bluuebunny/crossref_metadata_2025 huggingface dataset:
What Is the State of Compassion Education? A Systematic Review of Compassion Training in Health Care
Authors: Sinclair Shane , Kondejewski Jane , Jaggi Priya , Dennett Liz , Roze des Ordons Amanda L. , Hack Thomas F.
Published: April 2021

Purpose

To investigate the current state and quality of compassion education interventions offered to health care providers during training or practice, determine how the components of each education intervention map onto the domains of an empirically based clinical model of compassion, and identify the most common approaches to compassion education.

Method

The MEDLINE, Embase, CINAHL Plus with Full Text, Sociological Abstracts, Web of Science, ERIC, and Education Research Complete databases were searched from inception to March 2020 in this systematic review. Studies that evaluated a compassion education intervention for health care providers or those in training to enhance compassion toward patients and/or families were included. A narrative synthesis of the included studies was performed. The components of each intervention were mapped onto the domains of compassion described in the Patient Compassion Model.

Results

One hundred eight peer-reviewed publications describing 103 interventions were included. Modalities ranged from establishing curricula and interventions in clinical settings to programs that used humanities-based reflective practices, clinical simulation, role modeling, and contemplative practices, with many education interventions adopting a multimodal approach. Most interventions mapped to the virtuous response domain of the Patient Compassion Model; very few mapped to the other domains of this model.

Conclusions

Most interventions were limited as they focused on a single domain of compassion; did not adequately define compassion; were assessed exclusively by self-report; were devoid of a comparator/control group; and did not evaluate retention, sustainability, and translation to clinical practice over time. The authors suggest that compassion education interventions be grounded in an empirically based definition of compassion; use a competency-based approach; employ multimodal teaching methods that address the requisite attitudes, skills, behaviors, and knowledge within the multiple domains of compassion; evaluate learning over time; and incorporate patient, preceptor, and peer evaluations.
Design of a Situational Judgment Test for Preclinical Interprofessional Collaboration
Authors: Black Erik W. , Schrock Bailey , Prewett Matthew S. , Blue Amy V.
Published: April 2021

Problem

There is an unmet need for economically feasible, valid, reliable, and contextually relevant assessments of interprofessional collaborative knowledge and skills, particularly at the early stages of health professions education. This study sought to develop and gather content and internal structure validity for an Interprofessional Situational Judgement Test (IPSJT), a tool for the measurement of students’ interprofessional collaborative intentions during the early stages of their professional development.

Approach

After engaging in an item development and refinement process (January–June 2018), an 18-question IPSJT was administered to 953 first-year students enrolled in 10 health professions degree programs at the University of Florida Health Science Center in October 2018. The IPSJT’s performance was evaluated using item-level analyses, item difficulty, test-retest reliability, and exploratory factor analysis.

Outcomes

Seven hundred thirty-seven (77.3%) students consented to the use of their data. Student IPSJT scores ranged from 0 to 69, averaging 42.68 (standard deviation = 12.28), with some statistically significant differences in student performance by health professions degree program. IPSJT item difficulties ranged from 0.13 to 0.92. Once one item with poor properties was excluded from analysis, the IPSJT demonstrated an overall reliability of 0.62. Students were more successful at identifying the least effective than the most effective responses. Test-retest reliability provided evidence of consistency (r = 0.50, P < .001) and similar item difficulty across administrations. An exploratory factor analysis indicated a 3-factor model with multiple cross-factor loadings.

Next Steps

This work represents the first step toward the development of a valid, reliable IPSJT for early learners. The emergent 3-factor model provides evidence that multiple competencies can be assessed in early learners via this tool. Additional research is necessary to build a more robust question bank, explore different scoring and response methods, and gather additional sources of validity evidence, including relations to other variables.
How Are the Arts and Humanities Used in Medical Education? Results of a Scoping Review
Authors: Moniz Tracy , Golafshani Maryam , Gaspar Carolyn M. , Adams Nancy E. , Haidet Paul , Sukhera Javeed , Volpe Rebecca L. , de Boer Claire , Lingard Lorelei
Published: April 2021

Purpose

Although focused reviews have characterized subsets of the literature on the arts and humanities in medical education, a large-scale overview of the field is needed to inform efforts to strengthen these approaches in medicine.

Method

The authors conducted a scoping review in 2019 to identify how the arts and humanities are used to educate physicians and interprofessional learners across the medical education continuum in Canada and the United States. A search strategy involving 7 databases identified 21,985 citations. Five reviewers independently screened the titles and abstracts. Full-text screening followed (n = 4,649). Of these, 769 records met the inclusion criteria. The authors performed descriptive and statistical analyses and conducted semistructured interviews with 15 stakeholders.

Results

The literature is dominated by conceptual works (n = 294) that critically engaged with arts and humanities approaches or generally called for their use in medical education, followed by program descriptions (n = 255). The literary arts (n = 197) were most common. Less than a third of records explicitly engaged theory as a strong component (n = 230). Of descriptive and empirical records (n = 424), more than half concerned undergraduate medical education (n = 245). There were gaps in the literature on interprofessional education, program evaluation, and learner assessment. Programming was most often taught by medical faculty who published their initiatives (n = 236). Absent were voices of contributing artists, docents, and other arts and humanities practitioners from outside medicine. Stakeholders confirmed that these findings resonated with their experiences.

