bluuebunny/crossref_metadata_2025 huggingface dataset:
Lactate Level Versus Lactate Clearance for Predicting Mortality in Patients With Septic Shock Defined by Sepsis-3
Authors: Ryoo Seung Mok , Lee JungBok , Lee Yoon-Seon , Lee Jae Ho , Lim Kyoung Soo , Huh Jin Won , Hong Sang-Bum , Lim Chae-Man , Koh Younsuck , Kim Won Young
Published: February 2018

Objectives:

This study aimed to compare the prognostic value of lactate level and lactate clearance at 6 hours after septic shock recognition. And, we performed it to determine lactate kinetics in the Sepsis-3 defined septic shock.

Design:

This retrospective study was performed from a prospective septic shock registry.

Settings:

This study was performed at single urban tertiary center. And, all patients were treated with protocol-driven resuscitation bundle therapy between 2010 and 2016.

Patients:

We included septic shock patients who met the Sepsis-3 definition, which involves lactate levels greater than or equal to 2 mmol/L and vasopressor use.

Interventions:

Serum lactate levels were measured at initial and 6 hours from septic shock recognition.

Measurements and Main Results:

Lactate clearance was calculated as ([initial lactate – 6-hr lactate]/initial lactate) × 100. The prognostic value of measured lactate levels and lactate clearance for 28-day mortality was analyzed and compared with that of subsequent lactate levels greater than or equal to 2 mmol/L, greater than or equal to 3 mmol/L, and greater than or equal to 4 mmol/L and less than 10%, less than 20%, and less than 30% lactate clearance. A total of 1,060 septic shock patients by Sepsis-3, 265 patients died (28-d mortality: 25%). In survivor, groups had lower median 6-hour lactate level and higher lactate clearance than nonsurvivors (2.5 vs 4.6 mmol/L and 35.4% vs 14.8%; p < 0.01). Both lactate and lactate clearance were associated with mortality after adjusting for confounders (odd ratio, 1.27 [95% CI, 1.21–1.34] and 0.992 [95% CI, 0.989–0.995]), but lactate had a significantly higher prognostic value than lactate clearance (area under the curve, 0.70 vs 0.65; p < 0.01). The prognostic value of subsequent lactate levels (≥ 2, ≥ 3, and ≥ 4 mmol/L) and lactate clearances (< 10%, < 20%, and < 30%) was not significantly differed. However, lactate levels of greater than or equal to 2 mmol/L had the greatest sensitivity (85.3%).

Conclusions:

Our findings indicate lactate and lactate clearance are both useful targets in patients with septic shock defined by Sepsis-3. Serum lactate level at 6-hour can be an easier and more effective tool for prognosis of septic shock patients who were treated with protocol-driven resuscitation bundle therapy.
Impacts of Educating for Equity Workshop on Addressing Social Barriers of Type 2 Diabetes With Indigenous Patients
Authors: Crowshoe Lynden (Lindsay) , Han Han , Calam Betty , Henderson Rita , Jacklin Kristen , Walker Leah , Green Michael E.
Published: February 2018

Introduction:

Health education about Indigenous populations in Canada (First Nations, Inuit, and Métis people) is one approach to enable health services to mitigate health disparities faced by Indigenous peoples related to a history of colonization and ongoing social inequities. This evaluation of a continuing medical education workshop, to enhance family physicians' clinical approach by including social and cultural dimensions within diabetes management, was conducted to determine whether participation in the workshop improved self-reported knowledge, skills, and confidence in working with Indigenous patients with type 2 diabetes.

Methods:

The workshop, developed from rigorous national research with Indigenous patients, diabetes care physicians, and Indigenous health medical educators, was attended by 32 family physicians serving Indigenous populations on three sites in Northern Ontario. A same-day evaluation survey assessed participants' satisfaction with workshop content and delivery. Preworkshop and postworkshop surveys consisting of 5-point Likert and open-ended questions were administered 1 week before and 3 month after the workshop. Descriptive statistics and t test were performed to analyze Likert scale questions; thematic analysis was used to elicit and cluster themes from open-ended responses.

Results:

Participants reported high satisfaction with all aspects of the workshop. Reporting improved understanding of socioeconomic (P = .002), psychosocial, and cultural factors (P = .001), participants also described adapting their clinical approach to more actively incorporating social and cultural factors and focusing on patient-centered care.

Discussion:

The workshop was effective in shifting physician's self-reported knowledge, attitudes, and skills resulting in clinical approach modifications within social, psychosocial, and cultural domains for their Indigenous patients with diabetes.
Successfully Managing Impending Skin Necrosis following Hyaluronic Acid Filler Injection, using High-Dose Pulsed Hyaluronidase
Authors: Loh Kwok Thye David , Phoon Yi Shan , Phua Vanessa , Kapoor Krishan Mohan
Published: February 2018

