engineering and Mathematics (STEM) students an ALARA experience with a practical problem encountered in the radiation safety profession. Gamma dose rate measurements were performed with both a Mirion InSpectorTM 1000 spectrometer and Fluke 451P survey meter in the vault at locations identified as hotspots based on preliminary scoping surveys with the Ludlum model 44-9 detector. However, gamma spectra were measured with the spectrometer exclusively at hotspots along the west wall. Results indicated the maximum gamma dose rate of 129 ± 31 nSv h−1 was about 2 times background near the central beam transport line of the now inoperable cyclotron. Furthermore, gamma emission peaks were identified in the spectra from trace amounts of 60Co and 152Eu in the vault’s concrete walls.
Exploring Perceived Interactions Between Consequences of Traumatic Brain Injury
Authors: van den Broek Brenda , Spauwen Peggy , Ponds Rudolf , van Heugten Caroline , Bus Boudewijn
Published: September 2020

Objective:

To explore the perceived interactions between consequences of traumatic brain injury (TBI).

Participants:

Fifteen clinicians experienced in working with patients with TBI.

Methods:

Participating clinicians completed an online questionnaire in which they estimated the degree to which consequences of TBI (taken from the Brief ICF Core Set for Traumatic Brain Injury) causally relate to each other. Based on these perceived interactions, a visual network was constructed and centrality measures for this network were computed.

Results:

The resulting network demonstrates various strong perceived causal relations between the consequences of TBI. Impairments in consciousness were perceived to most strongly cause other TBI consequences in the network. Difficulties with acquiring, keeping, and terminating a job were perceived to be most strongly caused by other TBI consequences. Difficulties in partaking in complex interpersonal interactions were also perceived to play a central role in the network.

Conclusion:

In the perception of clinicians, consequences of TBI interact with each other and are thus not solely a direct result of the injury. While more research is needed to map the interactions between consequences of TBI, our results could have important implications for the way we understand and treat the problems patients are faced with after TBI.
Comparing the Westmead Posttraumatic Amnesia Scale, Galveston Orientation and Amnesia Test, and Confusion Assessment Protocol as Measures of Acute Recovery Following Traumatic Brain Injury
Authors: Spiteri Courtney , Ponsford Jennie , Jones Harvey , McKay Adam
Published: September 2020

Background:

The duration of the acute period of recovery following traumatic brain injury (TBI) remains a widely used criterion for injury severity and clinical management. Consensus regarding its most appropriate definition and assessment method has yet to be established.

Objective:

The present study compared the trajectory of recovery using 3 measures: the Westmead Post-Traumatic Amnesia Scale (WPTAS), the Galveston Orientation and Amnesia Test (GOAT), and the Confusion Assessment Protocol (CAP). Patterns of symptom recovery using the CAP were explored.

Participants:

Eighty-two participants with moderate to severe TBI in posttraumatic amnesia (PTA) on admission to an inpatient rehabilitation hospital.

Design:

Prospective longitudinal study.

Outcome Measures:

Length of PTA (days), agreement between measures (%, κ coefficient), and pattern of symptom recovery.

Results:

Participants emerged from PTA earliest on the CAP followed the GOAT, and last on the WPTAS. There was good agreement between the CAP and the GOAT as to PTA status, but both tests had poor agreement with the WPTAS. Of patients considered out of PTA on the CAP, the majority exhibited signs of amnesia on the WPTAS and one-third had clinical levels of agitation.

Conclusion:

The WPTAS identifies a later stage of PTA recovery that requires specialized management due to ongoing amnesia and agitation. The CAP and the GOAT are less sensitive to this extended period of PTA.
De-implementing Prolonged Rest Advice for Concussion in Primary Care Settings: A Pilot Stepped Wedge Cluster Randomized Trial
Authors: Silverberg Noah D. , Otamendi Thalia , Panenka William J. , Archambault Patrick , Babul Shelina , MacLellan Anna , Li Linda C.
Published: September 2020

Objective:

To evaluate the feasibility and preliminary efficacy of a de-implementation intervention to support return-to-activity guideline use after concussion.

Setting:

Community.

Participants:

Family physicians in community practice (n = 21 at 5 clinics).

Design:

Pilot stepped wedge cluster randomized trial with qualitative interviews. Training on new guidelines for return to activity after concussion was provided in education outreach visits.

Main Measures:

The primary feasibility outcomes were recruitment, retention, and postencounter form completion (physicians prospectively recorded what they did for each new patient with concussion). Efficacy indicators included a knowledge test and guideline compliance based on postencounter form data. Qualitative interviews covered Theoretical Domains Framework elements.