Conclusions

This literature is characterized by brief, episodic installments, privileging a biomedical orientation and largely lacking a theoretical frame to weave the installments into a larger story that accumulates over time and across subfields. These findings should inform efforts to promote, integrate, and study uses of the arts and humanities in medical education.
Symptoms of Intoxication and Withdrawal in a Sample of Egyptian Patients Using Synthetic Cannabinoids: A Cohort Study
Authors: Morsy Mahmoud H.A. , Mohamed Yasser A.R. , El Habiby Mahmoud M. , Mohamed Nayera K. , Soliman Mahmoud F.
Published: April 2021

Introduction:

Novel psychoactive substances that contain synthetic cannabinoids (SCs) have recently started to be used recreationally, especially by young adults. In contrast to the decline in the use of many novel psychoactive substances such as the cathinones and piperazines, it seems that the number of SC users is increasing. Although SC drugs mimic the psychotropic effects of cannabis, their undesired effects are unpredictable and more severe than those associated with cannabis. The majority of SC detected in herbal products has greater binding affinity to the cannabinoid CB1 receptor than Δ9-tetrahydrocannabinol, the primary psychoactive compound in the cannabis plant, and greater affinity at the CB1 than the CB2 receptor. In vitro and animal in vivo studies show SC pharmacological effects to be 2 to 100 times more potent than tetrahydrocannabinol. A limited number of studies have examined SC use among patients; hence little is known about the effects of their use on patients during intoxication, withdrawal, and 1 month after cessation of use of SC.

Objective:

This study is a cohort study aiming to investigate the symptoms of intoxication, withdrawal, and 1-month cessation of SCs.

Patients and Methods:

Between February 2019 and February 2020, 92 adult patients using SCs aged 18 to 65 years from both the Outpatient Clinic and Inpatient Department of Psychiatry, Ain Shams University and Masr El Gedida (El Matar) Psychiatric Hospital, Ministry of Health were subjected to full history taking using clinical history sheet for the assessment of medical symptoms and Addiction Severity Index (the Arabic version was used).

Results:

There was a significant association between the use of SCs and development of multiple symptoms, both medical and psychiatric symptoms, and even serious side effects necessitating emergency management. Regarding the most common symptoms reported by the patient, the most common cardiovascular symptom during intoxication was palpitations, while the most common reported psychiatric symptom was hallucinations developed during intoxication. It was found that the patients who were hospitalized due to medical problems had higher amount and longer duration of use of SC.

Conclusion:

SC use can cause an array of symptoms ranging from mild medical and psychiatric symptoms to extreme side effects.
Pediatric Venous Thromboembolism: Different Rates of Incidence, Anatomic Locations, and Risk Factors Between Orthopaedic and Nonorthopaedic Related Patients
Authors: Samineni Aneesh V. , Sanborn Ryan , Shea Jodie , Cook Danielle , May Collin J. , Heyworth Benton E. , Shore Benjamin J.
Published: April 2021

Background:

The prevalence of venous thromboembolism (VTE) may be increasing in children; however, scarce literature exists comparing incidence rates between pediatric orthopaedic patients and other pediatric patients. The purpose of this study was to compare the incidence, anatomic locations, and risk factors of VTEs between orthopaedic and nonorthopaedic pediatric related patients to determine if important differences exist.

Methods:

Computed tomography and ultrasound data were reviewed for children (below 19 y old) with a diagnosed VTE between January 1, 2009 and December 31, 2016. Demographic and clinical data, including VTE anatomic location and risk factors, were recorded. Two major cohorts were identified: orthopaedic-related (ORTH) and nonorthopaedic-related (NORTH) VTEs. Incidence rates were estimated and risk factors were compared using χ2 testing.

Results:

There were 373 children diagnosed with a VTE (average age 10.3 y) of a total of 810,097 treated as in-patients for an incidence rate of 4.60 per 10,000 cases (95% confidence interval=4.15 to 5.10 per 10,000 cases). The rate of ORTH VTEs (28 of 188,669 orthopaedic patients, 1.48 per 10,000 cases) was significantly lower than that of NORTH VTEs (345 of 621,428 nonorthopaedic patients, 5.55 per 10,000 cases; P<0.001). For the ORTH cohort, there was a significant difference in the proportion of deep vein thrombosis in the lower extremity (91%) compared with the upper extremity (9%) (P<0.001), while a more even distribution of NORTH deep vein thrombosis in the upper (50%) and lower (41%) extremities was appreciated. The primary risk factors for ORTH VTEs included surgery (93%; P<0.001), change in ambulatory status (61%; P<0.001), and trauma (18%; P<0.001), while the primary risk factors for NORTH VTEs included intravenous peripheral inserted central catheter/central line (61%; P<0.001) and cancer (27%; P=0.001).

Conclusions:

Pediatric ORTH VTEs have a significantly lower incidence rate and different primary risk factors than those of NORTH VTEs. This information is useful for health care providers when making decisions regarding risk and prophylaxis in pediatric patients with orthopaedic and nonorthopaedic conditions.

Level of Evidence:

Level III.
Complex Fracture-Dislocations of the Elbow in the Pediatric Population
Authors: Magee Lacey C. , Baghdadi Soroush , Gohel Shivani , Sankar Wudbhav N.
Published: April 2021

Background:

Complex fracture-dislocations of the elbow, including terrible triad of the elbow, are serious injuries with guarded outcomes in adults. Although described extensively in adults, little is known about similar complex fracture-dislocations of the elbow in the pediatric population. The purpose of this study was to describe patterns of elbow dislocations with associated fractures in children and report the outcomes of these injuries.