Facial fillers are becoming increasingly popular as aesthetic procedures to temporarily reduce the depth of wrinkles or to contour faces. However, even in the hands of very experienced injectors, there is always a small possibility of vascular complications like intra-arterial injection of filler substance. We present a case report of a patient who developed features of vascular obstruction in right infraorbital artery and tell-tale signs of impending skin necrosis, after hyaluronic acid filler injection by an experienced injector. The diagnosis of a vascular complication was made quickly with the help of clinical features like blanching, livedo reticularis, and poor capillary refill. Patient was treated promptly with “high-dose pulsed hyaluronidase protocol” comprising three 1,000-unit pulses of hyaluronidase, administered hourly. There was no further increase in size of the involved area after the first dose of hyaluronidase. All of the involved area, along with 1 cm overlapping in uninvolved skin area, was injected during each injection pulse, using a combination of cannula and needle. Complete reperfusion and good capillary filling were achieved after completion of 3 pulses, and these were taken as the end-point of high-dose pulsed hyaluronidase treatment. Immediate skin changes after filler injections, as well as after hyaluronidase injections and during the 3-week recovery period, were documented with photographs and clinical notes. Involved skin was found to have been fully recovered from this vascular episode, thus indicating that complete recovery of the ischemic skin changes secondary to possible intra-arterial injection could be achieved using high-dose pulsed hyaluronidase protocol.
Spindle Cell Lipoma of the Thumb
Authors: Ebisudani Shogo , Osugi Ikuko , Inagawa Kiichi , Suzuki Yoshinori , Kimura Tomomi
Published: February 2018

We report the case of a 34-year-old man who presented with a 4-year history of a soft tissue on the palmar aspect of the thumb. Magnetic resonance imaging demonstrated the presence of a mass with heterogeneous high intensities on T1-weighted images and high intensities on T2-weighted images. We performed excisional biopsy. Histologically, the tumor was composed of mature adipocytes and spindle cells in a collagen background. Immunohistochemically, the tumor cells showed strong expression of CD34. Therefore, we diagnosed it as spindle cell lipoma. To the best of our knowledge, only 2 cases of spindle cell lipoma of the thumb have previously been reported.
Practices in Human Dignity in Palliative Care
Authors: Akin Korhan Esra , Üstün Çağatay , Uzelli Yilmaz Derya
Published: February 2018

Respecting and valuing an individual's existential dignity forms the basis of nursing and medical practice and of nursing care. The objective of the study was to determine the approach to human dignity that nurses and physicians have while providing palliative care. This qualitative study was performed using a phenomenological research design. In-depth semistructured interviews were conducted in 9 nurses and 5 physicians with human dignity approach in palliative care. Following the qualitative Colaizzi method of analyzing the data, the statements made by the nurses and physicians during the interviews were grouped under 8 categories. Consistent with the questionnaire format, 8 themes and 43 subthemes of responses were determined describing the human dignity of the nurse and the physicians. The results of the study showed that in some of the decisions and practices of the nurses giving nursing care and physicians giving medical care to palliative care patients, while they displayed ethically sensitive behavior, on some points, they showed approaches that violated human dignity and showed lack of awareness of ethical, medical, and social responsibilities.
A Conceptual Framework Encompassing the Psychoneuroimmunoendocrinological Influences of Listening to Music in Patients With Heart Failure
Authors: Burrai Francesco , Hasan Wohaib , Luppi Marco , Micheluzzi Valentina
Published: February 2018

Patients with heart failure have been traditionally treated with a pharmacology-based approach, diet, exercise, and rehabilitation for reducing symptoms, hospitalizations, and mortality. We have developed a solid conceptual framework for music listening–based protocols, showing how music may have a broad range of positive effects on cardiovascular health through psychoneuroimmunoendocrinological pathways.
A Window Toward the World
Authors: Hemberg Jessica , Santamäki Fischer Regina
Published: February 2018

The population in the Nordic countries, as well as globally, is increasingly becoming older. Concurrently, with an increased aging population, there is an increase in poor health and loneliness among older adults. The aim of this study was to uncover, from a caring science perspective, community-living older adults' experiences of interacting with others via real video communication. The study uses a hermeneutical approach. The material consists of interviews with older adults regarding their experiences of using real video communication. The texts were interpreted through hermeneutical reading. Study participation and data storage and handling for research purposes were approved by the participants when they provided their informed consent. Ethical permission to conduct this study was granted by a research board. The findings uncovered that welfare technology offers a metaphor—a window toward the world—that comprises the overarching core theme “Being in a movement toward becoming a unity as a human being,” and 3 main themes: “Alleviating suffering through beating involuntary solitude,” “Being in the world as an equal and dignified human being,” and “Dedicating new perspectives and meaning in life.” Welfare technology seems to be an important means to improve the quality of life for older adults living at home. Welfare technology enables older people to be in contact with other people in an easy way. Further research is needed to uncover issues of welfare technology from different perspectives.
Complementary Diagnostic Value of Heart Type Fatty Acid-binding Protein in Early Detection of Acute Myocardial Infarction
Authors: Sotoudeh Anvari Maryam , Karimi Mahsa , Shafiee Akbar , Boroumand Mohammadali , Bozorgi Ali , Sedaghat Reza , Jalali Arash
Published: February 2018

Background:

Heart-type fatty acid-binding protein (H-FABP) is a novel biomarker for myocardial injury. We compared the use of H-FABP with serum levels of cardiac troponin-T (cTnT) and creatine kinase-MB (CK-MB) in the diagnosis of patients suspicious to acute myocardial infarction (AMI).

Methods:

From October 2013 to December 2014, 182 consecutive patients suspicious to acute coronary syndrome were enrolled in this study, who presented within the past 6 hours from the onset of symptoms. Venous blood samples were drawn at baseline to measure serum biochemistry, high-sensitive cardiac troponin T (hs-cTNT), creatine kinase-MB, and H-FABP, and the measurements were repeated after 8 hours. The patients were categorized into 3 groups based on the baseline and second measurements of cTnT and general characteristics, and changes of H-FABP levels were then compared between the groups. Sensitivity and specificity of H-FABP in predicting the presence of AMI was calculated.

