bluuebunny/crossref_metadata_2025 huggingface dataset:
Neural Representations of Death in the Cortical Midline Structures Promote Temporal Discounting
Authors: Yanagisawa Kuniaki , Kashima Emiko S , Shigemune Yayoi , Nakai Ryusuke , Abe Nobuhito
Published: February 2021

Death is an important reminder that our lives are finite. Although some studies have shown that thinking about one’s own death increases temporal discounting (i.e., the devaluing of future rewards), the underlying neural mechanisms are still unknown. In a functional magnetic resonance imaging experiment, we compared the neural and behavioral processes of temporal discounting across four conditions involving distinct types of future thinking (death related, negative, neutral, and positive). Replicating prior research, the behavioral evidence showed that temporal discounting increased when thinking about one’s own future death. Multivoxel pattern analysis showed that death-related future thinking was decoded in default mode regions, including the inferior parietal lobule, precuneus, and medial prefrontal cortex (MPFC). When future thinking was death related (vs. negative), increased temporal discounting was associated with a higher decoding accuracy in the precuneus and MPFC. The present findings suggest that death-related neural representations are distributed across default mode regions, and neural populations in the cortical midline structures play a crucial role in the integration of one's own death into economic decision-making.
Olfactory and taste dysfunctions in COVID-19
Authors: Rouadi Philip W. , Idriss Samar A. , Bousquet Jean
Published: February 2021

Purpose of review

Olfactory dysfunction (OD) can be a single and early prominent symptom of severe acute respiratory syndrome (SARS)-COV-2 infection unlike middle east respiratory syndrome (MERS) and SARS. OD data are very informative but many are not peer-reviewed, often inconclusive and may reveal variable and sometimes contradictory results. This is often due to incongruent data of subjective and objective OD testing. Mechanistic pathways of OD and taste dysfunction (TD) are slowly unveiling, not infrequently extrapolated from historical models of SARS and MERS and are still partly unclear.

Recent findings

We reviewed the literature on OD and TD during the COVID-19 pandemic analyzing current data on pathogenesis and clinical correlates including prevalence, recovery rates, risk factors, and predictive power. Also, we evaluated various methods of subjective and objective olfactory testing and discussed challenges in management of patients with OD and rhinitis during the pandemic.

Subjective evaluation of smell disturbances during COVID-19 pandemic likely underestimates true prevalence, severity, and recovery rates of OD when compared to objective testing. OD is predictive of COVID-19 infection, more so when associated with TD. Recognizing inherent limitations of both subjective and objective OD and TD testing enables us better to manage chemosensory dysfunction in COVID-19 patients. Besides, current mechanistic data suggest neurotropism of COVID-19 for olfactory neuro-epithelium and a potential role of transient receptor potential (TRP) channels. Future studies are needed to explore further the neurogenic inflammation in COVID-19.
Hemodynamic support in septic shock
Authors: García-de-Acilu Marina , Mesquida Jaume , Gruartmoner Guillem , Ferrer Ricard
Published: February 2021

Purpose of review

The current article reviews recent findings on the monitoring and hemodynamic support of septic shock patients.

Recent findings

The ultimate goal of hemodynamic resuscitation is to restore tissue oxygenation. A multimodal approach combining global and regional markers of tissue hypoxia seems appropriate to guide resuscitation. Several multicenter clinical trials have provided evidence against an aggressive fluid resuscitation strategy. Fluid administration should be personalized and based on the evidence of fluid responsiveness. Dynamic indices have proven to be highly predictive of responsiveness. Recent data suggest that balanced crystalloids may be associated with less renal failure. When fluid therapy is insufficient, a multimode approach with different types of vasopressors has been suggested as an initial approach. Dobutamine remains the firs inotropic option in patients with persistent hypotension and decrease ventricular systolic function. Calcium sensitizer and phosphodiesterase inhibitors may be considered, but evidence is still limited. Veno-arterial extracorporeal membrane oxygenation may be considered in selected unresponsive patients, particularly with myocardial depression, and in a highly experienced center.