Methods:

This was a retrospective review of patients who presented to a level I trauma center from 2007 to 2019 with an elbow dislocation and at least 2 associated fractures. Demographic data, fracture locations, and treatment modality were recorded. Operative reports and radiographs were reviewed to determine clinical outcomes and complications.

Results:

A total of 26 patients (mean age, 9.8 y) were identified. The majority of patients sustained an elbow dislocation and a medial epicondyle fracture (n=16). The most common third fractures involved the lateral condyle (n=8) or radial neck (n=7). At mean 6.03±3.11 months follow-up, 3 patients lacked ≥10 degrees of extension, and 2 patients lacked ≥15 degrees of flexion. Most patients had a Flynn score of “excellent” (n=20, 76.9%) or “good” (n=2, 7.7%). One patient with significant residual stiffness (>30 degrees flexion contracture) eventually underwent open contracture release.

Conclusions:

The most common complex elbow fracture-dislocation pattern in this series was an elbow dislocation with fracture of the medial epicondyle and lateral condyle or radial neck. In contrast to adult terrible triad injuries, most patients had a favorable clinical outcome, with nearly 80% excellent results and a low rate of complications.

Level of Evidence:

Therapeutic Level IV—case series.
Accessory Cuboid Facet Associated With Calcaneonavicular Coalitions
Authors: Scott Daniel J. , Riccio Anthony I. , Kanaan Yassine , Zide Jacob R.
Published: April 2021

Background:

Calcaneonavicular (CN) coalitions are the most commonly encountered tarsal coalition. No study has assessed anatomic variations of the adjacent joints in the presence of a CN coalition. This study sought to identify differences in the anatomy of the calcaneocuboid (CC) articulation in feet with and without CN coalitions.

Methods:

An institutional review board approved retrospective analysis of patients with symptomatic CN coalitions presenting to a single tertiary care pediatric orthopaedic hospital was performed. Patients without computed tomographic or magnetic resonance imaging were excluded. The morphology and dimensions of the cuboid portion of the CC joint were documented. When contralateral imaging was available in patients with a unilateral coalition, the morphology of the uninvolved side was evaluated to provide a cohort of controls for comparison.

Results:

Imaging was available for 55 patients who had a mean age of 11.7 years. There were 80 CN coalitions and 18 normal feet. An accessory cuboid facet was identified articulating with the calcaneal portion of the coalition in 60/80 (75%) feet in the coalition group. In feet with a coalition and an accessory facet, the mean total length of the cuboid articular surface measured 25.3 mm (range, 17.7 to 33.3 mm). The average length of the accessory facet was 10.7 mm (range, 5.4 to 15.5 mm), while the length of the primary vertical cuboid articulation with the calcaneus was 14.6 mm (range, 6.4 to 21 mm). The accessory facet comprised 42.3% of the cuboid articular surface in these patients. Feet without a coalition as well as feet with a coalition and no accessory facet had primary vertical cuboid articulations that were significantly larger than feet with a coalition and an accessory facet (P<0.0001). An accessory cuboid facet was identified in only a single control foot (5.6%).

Conclusions:

This study reports the frequent presence of an accessory cuboid facet in patients with CN coalitions. This facet was present in 75% of patients with CN coalitions and comprised just over 40% of the cuboid articular length. This anatomic variation represents a significant difference in CC joint morphology between feet with and without CN coalitions. This information may be useful when planning surgical resections.

Level of Evidence:

Level III—retrospective cohort study.
Does Surgical Experience Decrease Radiation Exposure in the Operating Room?
Authors: Magee Lacey C. , Karkenny Alexa J. , Nguyen Jie C. , Fazal Faris Z. , Talwar Divya , Zhu Xiaowei , Shah Apurva S.
Published: April 2021

Background:

Intraoperative fluoroscopy facilitates minimally invasive surgery, and although it is irreplaceable in terms of intraoperative guidance, it results in substantial radiation exposure to the patient and surgical team. Although the risk of radiation exposure because of equipment factors has been described, there is little known about the impact of surgeon experience on radiation exposure. The aim of this study was to determine whether there is a relationship between years of surgical experience and total dose of radiation used for an archetypal pediatric orthopaedic surgical procedure that requires intraoperative fluoroscopy.

Methods:

This was a retrospective cohort study of children undergoing closed reduction and percutaneous pinning for supracondylar humerus fractures at a level I pediatric trauma center. Information pertaining to radiation dosage was gathered including fluoroscopic time, total images acquired, magnification use, and dose area product (DAP). Regression analysis was used to evaluate the effect of surgeon experience on the outcome variables.

Results:

A total of 759 pediatric patients treated by 17 attending surgeons were included. The median surgeon experience was 8.94 years (interquartile range, 5.9 to 19.8). Increased number of pins was associated with increased DAP (P<0.001) and lower years of experience (P=0.025). There was significantly higher fluoroscopy time in seconds (56.9 vs. 42.1 s, P=0.001), DAP (179.9 vs. 110.3 mGy-cm2, P=0.001), use of magnification (39.5 vs. 31.9 s, P=0.043), and total number of images obtained (74.5 vs. 57.6, P=0.008) in attending surgeons with <1 year of experience compared with those with greater experience. An operator extremity was visible in at least 1 saved image in 263 of 759 (35%) cases.