Results:

A total of 91 patients had AMI. Changes of H-FABP through time were also significantly different between the AMI and non-AMI patients (P < 0.001). A cutoff point of 7.15 for H-FABP could predict AMI with a sensitivity of 51.5%, specificity of 96.3%, and diagnostic accuracy of 68.3%. The area under the receiver operating characteristic curve for H-FABP at 8 hours was 79.4% (95% confidence interval: 73.0–85.9; P < 0.001). Positive predictive value and negative predictive value for H-FABP were 85% and 60%, respectively.

Conclusions:

H-FABP can be used as an additional cardiac biomarker in the diagnosis of AMI.
Contrast-Induced Nephropathy in STEMI Patients With and Without Chronic Kidney Disease
Authors: Jain Tarun , Shah Sunay , Shah Jainil , Jacobsen Gordon , Khandelwal Akshay
Published: February 2018

Introduction:

Contrast-induced nephropathy (CIN) following percutaneous coronary intervention (PCI) is associated with adverse outcomes; however, there are scarce data comparing clinical outcomes of post-PCI CIN in ST elevation myocardial infarction (STEMI) patients with and without chronic kidney disease (CKD). We sought to assess the incidence, clinical predictors, and short-term and long-term clinical outcomes of post-PCI CIN in STEMI patients with and without CKD.

Methods:

We performed a retrospective observational cohort study involving 554 patients who underwent PCI for STEMI from February 2010 to November 2013. CKD was defined as estimated glomerular filtration rate ≤60 mL/min and CIN as creatinine increase by ≥25% or ≥0.5 mg/dL from baseline within 72 hours after catheterization contrast exposure.

Results:

In the entire population, CIN developed in 89 (16%) patients. The incidence of CIN was 19.7% (27/137) in CKD patients and 11.1% (62/417) in non-CKD patients, P < 0.05. Univariate analysis predictors of CIN were older age (65 vs. 60 years), diabetes (35% vs. 21%), peripheral artery disease (11% vs. 5%), cardiogenic shock (24% vs. 13%), hemodynamic support placement (34% vs. 14%), and Mehran score (9.4 ± 7 vs. 5.4 ± 5.2) with all P < 0.05. The predictors of CIN were the same across the CKD and non-CKD cohort with the exception of diabetes. In multivariate analysis, the strongest predictor of CIN in CKD patients was diabetes (odds ratio, 5.8; CI, 1.8–18.6); however, diabetes was not a predictor in the non-CKD population. In the non-CKD population, each single unit increase in the Mehran score was associated with a 1.1 times greater likelihood of CIN (odds ratio, 1.1; CI, 1.01–1.2). Patients with CIN had higher rates of inpatient mortality (14.6% vs. 2.8%), longer length of hospitalization (8 ± 11 vs. 3.4 ± 4.4 days), need for inpatient dialysis (11.2% vs. 0%), higher 30-day mortality (14.6% vs. 3.0%), and higher incidence of long-term serum creatinine >0.5 mg/dL from baseline (16.9% vs. 2.4%) with all P < 0.05.

Conclusions:

Overall, we found that CKD patients undergoing PCI for STEMI have a higher incidence of CIN than non-CKD patients. CIN confers worse short-term and long-term outcomes irrespective of baseline renal function.
Development of an Outpatient Guideline for Optimal Anticoagulation Bridging in Patients With Durable Mechanical Circulatory Support
Authors: Levesque Amy A. , Rimsans Jessica M. , Sylvester Katelyn W. , Lyons Erin N. , Frankel Katie A. , Coakley Lara L. , Hickey Maryclare , Montoya Krystin A. , Mehra Mandeep R. , Givertz Michael M. , Stewart Garrick C. , Connors Jean M.
Published: February 2018

Patients with durable mechanical circulatory support are at increased risk of thromboembolic and bleeding complications. Current guidelines recommend that these patients receive chronic anticoagulation with warfarin to maintain a target international normalized ratio (INR) as specified by device manufacturers. Limited data exist regarding management of subtherapeutic INRs in this setting. To standardize clinical practice at our institution, we assembled a multidisciplinary task force including members from various specialties to develop a guideline for managing subtherapeutic INRs that incorporates published data and expert opinion. In this article, we present our clinical practice guideline as a decision support tool to aid clinicians in developing a consistent strategy for managing subtherapeutic INRs and for safely bridging anticoagulation in patients receiving mechanical circulatory support.
Implementation of an Early Discharge Protocol and Chest Pain Clinic for Low-Risk Chest Pain in the Emergency Department
Authors: Kashef Mohammad Amin , Garb Jane , Kugelmass Aaron , Lotfi Amir
Published: February 2018

Background:

Most of the patients presenting to emergency department with chest pain are at low risk of adverse events. Identifying high-risk patients can be challenging and resource intensive.

Methods:

We created a protocol to assist early discharge of low-risk adults with chest pain from emergency department. Also a chest pain clinic (CPC) was started for cardiology follow-up within 72 hours. In a retrospective cohort study, primary outcome of major adverse cardiac events (MACEs) of death, myocardial infarction, or revascularization was compared between CPC patients and those hospitalized for observation. In addition, rate of observation admissions and MACE were compared in the pre- and postintervention periods using piecewise regression and multiple logistic regression, respectively.

Results:

A total of 1422 patients were admitted for observation, and 290 were seen in CPC in the 1-year postintervention period. Thirty-day MACE was very low (0.7% in observation and 0.3% in CPC) postintervention. A total of 3637 patients were admitted for observation over the 2-year preintervention period. Thirty-day–adjusted MACE rate was not significantly different between pre- and postintervention periods (0.4% vs. 0.6%, P = 0.3), also monthly observation admissions did not change significantly; however, utilization of stress testing (57.2% vs. 41.0%, P < 0.001) and cardiac catheterization (2.3% vs. 1.6%, P = 0.036) was reduced.