Resuscitation should be personalized and based on global and regional markers of tissue hypoxia as well as the fluid responsiveness indices. The beneficial effect of multimode approach with different types of vasopressors, remains to be determined.
Healthcare Patterns of Pregnant Women and Children Affected by OUD in 9 State Medicaid Populations
Authors: Jarlenski Marian , Kim Joo Yeon , Ahrens Katherine A. , Allen Lindsay , Austin Anna , Barnes Andrew J. , Crane Dushka , Lanier Paul , Mauk Rachel , Mohamoud Shamis , Pauly Nathan , Talbert Jeffrey , Zivin Kara , Donohue Julie M.
Published: February 2021

Objectives:

State Medicaid programs are the largest single provider of healthcare for pregnant persons with opioid use disorder (OUD). Our objective was to provide comparable, multistate measures estimating the burden of OUD in pregnancy, medication for OUD (MOUD) in pregnancy, and related neonatal and child outcomes.

Methods:

Drawing on the Medicaid Outcomes Distributed Research Network (MODRN), we accessed administrative healthcare data for 1.6 million pregnancies and 1.3 million live births in 9 state Medicaid populations from 2014 to 2017. We analyzed within- and between-state prevalences and time trends in the following outcomes: diagnosis of OUD in pregnancy, initiation, and continuity of MOUD in pregnancy, Neonatal Opioid Withdrawal Syndrome (NOWS), and well-child visit utilization among children with NOWS.

Results:

OUD diagnosis increased from 49.6 per 1000 to 54.1 per 1000 pregnancies, and the percentage of those with any MOUD in pregnancy increased from 53.4% to 57.9%, during our study time period. State-specific percentages of 180-day continuity of MOUD ranged from 41.2% to 84.5%. The rate of neonates diagnosed with NOWS increased from 32.7 to 37.0 per 1000 live births. State-specific percentages of children diagnosed with NOWS who had the recommended well-child visits in the first 15 months ranged from 39.3% to 62.5%.

Conclusions:

Medicaid data, which allow for longitudinal surveillance of care across different settings, can be used to monitor OUD and related pregnancy and child health outcomes. Findings highlight the need for public health efforts to improve care for pregnant persons and children affected by OUD.
Uptake of Hearing Aids and Hearing Assistive Technology in a Working Population: Longitudinal Analyses of The Netherlands Longitudinal Study on Hearing
Authors: van Leeuwen Lisette M. , Goderie Thadé P. M. , van Wier Marieke F. , Lissenberg-Witte Birgit I. , Lemke Ulrike , Kramer Sophia E.
Published: February 2021

Objective:

To identify predictors of the 5-year uptake of hearing aids (HAs) and hearing assistive technology (HAT) in a sample of Dutch employees eligible for HAs and/or HAT. The potential predictors included demographic factors (age, sex, marital status, and living situation), education, hearing factors (ability to recognize speech in noise and self-reported hearing disability), distress, self-efficacy, and work-related factors (job demand, job control, and need for recovery).

Design:

Five-year follow-up data of the Netherlands Longitudinal Study on Hearing (NL-SH) collected until January 2019 were included. An online digit-triplet in noise test, the National Hearing Test (NHT), was used to assess speech-recognition-in-noise ability. In addition, online questionnaires on demographic, socioeconomic, self-reported hearing disability, health, and work-related characteristics were administered. Adults who worked over 12 hours per week, who had not yet taken up HAs or HAT, but who would be eligible for HAs/HAT based on their NHT score (insufficient or poor hearing ability), were included in the study. The 5-year uptake of HAs/HAT was defined as a dichotomous variable of self-reported HA/HAT use reported 5 years later. Generalized Estimating Equations analyses were performed to analyze the associations between potential predicting factors and the 5-year uptake of HAs/HAT, taking into account the repeated measurements of the predicting factors and the 5-year uptake of HAs/HAT.

Results:

Data of 218 participants were included. The cumulative incidence of the 5-year uptake of HAs/HAT was 15 to 33%, of which 52 employees took up HAs and 11 employees took up HAT. Married participants had increased odds for 5-year uptake of HAs/HAT compared with unmarried participants (odds ratio [OR] = 2.13, 95% confidence interval [CI] = 1.05 to 4.35). Higher self-reported hearing disability (per one unit, scale range 0 to 74) was associated with increased odds for 5-year uptake of HAs/HAT (OR = 1.05, 95% CI = 1.03 to 1.07). Job demand showed a significant interaction with sex (p = 0.002), and therefore, stratified analyses were performed. In male participants, participants with higher job demand scores (per one unit, scale range 12 to 48) had increased odds for 5-year uptake of HAs/HAT (OR = 1.18, 95% CI = 1.05 to 1.35). No difference was seen in females.