Conclusion:

Increased surgical experience was significantly associated with decreased fluoroscopy usage, including time, number of images, and dose. Surgeon inexperience increases radiation exposure for patients and staff by over 60% when treating supracondylar humerus fractures. This study clearly identifies methods to reduce radiation exposure, including use of pulsed fluoroscopy instead of continuous fluoroscopy, decreasing use of magnification, removing the operator’s extremity from the field, and judicious use and placement of each additional pin.

Level of Evidence:

Level III.
Retrograde Extramedullary Lengthening of the Femur Using the PRECICE Nail: Technique and Results
Authors: Iobst Christopher A. , Bafor Anirejouritse
Published: April 2021

Background:

Lengthening of long bones by distraction osteogenesis is now possible using intramedullary lengthening nails. Constraints of bone size, medullary canal obstruction, and the presence of an open physis are contraindications in skeletally immature patients. We present a technique describing the “off-label” use of a magnetic lengthening nail placed extramedullary and in retrograde manner, for lengthening of the femur in skeletally immature patients.

Methods:

A retrospective review of 5 skeletally immature patients with significant length discrepancy of the femur are presented along with a description of the surgical technique. Data collected included age, sex, date of surgery, diagnosis, presence of associated deformities, the magnitude of length discrepancy, the amount of length gained, the amount of time to achieve full weight-bearing, the time to hardware removal, and any complications.

Results:

There were 5 patients (3 females). The mean age was 7.2±2.7 years (4 to 10 y). The mean limb length discrepancy was 6.5±3.7 cm (3.5 to 11 cm). A mean length of 3.46±0.4 cm (3.1 to 4 cm) was achieved which represents 12.9±1.8% (10.32 to 13.47%) of the bone length. The time taken to achieve full weight-bearing ambulation was 89.2±19.3 days (60 to 109 d) or 12.7 weeks. All hardware was removed 247.6±215.6 days (99 to 628 d) after surgery. Patients were followed up for a mean duration of 19.2 months (11 to 30 mo). No supplemental fixation was required and no complications were noted. Acute deformity correction was also performed at the time of surgery in 2 patients who had distal femur valgus deformity.

Conclusions:

Retrograde extramedullary lengthening of the femur is an option that should be considered for limb length equalization in skeletally immature patients. It avoids the inconvenience of external fixation and can be used to simultaneously correct deformities of the distal femur. Although the total amount of length gained is modest, we believe it is a promising limb lengthening technique that merits further investigation.

Level of Evidence:

Level III.
Combining Lower Extremity Radiographic Markers Begets More Accurate Predictions of Remaining Skeletal Growth
Authors: Yu Kristin E. , Coghill Griffin A. , Vernik David , Lapow Justin M. , Cooperman Daniel R.
Published: April 2021

Background:

Radiographic markers of skeletal maturity are vital to the prediction and interpretation of skeletal growth patterns. Accurate predictions of skeletal maturity factor into the management of common musculoskeletal disorders. Bone age is conventionally measured using hand and wrist radiographs. The primary study objective was to optimize skeletal maturity estimates based on the morphology of markers at the hip, knee, and foot rather than conventional upper extremity radiographs.

Methods:

This was a retrospective analysis of children from the Bolton-Brush collection with anteroposterior radiographs of the hip and anteroposterior and lateral radiographs of the knee and foot, and heights recorded at the time of each radiograph. The percent growth achieved (%GA) was calculated as a function of final patient height. Poor quality radiographs were excluded, leaving 50 patients—32 females and 18 males—and 1068 radiographs for analysis. Skeletal maturity was evaluated using the Oxford bone, O’Connor knee, and calcaneal apophyseal scores. Interrater and intrarater reliability analyses were performed for hip and knee scores. Multiple linear regressions were conducted on these scores and chronologic age as predictors of %GA. Mean differences were calculated between actual and estimated %GAs. All analyses were performed in Prism 8.0.

Results:

Each lower extremity skeletal maturity score served as statistically significant, independent predictors of %GA, the accuracy and strength of which increased with the addition of chronologic age. The integration of all 3 systems and chronologic age yielded the most predictive, accurate model predictive of %GA, which can be used to determine percent growth remaining. However, this fully integrated system was not statistically superior to the combination of knee and foot scores and knee score and chronologic age, which yield similarly accurate %GA predictions. The hip and knee systems demonstrated good to excellent interrater and intrarater reliability.

Conclusions:

Integration of bone age scores across different regions of the lower extremity has the potential to facilitate orthopaedic decision-making using radiographs already obtained in the treatment of pediatric musculoskeletal conditions.

Level of Evidence:

Level IV.
Variation in Initial U.S. Hospital Responses to the Coronavirus Disease 2019 Pandemic*
Authors: Mathews Kusum S. , Seitz Kevin P. , Vranas Kelly C. , Duggal Abhijit , Valley Thomas S. , Zhao Bo , Gundel Stephanie , Harhay Michael O. , Chang Steven Y. , Hough Catherine L.
Published: April 2021

OBJECTIVES:

The coronavirus disease 2019 pandemic has strained many healthcare systems. In response, U.S. hospitals altered their care delivery systems, but there are few data regarding specific structural changes. Understanding these changes is important to guide interpretation of outcomes and inform pandemic preparedness. We sought to characterize emergency responses across hospitals in the United States over time and in the context of local case rates early in the coronavirus disease 2019 pandemic.