Conclusion:

Chest pain patients admitted for observation and risk stratification are at very low risk of 30-day MACE. An intervention based on a chest pain protocol and availability of early cardiology follow-up did not change the admission rate of these patients. This intervention was not associated with increased risk of adverse outcomes.
Experiences of a One-hour Algorithm in Chest Pain Patients With a Nonelevated Troponin T at Presentation
Authors: Pettersson Anna , Ljung Lina , Johansson Caroline , Heilborn Umut , Jernberg Tomas , Frick Mats , Eggers Kai M. , Lindahl Bertil , Linder Rikard , Martinsson Arne , Svensson Per
Published: February 2018

Background:

We aimed to evaluate the use of a 1-hour measurement of high-sensitivity cardiac troponin T (hs-cTnT) in an emergency department (ED) population of chest pain patients with a nonelevated baseline hs-cTnT and to examine the prevalence of early dynamic changes in hs-cTnT and the association with admission rate, diagnosis, and outcome.

Methods:

All patients with a chief complaint of chest pain presenting to the ED of Karolinska University Hospital, Solna, Sweden, from December 2014 to September 2015 who had a baseline hs-cTnT of ≤14 ng/L and a second value obtained within >30 to ≤90 minutes were followed for 30 days regarding admission, readmission, myocardial infarction (MI), and death.

Results:

A total of 1091 patients were included. Dynamic 1-hour changes in hs-cTnT defined as an increase or decrease of ≥3 ng/L occurred in 23 patients (2.1%). Fifteen patients (65.2%) in the dynamic group were admitted, compared with 148 patients (13.9%) in the nondynamic group (P < 0.001). Four of the admitted patients (26.7%) in the dynamic and 1 (0.7%) in the nondynamic group were diagnosed with an MI (P < 0.001). No death or MI occurred within 30 days among those discharged from the ED.

Conclusions:

Dynamic 1-hour changes in hs-cTnT were uncommon but associated with a higher rate of admission and of MI in an unselected population of chest pain patients with a nonelevated hs-cTnT at presentation. Lack of dynamic changes makes MI highly unlikely, and a 1-hour measurement may facilitate an early rule out of MI but should be used together with clinical assessment.
Periareolar Access for Minimally Invasive Cardiac Surgery the Brazilian Technique
Authors: Poffo Robinson , Montanhesi Paola K. , Toschi Alisson P. , Pope Renato B. , Mokross Cláudio A.
Published: February 2018

The periareolar access has been the preferred technique used at our institution for minimally invasive cardiac surgery since 2006. The surgical approach consists of video-assisted minithoracotomy in the 4th right intercostal space, through a periareolar incision. Initially, the technique was restricted to minimally invasive mitral valve surgeries but, due to its feasibility and safety, was soon incorporated as an ideal access for other cardiac pathologies such as tricuspid valve disease, atrial septal defect, atrial fibrillation, and pacemaker leads endocarditis. The technique was performed in 214 patients, and it is associated with excellent aesthetic and functional results, with low morbimortality and no reoperations at long-term follow-up. Here, we describe and support the use of periareolar access as a routine surgical technique for correction of several cardiac pathologies, especially in women.
Per-Ventricular Insertion of Melody Valve-in-Valve in the Neoaortic Position in a Single-Ventricle Patient
Authors: Clarke Nicholas S. , El-Said Howaida , Lamberti John J. , Murthy Raghav A.
Published: February 2018

Percutaneous therapies for congenital heart disease have been evolving rapidly despite limited investment from industry. The Melody transcatheter pulmonary valve (Medtronic, Inc, Minneapolis, MN USA) replacement therapy represents an important advancement in this arena. It has been approved in the United States for use in the pulmonary position, on a Humanitarian Device Exemption status. Off-label use of the Melody transcatheter pulmonary valve has extended to the mitral, pulmonary, and aortic valves, especially in previously implanted valves with prosthetic valve degeneration. The single-ventricle patient poses additional challenges. However, there exists one report in the English literature of a patient undergoing Melody transcatheter neoaortic valve replacement after the patient developed severe neoaortic regurgitation after Fontan palliation. Here, we describe a patient with hypoplastic left heart syndrome, palliated with a Norwood modified Blalock-Taussig shunt, with a progressively regurgitant quadricusp neoaortic valve who underwent bioprosthetic valve replacement. There was early prosthetic valve degeneration after a year of bioprosthesis implantation. As he was declined for transplantation, he underwent successful perventricular Melody valve-in-valve replacement.
Left Axillary Artery Cannulation Facilitates Reoperative Total Aortic Arch Replacement
Authors: Hemli Jonathan M. , Gu Bo , Scheinerman S. Jacob , Brinster Derek R.
Published: February 2018

Total aortic arch replacement remains a technically formidable procedure, particularly in patients with previous proximal aortic dissection repair. Our case discussion highlights a useful strategy for extracorporeal support and circulation management to facilitate total arch reconstruction in the reoperative setting, based on cannulation of the left axillary artery. Our preference is to use a left axillary artery approach to initiate cardiopulmonary bypass and to ultimately revascularize the left arm via an extra-anatomic graft. Our technique, as described, affords the option to initiate cardiopulmonary bypass before sternal re-entry, it reduces the risk of embolic complications and possible stroke, and it directly facilitates simple extra-anatomic debranching of the left subclavian artery, resulting in easier arch and great vessel reconstruction within the chest.
Sternotomy Sparing Thoratec Heartmate 3 Implantation via Bilateral Minithoracotomy
Authors: Riebandt Julia , Wiedemann Dominik , Laufer Guenther , Zimpfer Daniel
Published: February 2018