Results:

Recruitment, retention, and postencounter form completion rates all fell below feasibility benchmarks. Family physicians demonstrated increased knowledge about the return-to-activity guideline (M = 8.8 true-false items correct out of 10 after vs 6.3 before) and improved guideline adherence (86% after vs 25% before) after the training. Qualitative interviews revealed important barriers (eg, beliefs about contraindications) and facilitators (eg, patient handouts) to behavior change.

Conclusions:

Education outreach visits might facilitate de-implementation of prolonged rest advice after concussion, but methodological changes will be necessary to improve the feasibility of a larger trial. The qualitative findings highlight opportunities for refining the intervention.
Cognition and Other Predictors of Functional Disability Among Veterans With Mild Traumatic Brain Injury and Posttraumatic Stress Disorder
Authors: Stika Monica M. , Riordan Patrick , Aaronson Alexandra , Herrold Amy A. , Ellison Rachael L. , Kletzel Sandra , Drzewiecki Michelle , Evans Charlesnika T. , Mallinson Trudy , High Walter M. , Babcock-Parziale Judith , Urban Amanda , Pape Theresa Louise-Bender , Smith Bridget
Published: September 2020

Background:

Limitations in everyday functioning are frequently reported by veterans with a history of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD). Multiple factors are associated with functional disability among veterans, including depression, poor social support, cognition, and substance use. However, the degree to which these factors, particularly cognitive capacities, contribute to functional limitations remains unclear.

Methods:

We evaluated performance on tests of processing speed, executive functioning, attention, and memory as predictors of functioning on the World Health Organization Disability Assessment Scale (WHODAS) 2.0 in 288 veterans. Participants were placed in one of the following groups: PTSD-only, mTBI-only, mTBI + PTSD, and neither PTSD nor mTBI (deployed control group). Cognitive test performances were evaluated as predictors of WHODAS 2.0 functional ratings in regression models that included demographic variables and a range of mood, behavioral health, and postconcussive symptom ratings.

Results:

Multiple cognitive test performances predicted WHODAS 2.0 scores in the deployed control group, but they generally did not predict functioning in the clinical groups when accounting for demographics, mood, behavioral health, and postconcussive symptoms.

Conclusions:

In veterans with mTBI and/or PTSD, cognitive test performances are less associated with everyday functioning than mood and postconcussive symptoms.
The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury
Authors: McKay Adam , Trevena-Peters Jessica , Ponsford Jennie
Published: September 2020

Objective:

This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior.

Design:

Observational prospective study with correlational design.

Setting:

Inpatient rehabilitation hospital for TBI.

Participants:

A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI.

Measures:

Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS).

Results:

Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase.

Conclusions:

Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.
Making a Difference: Affective Distress Explains Discrepancy Between Objective and Subjective Cognitive Functioning After Mild Traumatic Brain Injury
Authors: Hromas Gabrielle A. , Houck Zachary M. , Asken Breton M. , Svingos Adrian M. , Greif Sarah M. , Heaton Shelley C. , Jaffee Michael S. , Bauer Russell M.
Published: September 2020

Objective:

To assess the relationship between subjective cognitive symptoms and objective cognitive test scores in patients after concussion. We additionally examined factors associated with subjective and objective cognitive dysfunction, as well as their discrepancy.

Participants:

Eighty-six individuals (65.1% female; 74.4% adult) from an interdisciplinary concussion clinic.

Methods:

Subjective and objective cognitive functioning was measured via the SCAT—Symptom Evaluation and the CNS Vital Signs Neurocognition Index (NCI), respectively. Cognitive discrepancy scores were derived by calculating standardized residuals (via linear regression) using subjective symptoms as the outcome and NCI score as the predictor. Hierarchical regression assessed predictors (age, education, time postinjury, attention-deficit/hyperactivity disorder, affective distress, and sleep disturbance) of cognitive discrepancy scores. Nonparametric analyses evaluated relationships between predictor variables, subjective symptoms, and NCI.

Results:

More severe affective and sleep symptoms (large and medium effects), less time postinjury (small effect), and older age (small effect) were associated with higher subjective cognitive symptoms. Higher levels of affective distress and less time since injury were associated with higher cognitive discrepancy scores (β = .723, P < .001; β = −.204, P < .05, respectively).

Conclusion:

Clinical interpretation of subjective cognitive dysfunction should consider these additional variables. Evaluation of affective distress is warranted in the context of higher subjective cognitive complaints than objective test performance.