DESIGN:

We surveyed hospitals from a national acute care trials group regarding operational and structural changes made in response to the coronavirus disease 2019 pandemic from January to August 2020. We collected prepandemic characteristics and changes to hospital system, space, staffing, and equipment during the pandemic. We compared the timing of these changes with county-level coronavirus disease 2019 case rates.

SETTING AND PARTICIPANTS:

U.S. hospitals participating in the Prevention and Early Treatment of Acute Lung Injury Network Coronavirus Disease 2019 Observational study. Site investigators at each hospital collected local data.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Forty-five sites participated (94% response rate). System-level changes (incident command activation and elective procedure cancellation) occurred at nearly all sites, preceding rises in local case rates. The peak inpatient census during the pandemic was greater than the prior hospital bed capacity in 57% of sites with notable regional variation. Nearly half (49%) expanded ward capacity, and 63% expanded ICU capacity, with nearly all bed expansion achieved through repurposing of clinical spaces. Two-thirds of sites adapted staffing to care for patients with coronavirus disease 2019, with 48% implementing tiered staffing models, 49% adding temporary physicians, nurses, or respiratory therapists, and 30% changing the ratios of physicians or nurses to patients.

CONCLUSIONS:

The coronavirus disease 2019 pandemic prompted widespread system-level changes, but front-line clinical care varied widely according to specific hospital needs and infrastructure. Linking operational changes to care delivery processes is a necessary step to understand the impact of the coronavirus disease 2019 pandemic on patient outcomes.
Quality of Life and Long-Term Mortality Among Survivors of Extracorporeal Membrane Oxygenation: A Nationwide Cohort Study in South Korea
Authors: Cho Hyoung-Won , Song In-Ae , Oh Tak Kyu
Published: April 2021

OBJECTIVES:

The quality of life after extracorporeal membrane oxygenation therapy has emerged as an important issue for extracorporeal membrane oxygenation survival; however, its association with long-term prognosis has not been identified. We investigated the changes in the quality of life after extracorporeal membrane oxygenation among the survivors and examine the association between a worse quality of life and 3-year all-cause mortality.

DESIGN:

This was a population-based cohort study.

SETTING:

Data were obtained from the National Health Insurance Service database in South Korea.

PATIENTS:

Adult individuals (≥ 18 yr old) who received extracorporeal membrane oxygenation therapy from 2006 to 2017 were included. Extracorporeal membrane oxygenation survivors were defined as patients who had survived for 1-year after the initiation of extracorporeal membrane oxygenation therapy.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

The income level, employment status, and registered disability were examined before and 1-year after extracorporeal membrane oxygenation therapy. The decreased income level, job loss, and newly acquired disability were considered as change in the quality of life among extracorporeal membrane oxygenation survivors. A total of 5,821 adult extracorporeal membrane oxygenation survivors were included in the final analysis, and 2,959 patients (50.8%) experienced quality of life change. Specifically, 1,782 patients (30.6%) experienced a decrease in income, 682 (11.7%) lost their jobs, and 1,540 (26.5%) had a new disability within 1-year after extracorporeal membrane oxygenation therapy. In the multivariable Cox regression model, newly acquired disability was associated with 2.31-fold higher 3-year all-cause mortality among extracorporeal membrane oxygenation survivors (hazard ratio, 2.31; 95% CI, 1.79–2.97; p < 0.001), while job loss (p = 0.180) and decreased income (p = 0.993) were not associated with the 3-year all-cause mortality.

CONCLUSIONS:

At 12 months after extracorporeal membrane oxygenation therapy, nearly half survivors experienced quality of life worsening such as unemployment, decreased income, and new disability. Additionally, among the three factors, acquiring a new disability might significantly increase the 3-year mortality. This is the first study to report the association between changes in the quality of life and long-term prognosis in extracorporeal membrane oxygenation survivors.
Current Trends in Sepsis-Related Mortality in the United States*
Authors: Prest Jonathan , Sathananthan Matheni , Jeganathan Niranjan
Published: April 2021

OBJECTIVES:

Sepsis is a life-threatening condition and is one of the leading causes of death in the United States. The burden of sepsis-related mortality in the United States in recent years is not well characterized. We sought to describe sepsis-related mortality rates and mortality trends in the United States from 2005 to 2018.

DESIGN:

Retrospective population-based study.

SETTING:

We used the Multiple Cause of Death Database available through the Centers for Disease Control and Prevention website.

PATIENTS:

Decedents with sepsis-related deaths were identified using previously validated International Classification of Diseases codes.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

From 2005 to 2018, 6.7% of decedents had a diagnosis of sepsis. The overall sepsis-related mortality rates remained stable in both males (57 deaths per 100,000) and females (45.1 deaths per 100,000) during this period. Compared with Whites, the sepsis-related mortality rates were higher in Blacks (rate ratio = 1.78), Native Americans (rate ratio = 1.43), and Hispanics (rate ratio = 1.04) and were lower in Asians (rate ratio = 0.73). Sepsis-related mortality rates declined in Blacks, Hispanics, and Asians but increased in Whites and Native Americans. The majority of sepsis-related deaths occurred in the hospital. The percentage of deaths in the nursing home decreased, whereas deaths occurring at home and hospice increased.