A novel sternotomy sparing implantation technique for the Thoratec HeartMate 3 is described. Cannulation of the left ventricular apex is performed via a minithoracotomy in the left fourth or fifth intercostal space. The outflow graft is advanced through the pericardium to a second minithoracotomy in the right second intercostal space and then anastomosed to the ascending aorta. This approach was performed in three patients so far with no need for conversion. We did not observe any perioperative adverse events, such as bleeding or thromboembolic complications, as well as no short-term mortality. This technique is especially appealing in multimorbid and frail patients, future transplant candidates, and patients with impaired right ventricular function.
Mixed-methods development of a new patient-reported outcome instrument for chronic low back pain: part 1—the Patient Assessment for Low Back Pain - Symptoms (PAL-S)
Authors: Martin Mona L. , Blum Steven I. , Liedgens Hiltrud , Bushnell Donald M. , McCarrier Kelly P. , Hatley Noël V. , Ramasamy Abhilasha , Freynhagen Rainer , Wallace Mark , Argoff Charles , Eerdekens Mariёlle , Kok Maurits , Patrick Donald L.
Published: February 2018

We describe the mixed-methods (qualitative and quantitative) development and preliminary validation of the Patient Assessment for Low Back Pain–Symptoms (PAL-S), a patient-reported outcome measure for use in chronic low back pain (cLBP) clinical trials. Qualitative methods (concept elicitation and cognitive interviews) were used to identify and refine symptom concepts and quantitative methods (classical test theory and Rasch measurement theory) were used to evaluate item- and scale-level performance of the measure using an iterative approach. Patients with cLBP participated in concept elicitation interviews (N = 43), cognitive interviews (N = 38), and interview-based assessment of paper-to-electronic mode equivalence (N = 8). A web-based sample of patients with self-reported cLBP participated in quantitative studies to evaluate preliminary (N = 598) and revised (n = 401) drafts and a physician-diagnosed cohort of patients with cLBP (N = 45) participated in preliminary validation of the measure. The PAL-S contained 14 items describing symptoms (overall pain, sharp, prickling, sensitive, tender, radiating, shocking, shooting, burning, squeezing, muscle spasms, throbbing, aching, and stiffness). Item-level performance, scale structure, and scoring seemed to be appropriate. One-week test–retest reproducibility was acceptable (intraclass correlation coefficient 0.81 [95% confidence interval, 0.61-0.91]). Convergent validity was demonstrated with total score and MOS-36 Bodily Pain (Pearson correlation −0.79), Neuropathic Pain Symptom Inventory (0.73), Roland-Morris Disability Questionnaire (0.67), and MOS-36 Physical Functioning (−0.65). Individual item scores and total score discriminated between numeric rating scale tertile groups and painDETECT categories. Respondent interpretation of paper and electronic administration modes was equivalent. The PAL-S has demonstrated content validity and is potentially useful to assess treatment benefit in cLBP clinical trials.
Evaluation of the Effect of Fluvoxamine in Patients With Schizophrenia Under Risperidone Treatment
Authors: Haji Seyed Javadi Alireza , Shafikhani Ali Akbar , Zamir Seyed Mohsen , Khanshir Zahra Farzane
Published: February 2018

Purpose/Background

The effectiveness of selective-serotonin reuptake inhibitors in the improvement of schizophrenia is a controversial issue. The aim of this study was to evaluate the effect of fluvoxamine on the symptoms of schizophrenia including positive and negative symptoms, cognitive impairment, and quality of life.

Methods/Procedures

This clinical trial was performed on 68 patients with chronic schizophrenia, treated with risperidone at 22 Bahman Hospital of Qazvin, Iran during 2015 to 2016. The patients were randomly divided into control and intervention groups (34 patients per group). The control group was treated with risperidone and biperiden, whereas the intervention group received fluvoxamine, besides risperidone, and biperiden. The participants completed the Wechsler Memory Scale, Scale for the Assessment of Positive Symptoms, Scale for the Assessment of Negative Symptoms (SANS), and the World Health Organization Quality of Life Scale, and the findings were statistically analyzed at baseline and postintervention (8 and 10 weeks).

Findings/Results

The mean ± SD Wechsler Memory Scale scores in the evaluated intervals (baseline, week 8, and week 10), respectively, were 70.58 ± 11.51, 70.76 ± 11.36, and 70.88 ± 11.40 in the control group and 74.76 ± 10.56, 77.76 ± 10.56, and 77.76 ± 10.73 in the intervention group (F = 126.73, P ≤ 0.001). The difference between the groups in terms of SANS and quality of life scores was significant in the specified intervals, SANS (F = 6.36, P = 0.004), and quality of life (F = 15.13, P ≤ 0.001). Nevertheless, no difference was observed in terms of Scale for the Assessment of Positive Symptoms scores (P > 0.05).

Implications/Conclusions

The results indicated that risperidone augmentation with fluvoxamine could significantly improve cognitive impairments and negative symptoms among patients with schizophrenia. Moreover, this augmentation led to higher quality of life among these patients.
An Outpatient Heart Failure Clinic Reduces 30-Day Readmission and Mortality Rates for Discharged Patients: Process and Preliminary Outcomes
Authors: KOSER Kristin Danielle , BALL Lisa S. , HOMA Jennifer K. , MEHTA Vinay
Published: February 2018

Background:

The first outpatient heart failure clinic (HFC) in Western New York was developed within a large private cardiology practice with the objective of reducing 30-day all-cause rehospitalization and inpatient mortality.