CONCLUSIONS:

From 2005 to 2018, the overall sepsis-related mortality rates were stable, but there were significant racial and gender disparities in mortality trends. Further research is needed to evaluate the genetic and environmental contributors to these differences.
Coronavirus Disease 2019 Policy Restricting Family Presence May Have Delayed End-of-Life Decisions for Critically Ill Patients
Authors: Azad Tej D. , Al-Kawaz Mais N. , Turnbull Alison E. , Rivera-Lara Lucia
Published: April 2021

OBJECTIVES:

To determine if a restrictive visitor policy inadvertently lengthened the decision-making process for dying inpatients without coronavirus disease 2019.

DESIGN:

Regression discontinuity and time-to-event analysis.

SETTING:

Two large academic hospitals in a unified health system.

PATIENTS OR SUBJECTS:

Adult decedents who received greater than or equal to 1 day of ICU care during their terminal admission over a 12-month period.

INTERVENTIONS:

Implementation of a visit restriction policy.

MEASUREMENTS AND MAIN RESULTS:

We identified 940 adult decedents without coronavirus disease 2019 during the study period. For these patients, ICU length of stay was 0.8 days longer following policy implementation, although this effect was not statistically significant (95% CI, –2.3 to 3.8; p = 0.63). After excluding patients admitted before the policy but who died after implementation, we observed that ICU length of stay was 2.9 days longer post-policy (95% CI, 0.27–5.6; p = 0.03). A time-to-event analysis revealed that admission after policy implementation was associated with a significantly longer time to first do not resuscitate/do not intubate/comfort care order (adjusted hazard ratio, 2.2; 95% CI, 1.6–3.1; p < 0.0001).

CONCLUSIONS:

Policies restricting family presence may lead to longer ICU stays and delay decisions to limit treatment prior to death. Further policy evaluation and programs enabling access to family-centered care and palliative care during the ongoing coronavirus disease 2019 pandemic are imperative.
The LN Flap for Nasal Defect Reconstruction: An 84-case Experience with a Novel Technique
Authors: Iyer Hari , Bussière Nicholas , Salib George Emmanuel
Published: April 2021

Background:

The nose is a common site for cutaneous malignancy and post-ablative reconstruction. To our knowledge, a myocutaneous island flap based on the levator labii superioris alaeque nasi (LLSAN) and nasalis muscles, with vascularity from the lateral nasal and angular arteries, has not been described for reconstruction of the lower lateral nose.

Methods:

A retrospective chart review of patients who underwent LLSAN-nasalis island flap reconstruction between 2015 and 2019 was performed. The surgical technique involved marking of an inverted-V flap on the nasal sidewall. The skin lateral to the flap was then developed in the subcutaneous plane to expose the LLSAN muscle and divide its origin on the maxillary frontal process and its caudal insertions into the alar dermis. The medial incision was down to periosteum and perichondrium, and dissection beneath the flap separated it from the nasal support structure. The resultant flap had a great caudal mobility. The donor site was closed in a V-to-Y pattern.

Results: In total,

84 procedures were completed, mostly for alar defects (57.1%) between 100 and 400 mm2 (71.4%). The average age of patients was 74.9 years. An estimated 27 patients were lost to follow-up. At mean follow-up of 24.3 weeks, there were no cases of flap necrosis, 1 case of hematoma (1.8%), 1 case of infection (1.8%), 3 cases of persistent trapdoor deformity (5.3%), and 3 cases of alar notching (5.3%), 1 of whom required revision surgery.

Conclusion:

The LLSAN-nasalis myocutaneous island flap is a simple, reliable technique for resurfacing lateral lower nasal defects up to 2 × 2 cm.
Factors associated with post-electroconvulsive therapy delirium
Authors: Jo Young Tak , Joo Sung Woo , Lee Jungsun , Joo Yeon Ho
Published: April 2021

Although electroconvulsive therapy (ECT) is generally a safe therapeutic method, unexpected adverse effects, such as post-ECT delirium, may occur. Despite its harmful consequences, there has been little discussion about the predictors of post-ECT delirium. Thus, the current study aimed to clarify the factors associated with post-ECT delirium by reviewing electronic medical records of 268 bitemporal ECT sessions from December 2006 to July 2018 in a university hospital.

Demographic and clinical characteristics of sessions involving patients with or without post-ECT delirium were compared. Multiple logistic regression analysis was applied to analyze the correlation between variables and post-ECT delirium.

Post-ECT delirium developed in 23 sessions (8.6%). Of all the demographic and clinical variables measured, only etomidate use was significantly different between delirium-positive and delirium-negative groups after Bonferroni correction. The regression model also indicated that etomidate use to be significantly associated with post-ECT delirium.

In this study, etomidate was associated with a higher risk of developing post-ECT delirium, an association that appeared unrelated to other possible measured variables. Practitioners should take into account the risk of post-ECT delirium while choosing anesthetics, so as to prevent early discontinuation before sufficient therapeutic gain is achieved.
Acupuncture therapy on chronic fatigue syndrome based on radar plot
Authors: Tang Lijie , Jiang Taijun , ZHu Feng-Ya , Liu ZHengkang , Wu Xi
Published: April 2021

Background:

Chronic fatigue syndrome (CFS) is a debilitating chronic disease of unknown etiology that is recognized by the World Health Organization (WHO) and the United States Center for Disease Control and Prevention (US CDC) as a disorder of the brain. CFS affects 1% (17–24 million people) of the world's population and is a major and costly public health problem. In traditional Chinese medicine (TCM), acupuncture can achieve a certain effect in the treatment of chronic fatigue syndrome, but evidence-based medicine is controversial. This protocol aims to multi-evaluate the literature quality and evidence quality of the current systematic reviews (SRs)/meta-analyses (MAs) of acupuncture treatment for chronic fatigue syndrome, and provide intuitive and reliable evidence synthesis and decision-making basis for clinical treatment.