Purpose:

The aim of this study was to analyze the process and patient outcomes of this independent outpatient HFC. The specific aims were to (a) describe the outpatient care strategies employed and (b) determine whether the HFC reduced 30-day all-cause rehospitalizations and inpatient mortality by comparing HFC data with census data.

Methods:

This study used a retrospective chart analysis of 415 adults who had been enrolled in the target HFC after hospitalization for HF. Data were summarized using frequency comparisons and descriptive statistics. One-sample chi-square tests were conducted to test the observed values in the study sample against census data.

Results:

Patients in the HFC were less likely to experience a readmission to hospital within 30 days of discharge (69% reduction within the study period, p < .001). Patients were seen acutely after discharge, had multiple medication adjustments, and received ongoing telephonic follow-up. The HFC had statistically lower inpatient mortality rates (1.2% vs. 11.6% national average, p < .001), likely a result of the HFC care regimen and referrals for palliative care (17%).

Conclusions:

The results of this analysis highlight the importance of developing an outpatient HFC in collaboration with hospitals that is aimed at reducing 30-day all-cause readmissions and inpatient mortality, with referral to palliative care when indicated.
Ventricular Assist Device Patients Have Different Clinical Outcomes and Altered Patterns of Bleeding with Intracranial Hemorrhage
Authors: Ahmed Mustafa M. , Rahman Maryam , Neal Dan , Aranda Juan M. , Klodell Charles T.
Published: February 2018

Intracranial hemorrhage (ICH) is one of the most feared complications of left ventricular assist device (LVAD) support. However, outcomes in this group have not been well described. We therefore sought to examine clinical outcomes in this patient population in comparison to those with heart failure (HF) and no LVAD, as well as those without HF or LVAD. The National Inpatient Sample database, years 2002–2012, was queried to classify patients into 3 groups: any ICH (group 1), any HF with any ICH (group 2), and any LVAD with any ICH (group 3). Clinical outcomes, hemorrhage type, neurosurgical intervention rates, and hospital factors were collected and analyzed. Group 1 consisted of 419,264 patients, group 2 had 41,186, and group 3 had 118 patients. Group 3 patients were more likely to be in large, academic medical centers, with longer length of stay and higher hospital charges. Inpatient mortality was highest in this group at 39%; however, 46.2% were ultimately discharged to home. Patients in group 3 were more likely to have a subarachnoid or intracerebral hemorrhage versus a subdural or epidural hemorrhage. Neurosurgical intervention rates did not differ between the groups. Although LVAD patients with ICH have worse clinical outcomes, the majority survived their event and nearly half were able to be discharged home. Left ventricular assist device patients also have a distinct pattern of bleeding with ICH. Additional study is required to understand risk factors for the development of ICH in this population and ideal management strategies.
Should fecal microbial transplantation be used in the ICU?
Authors: McClave Stephen A. , Patel Jayshil , Bhutiani Neal
Published: February 2018

Purpose of review

Maintaining gut barrier defenses, modulating immune responses, and supporting the role of commensal microbiota are major factors influencing outcome in critical illness. Of these, maintaining a commensal ‘lifestyle’ and preventing the emergence of a virulent pathobiome may be most important in reducing risk of infection and multiple organ failure.

Recent findings

The polymeric formulas utilized for enteral nutrition in the ICU are absorbed high in the gastrointestinal tract and may not reach the microbial burden in the cecum where their effect is most needed. The provision of a few select probiotic organisms may be insufficient to refaunate the gut and establish a ‘recovery pattern,’ propelling the patient toward health and homeostasis. Use of fecal microbial transplantation (FMT) appears to be a more successful strategy for replenishing the intestinal microbiome and maintaining its commensal phenotypic expression.

FMT has become an attractive option to mitigate multiple organ dysfunction in the ICU. This article discusses the physiology, rationale, early experience, and expectations for such therapy in the critically ill patient.
Regulation of intestinal lipid and lipoprotein metabolism by the proglucagon-derived peptides glucagon like peptide 1 and glucagon like peptide 2
Authors: Mulvihill Erin E.
Published: February 2018

Purpose of review

The intestine is highly efficient at absorbing and packaging dietary lipids onto the structural protein apoB48 for distribution throughout the body. Here, we summarize recent advances into understanding the physiological and pharmacological actions of the proglucagon-derived peptides: glucagon like peptide 1 (GLP-1) and glucagon like peptide 2 (GLP-2) on intestinal lipoprotein secretion.

Recent findings

Several recent studies have elucidated mechanisms underlying the paradoxical effects of GLP-1 and GLP-2 on intestinal production of triglyceride-rich lipoproteins (TRLs). Both gut-derived peptides are secreted on an equimolar basis in response to the same nutrient stimulus. Despite neither receptor demonstrating clear localization to enterocytes, a single injection of a GLP-1R agonist rapidly decreases delivery of intestinally packaged fatty acids into the plasma, while conversely GLP-2 receptor (GLP-2R) activation acutely increases TRL concentrations in plasma.