Methods:

Eight databases will be searched from their inception to 1 June, 2020: the Chinese Biomedical Literature Database (CBM), China Science and Technology Journal Database (VIP), China National Knowledge Infrastructure (CNKI), WanFang Database (WF), Web of Science, Embase, PubMed, and Cochrane Library. Published systematic reviews that were reported in Chinese or English, and the included studies were randomized controlled clinical trials (RCTs) for acupuncture in people with CFS will be included. Reviews selection, data extraction and management, and assessment of the study quality will be completed independently by 2 or more reviewers. The quality of evidence, methodological quality, and reporting quality will be evaluated by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE), A Measurement Tool to Assessment of Multiple Systematic Reviews-2 (AMSTAR-2), Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), and Adobe Illustrator Creative Cloud (Adobe Illustrator CC) will be used to draw and optimize the radar plot.

Results:

The article in this overview will be submitted for publication in a peer-reviewed journal.

Conclusion:

We hope to collect evidence from accessible and useful systematic reviews of acupuncture treatment for chronic fatigue syndrome, to provide visual and scientific decision-making methods for more clinical practice and medical research.

Systematic Review Registration:

INPLASY 202060052.
Nonadherence to antihypertensive medications amongst patients with uncontrolled hypertension
Authors: Kulkarni Spoorthy , Rao Raunak , Goodman James Delman Harry , Connolly Kathleen , O'Shaughnessy Kevin M.
Published: April 2021

Medication nonadherence represents a modifiable risk factor for patients with hypertension. Identification of nonadherent patients could have significant clinical and economic implications in the management of uncontrolled hypertension.

We analysed the results of 174 urinary adherence screens from patients referred to Addenbrooke's Hospital, Cambridge, for uncontrolled hypertension. Cases were identified for evaluation by results of liquid chromatography-tandem mass spectrometry of urine samples (males: 91; females: 83; age range: 17–87). We performed a binary logistic regression analysis for nonadherence using age, sex, and number of medications prescribed (both antihypertensives and non-antihypertensives separately) as independent predictors. Rates of nonadherence for individual antihypertensive drugs were calculated if prescribed to ≥10 patients.

The overall rate of nonadherence to one or more prescribed antihypertensive medications was 40.3%. 14.4% of all patients were nonadherent to all prescribed antihypertensive medications (complete nonadherence), whereas 25.9% of all patients were nonadherent to at least 1, (but not all) prescribed antihypertensive medications (partial nonadherence). 72% of patients were prescribed ≥3 antihypertensives And for every increase in the number of antihypertensive medications prescribed, nonadherence increased with adjusted odds ratios of 2.9 (P < .001). Logistic regression showed that women were 3.3 times more likely to be nonadherent (P = .004). Polypharmacy (≥6 medications prescribed for hypertension and/or concomitant comorbidities) was prevalent in 52%. Bendroflumethiazide and chlortalidone demonstrated the highest and lowest nonadherences respectively (45.5% and 11.8%).

Rate of nonadherence in patients with hypertension was significantly impacted by sex and number of antihypertensive medications prescribed. Understanding these factors is crucial in identifying and managing nonadherence.
Compressive optic neuropathy (CON) in Graves’ disease caused by hypertrophy of levator and superior rectus muscles
Authors: Hirokawa Takahisa , Mimura Masashi , Tonari Masahiro , Sato Yohei , Fujita Yasushi , Matsuo Junko , Oku Hidehiro , Sugasawa Jun , Ikeda Tsunehiko
Published: April 2021

Rationale:

Enlargemento of the medial rectus is the most predominant factor of compressive optic neuropathy (CON) in Graves‘ disease. This case report indicates that CON could develop only from the hypertrophic superior levator and superior rectus (SL/SR) muscle in a patient with poorly controlled Graves‘ disease, and described the possible risk of FT3-thyrotoxicosis with a prominent goiter to develop the current rare case with a review of the literature.

Patient concerns:

A 66-year-old woman undergoing endocrine management of hyperthyroidism with prominent goiter visited the Department of Ophthalmology due to right-eye upper-eyelid retraction.

Diagnoses:

At initial presentation, the right and left margin reflex distance-1 (MRD-1) was 3.2 mm and 2.1 mm, respectively, and no proptosis or visual dysfunction was observed. Despite insufficient hormonal regulation, she refused to undergo goiter removal. The upper eyelid retraction gradually worsened to 7.7 mm of MRD-1, followed by the onset of 20 prism diopters (PD) of the right hypertropia, resulting in right-eye CON after 6 months. Her free thyroxin level was 3.88 ng/dl and free triiodothyronine was 24.90 pg/ml. Computed tomography and magnetic resonance imaging showed only SL/SR enlargement in the right orbit.

Interventions:

Intravenous steroid and radiation therapy resulted in visual improvement; however, a prominent upper eyelid retraction and 35PD of hypertropia remained in her right eye. Orbital decompression, upper retraction repair, and superior rectus recession were performed to prevent the recurrence of CON and correct any disfigurement.