The regulation of TRL secretion is dependent on the coordination of many processes: fatty acid availability uptake, assembly onto the apoB48 polypeptide backbone, secretion and reuptake, which the hormonal, neural, inflammatory and metabolic milieu can all strongly influence. Understanding of how GLP-1 and GLP-2 receptor agonists control TRL production has clinical importance given that GLP1R agonists were recently demonstrated not only to provide glycemic control but also to prevent major adverse cardiovascular events in patients with T2DM and the success of GLP-2R agonists in treating short bowel disease.
13C‐Mixed Triglyceride Breath Test and Fecal Elastase as an Indirect Pancreatic Function Test in Cystic Fibrosis Infants
Authors: Kent Dorothea Stark , Remer Thomas , Blumenthal Caron , Hunt Sharon , Simonds Sharon , Egert Sarah , Gaskin Kevin J.
Published: February 2018

Background:

The ‘gold standard’ test for the indirect determination of pancreatic function status in infants with cystic fibrosis (CF), the 72‐hour fecal fat excretion test, is likely to become obsolete in the near future. Alternative indirect pancreatic function tests with sufficient sensitivity and specificity to determine pancreatic phenotype need further evaluation in CF infants.

Objective:

Evaluation of the clinical utility of both the noninvasive, nonradioactive 13C‐mixed triglyceride (MTG) breath test and fecal elastase‐1 (FE1) in comparison with the 72‐hour fecal fat assessment in infants with CF.

Methods:

13C‐MTG breath test and the monoclonal and polyclonal FE1 assessment in stool was compared with the 72‐hour fecal fat assessment in 24 infants with CF. Oral pancreatic enzyme substitution (PERT; if already commenced) was stopped before the tests.

Results:

Sensitivity rates between 82% and 100% for CF patients with pancreatic insufficiency assessed by both the 13C‐MTG breath test and the FE1 tests proved to be high and promising. The 13C‐MTG breath test (31%–38%) as well as both FE1 tests assessed by the monoclonal (46%–54%) and the polyclonal (45%) ELISA kits, however, showed unacceptably low‐sensitivity rates for the detection of pancreatic‐sufficient CF patients in the present study.

Conclusions:

The 13C‐MTG breath test with nondispersive infrared spectroscopy (NDIRS) technique, as well as both FE1 tests, are not alternatives to the fecal fat balance test for the evaluation of pancreatic function in CF infants during the first year of life.
Limited Documentation and Treatment Quality of Glycemic Inpatient Care in Relation to Structural Deficits of Heterogeneous Insulin Charts at a Large University Hospital
Authors: Kopanz Julia , Lichtenegger Katharina M. , Sendlhofer Gerald , Semlitsch Barbara , Cuder Gerald , Pak Andreas , Pieber Thomas R. , Tax Christa , Brunner Gernot , Plank Johannes
Published: February 2018

Objectives

Insulin charts represent a key component in the inpatient glycemic management process. The aim was to evaluate the quality of structure, documentation, and treatment of diabetic inpatient care to design a new standardized insulin chart for a large university hospital setting.

Methods

Historically grown blank insulin charts in use at 39 general wards were collected and evaluated for quality structure features. Documentation and treatment quality were evaluated in a consecutive snapshot audit of filled-in charts. The primary end point was the percentage of charts with any medication error.

Results

Overall, 20 different blank insulin charts with variable designs and significant structural deficits were identified. A medication error occurred in 55% of the 102 audited filled-in insulin charts, consisting of prescription and management errors in 48% and 16%, respectively. Charts of insulin-treated patients had more medication errors relative to patients treated with oral medication (P < 0.01). Chart design did support neither clinical authorization of individual insulin prescription (10%), nor insulin administration confirmed by nurses’ signature (25%), nor treatment of hypoglycemia (0%), which resulted in a reduced documentation and treatment quality in clinical practice 7%, 30%, 25%, respectively.

Conclusions

A multitude of charts with variable design characteristics and structural deficits were in use across the inpatient wards. More than half of the inpatients had a chart displaying a medication error. Lack of structure quality features of the charts had an impact on documentation and treatment quality. Based on identified deficits and international standards, a new insulin chart was developed to overcome these quality hurdles.
Improving Patient Safety Culture: A Report of a Multifaceted Intervention
Authors: Basson Tom , Montoya Alfred , Neily Julia , Harmon Lisa , Watts Bradley V.
Published: February 2018

Objective

The aim of the study was to improve the safety culture at a Veterans Administration hospital using evidence-based approaches.

Methods

We implemented a patient safety summit with follow-up actions. We measured safety climate before and after the summit using the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety Culture with modifications and the Safety Attitudes Questionnaire (SAQ). The summit brought hospital leaders together to discuss patient safety topics and relate them to our hospital. At the summit’s end, hospital workgroups collectively submitted Safety Culture Action forms, indicating their intended actions to improve safety culture. We analyzed all survey results using the χ2 test. We shared lessons learned.

Results

The hospital leadership started safety walk rounds. There were 107 hospital employees at the summit. Attendees submitted 53 Safety Culture Action forms. We received 232 AHRQ survey responses in 2014 and 116 in 2016, for response rates of approximately 11% and 8.9%, respectively. We received 140 SAQ responses (11%) from 1244 employees in 2016 and 242 responses (18%) from 1342 employees in 2017. The AHRQ survey results indicated that perception of teamwork within hospital units improved. The SAQ results indicated that employees’ comfort with reporting errors and expressing disagreement with physicians improved, and employees’ perceptions of leadership’s safety efforts and the levels of staffing worsened.

Conclusions

Although some aspects of safety culture improved after the summit and follow-up interventions, others did not. Future interventions should be targeted toward individual microsystems or units and measure safety climate perceptions for intervention recipients exclusively.
Patient-Reported Experience in the Pediatric Emergency Department: What Matters Most?
Authors: Barbarian Mher , Bishop Andrea , Alfaro Patricia , Biron Alain , Brody Daniel Adam , Cunningham-Allard Gabrielle , Dubrovsky Alexander Sasha
Published: February 2018

Introduction

Although the Child Hospital Consumer Assessment of Healthcare Providers and Systems is a validated tool for the inpatient experience, it may not address features unique to the pediatric emergency department (PED). There is currently no publicly available validated patient-reported experience survey for the PED, and what matters most in this setting remains unknown.

Methods

Twelve semistructured interviews were conducted with a convenience sample of parents of children younger than 14 years at a Canadian PED. Data analysis was performed using inductive thematic analysis to identify aspects of patient-reported experiences that matter most to parents in the PED.

Results

Five themes were identified: (1) making waiting a positive experience, (2) taking the time to provide care, (3) forging a positive partnership, (4) speak up for safe care, and (5) making the environment feel safer. Parents highlighted that while waiting for care is not desirable, it is made more acceptable through the communication of wait time estimates and the presence of child activities in the waiting room. Furthermore, although interactions with providers are brief, parents emphasized the importance of creating an environment of partnership with open communication, taking the time to examine their child, and actively demonstrating the provision of safe, quality care.

Conclusions

Results from this study suggest that a patient-reported experience survey in the PED may need to embed elements not currently captured in Child Hospital Consumer Assessment of Healthcare Providers and Systems, such as waiting room experience, comprehensiveness of health assessments, and observations of safety measures. Future studies can use these findings to develop a patient-reported experience survey for use in the PED.
18F-Choline PET/MR Can Detect and Delineate Local Recurrence After High-Intensity Focused Ultrasound Therapy of Prostate Cancer
Authors: Burger Irene A. , Gafita Andrei , Müller Julian , Kranzbühler Benedikt , Donati Olivio F. , Eberli Daniel
Published: February 2018

Restaging local recurrence after high-intensity focused ultra-sound (HIFU) is based on multiparametric MRI (mpMRI). However, postinterventional changes of the tissue, such as edema or hemorrhage, are limiting tumor detection on mpMRI. We present a case of a rising prostate-specific antigen values, negative mpMRI, and a Gleason score of 4+4 on template biopsy after HIFU. On 18F-choline PET/MR, high focal uptake was detected at the location of positive biopsy. Re-HIFU based on the fused 18F-choline PET/MR images was performed, followed by a recurrence-free period of 11 months. Thus, 18F-choline PET/MR could improve guiding retreatment in patients with recurrence after HIFU.
Rare Case of Intratracheal Metastasis Detected on 68Ga–Prostate-Specific Membrane Antigen PET/CT Scan in a Case of Thyroglobulin Elevated Negative Iodine Scan Syndrome
Authors: Sasikumar Arun , Joy Ajith , Pillai M. R. A. , Oommen Karuna Elza , Jayakumar R.
Published: February 2018

A 64-year-old woman underwent completion thyroidectomy with upper tracheal ring resection and right-sided neck dissection for papillary carcinoma of the thyroid infiltrating the trachea and was given 131I radioiodine treatment. Three years later, she presented with hemoptysis. On evaluation, she had increased serum thyroglobulin and negative iodine scan (TENIS). 18F-FDG PET/CT scan did not identify any site of disease. One year later, 68Ga-PSMA scan done revealed a moderate focal tracer-avid intratracheal soft tissue; biopsy revealed it to be metastatic papillary carcinoma of the thyroid. This case kindles the possibility of using 68Ga-PSMA PET/CT to reveal occult disease in cases of TENIS.
Long-lasting Intense Bone Tracer Activity at the Sites of Collagen Injection
Authors: Wang Ling , Jin Xiaona , Li Fang
Published: February 2018

Collagen injection has been used as dermal filler in plastic and cosmetic surgery. A technetium 99mTc methylene diphosphonate bone scintigraphy was performed in a 47-year-old woman as part of the breast cancer evaluation. The images showed intense methylene diphosphonate activity on both sides of the frontal head, where she received collagen injection 1 year prior. The activity was visualized again in all 3 follow-up bone scans over the subsequent 3 years.
Castleman’s Disease of the Kidney Mimicking Renal Cell Carcinoma on FDG PET/CT
Authors: Wang Yang , Dong Aisheng , Yang Bo , Lu Jianping
Published: February 2018

Castleman’s disease of the kidney is extremely rare. We present a case of Castleman’s disease in the left kidney with multiple para-aortic enlarged lymph nodes. Both the renal lesion and para-aortic lymph nodes showed hypervascularity on enhanced CT and minimally increased FDG uptake on FDG PET/CT, mimicking renal cell carcinoma with para-aortic nodal metastases. This case suggests that Castleman’s disease should be considered as a rare differential diagnosis in patients with a hypervascular and hypermetabolic renal lesion.
Metaplastic Squamous Cell Carcinoma of Breast Demonstrated on 18F-FDG PET/CT
Authors: Yin Hongyan , Xiu Yan , Luo Rongkui , Zhang Hongwei , Shi Hongcheng
Published: February 2018

A 32-year-old woman presented with 3 months’ history of rapid enlargement of the left breast and superficial ulceration. Staging 18F-FDG PET/CT performed after admission demonstrated a hypermetabolic mass in the left breast, with smaller hypermetabolic areas in the left axillary and internal mammary lymph nodes, as well as in the sternum. Postoperatively, the mass was diagnosed as metaplastic squamous cell carcinoma of the breast.