Outcomes:

The combination of conventional intravenous steroid pulse therapy, radiotherapy, and orbital decompression was effective, and no recurrence was observed for more than 1.5-years postoperatively.

Lessons:

Enlargement of the SL/SR muscle complex may independently induce the CON. We believe that strict attention should be paid to patients with triiodothyronine thyrotoxicosis with progressive eyelid retraction and hypertropia.
Intravenous versus oral omeprazole on patients with high risk bleeding peptic ulcers
Authors: Zhang Jing , Diao Panya , Zhang Lin
Published: April 2021

Background:

Proton pump inhibitors (PPIs) decrease the rate of rebleeding following endoscopic hemostatic therapy in patients with bleeding peptic ulcers. This study compares the efficacy of oral omeprazole vs intravenous omeprazole in decrease of rebleeding of peptic ulcer patients.

Method:

The present study was authorized by the local research ethics committee of Jiangjin District Central Hospital (2020120987) and informed consent was obtained from all patients. All adult patients who were admitted to medical emergency rooms of Jiangjin District Central Hospital due to upper gastrointestinal bleeding (as evidenced by hematemesis, melena or hematochezia) were considered for inclusion in the study. Endoscopy was performed within 24 hours after admission. Patients older than 18 years with successful endoscopic therapy of high risk ulcers [defined as active bleeding (Forrest IA, IB), non-bleeding visible vessel (NBVV, Forrest IIA) or adherent clots (Forrest IIB)] were enrolled. Patients with low risk ulcers (clean base, ulcers with a simple washable clot), suspicious malignant ulcer, bleeding tendency, uremia, liver cirrhosis, Mallory Weiss tear or already on PPI as an outpatient were excluded from study. All were managed endoscopically by injecting 5–30 ml of epinephrine (diluted 1:10000) around the ulcer crater. Cavitations or flattening of bleeding vessel and disappearance of NBVV was considered as established homeostasis. A biopsy was taken from antrum for evaluating Helicobacter pylori infection. Patient with unsuccessful endoscopic therapy were not enrolled and were referred to general surgeon. Information on demography, history of previous upper gastrointestinal bleeding, NSAID or ASA ingestion, ulcer location, bleeding stigmata and blood transfusion volume at entry were recorded in all patients. In the oral omeprazole group, the patients received 40 mg omeprazole orally twice daily for 72 hours. In intravenous omeprazole group, they received omeprazole 80 mg bolus and then 8 mg/hour infusion for 48–72 hours. Then, all patients received omeprazole 20 mg orally for 30 days. On the day of discharge Helicobacter pylori infected patients received standard regimens.

Results:

Figure 1 showed the primary and secondary end points.

Discussion:

Intravenous administration of PPIs has limitations. They are expensive, require a dedicated intravenous line, need nursing supervision and hospital admission. So, it would be reasonable to prescribe oral PPIs to patients with high risk bleeding ulcers provided that it is as effective as its intravenous counterpart. Oral PPIs have a high bioavailability. Its effect initiates one hour after ingestion and the maximal plasma concentration is achieved after 2–3 hours. However, there are few studies comparing oral and intravenous PPI in decreasing risk of rebleeding in peptic ulcer patients. More high quality randomized controlled trials are still necessary.

Registration number:

researchregistry 6588
Palbociclib with letrozole as second-line neo-systemic therapy after failure of neo-adjuvant chemotherapy for luminal type breast cancer
Authors: Jung Sung Ui , Jung Minjung , Choi Jin Hyuk , Jeon Chang Wan
Published: April 2021

Rationale.

Neo-adjuvant systemic therapy includes endocrine therapy and chemotherapy, which is widely used. Luminal breast cancer is resistant to chemotherapy and is more likely to not respond to chemotherapy before surgery. Palbociclib is a cyclin-dependent kinase 4 and 6 inhibitor. Palbociclib with letrozole combination therapy was an effective chemotherapy in metastatic luminal type breast cancer and had fewer side effects; however, the benefit of palbociclib in neoadjuvant systemic therapy is unclear.

Patient concerns

A 50-year-old female patient visited our hospital with palpable lump in the right breast. The lymph nodes fixed in the ipsilateral axilla.

Diagnosis

The patient was diagnosed with invasive ductal carcinoma of the right breast; the nuclear grade was moderate. The ipsilateral fixed lymph node was diagnosed as metastasis. The breast cancer subtype was luminal A type and was positive for estrogen receptor and progesterone receptor, and negative for HER2/neu and Ki-67 marker index <10% on immunohistochemistry.

Interventions

Neo-systemic therapy was performed with 3 cycles of adriamycin with docetaxel. After follow-up study, the breast and axillary lesions progressed. Palbociclib with letrozole was administered as second neo-systemic therapy for 10 months. Subsequently, breast-conserving surgery with sentinel lymph node biopsy was performed.

Outcomes

In the postoperative pathologic result, 4 mm invasive lesion remained, and the sentinel lymph node biopsy was negative. The results achieved a residual cancer burden classification class 1.

Conclusion

Second-line neo-systemic therapy can further reduce the size of the tumor and increase the likelihood of avoiding the side effects of surgery. Palbociclib with letrozole may be a good treatment in the preoperative stage for luminal breast cancer that is resistant to chemotherapy.