Conclusion:

This study confirms that factors predicting the uptake of HAs/HAT in the general or older populations, including marital status and self-reported hearing disability, also extend to the working population. The identification of job demand as a predictor of the uptake of HAs/HAT (in males only) was a novel finding. It demonstrates the importance of considering work-related factors in aural rehabilitation.
Problems, Complications, and Factors Predisposing to Failure of Fassier-Duval Rodding in Children With Osteogenesis Imperfecta: A Double-center Study
Authors: Musielak Bartosz Jan , Woźniak Łukasz , Sułko Jerzy , Oberc Artur , Jóźwiak Marek
Published: February 2021

Background:

Although Fassier-Duval (FD) rods have been used for almost 2 decades, knowledge of factors predisposing to their failure is limited. Thus, the purpose of this study was to: (1) present the most common complications of FD rodding, (2) present tips on how to avoid or overcome them, and (3) identify factors predisposing to treatment failure.

Methods:

Fifty-eight rod segments in 19 patients with osteogenesis imperfecta (mainly type III) underwent analysis with a median follow-up (FU) time of 4.4 years. We assessed the total number of complications clinically and radiographically. Next, the possible predisposing factors leading to failure were assessed using the Mann-Whitney U test. In addition, we evaluated the cutoff age for the increased rate of complications using the Youden index. A P<0.05 was considered significant.

Results:

The total number of complications reached 44.8%. The most common complications included: migration of the male or female implant (45.7% and 25.7% out of the total number of complications, respectively), bone fracture with bending of the rod (8.6%), and rotational deformities (8.6%). Significant differences in patients’ ages at the time of surgery were found between the group with and without complications (P=0.04), while sex, segment treated, preceding surgeries, length of FU, FD rod diameter, and length of bisphosphonate treatment were not significant. The Youden index showed that the risk of complications rose significantly in patients treated when younger than 5.5 years of age (P<0.05).

Conclusions:

This series displays the effectiveness and utility of FD rods at a median FU of over 4 years. Complication rates were comparable with the existing literature, with a notable increase in the number of side effects observed in younger patients (below the age of 5).

Level of Evidence:

Level IV—therapeutic study.
Femoral Neck Growth and Remodeling With Free-Gliding Screw Fixation of Slipped Capital Femoral Epiphysis
Authors: Morash Kevin , Orlik Benjamin , El-Hawary Ron , Gauthier Luke , Logan Karl
Published: February 2021

Background:

Treatment of stable slipped capital femoral epiphysis (SCFE) most commonly involves in situ fixation with a standard cannulated screw, leading to physeal arrest. Recently, Pega Medical (Laval, Canada) introduced the free-gliding (FG) SCFE screw, which employs a growth-friendly, telescopic design. This study examines femoral neck growth and remodeling over the first 2 postoperative years in stable SCFE treated with FG versus standard screws.

Methods:

We retrospectively reviewed 32 hips (19 SCFE, 13 prophylactic) in 16 patients treated with FG screws for stable SCFE. We also reviewed 102 hips (63 SCFE, 19 prophylactic, 20 controls) in 55 patients treated with standard screws. Immediate postoperative radiographs were compared with 1- and 2-year follow-up images.

Results:

For the overall study cohort, mean age at surgery was 12.2±1.9 years, with a mean slip angle of 26.9±18.0 degrees. In FG SCFE hips, the alpha angle remodeled 12.9±19.2 degrees in the first postoperative year (P=0.018) and articulotrochanteric distance decreased by 4.2±4.6 mm at 2 years (P=0.018). In standard SCFE hips, the alpha angle remodeled 4.3±11.3 degrees at 1 year (P=0.014), while articulotrochanteric distance decreased by 4.5±3.2 mm at 2 years (P<0.001). By 2 years, FG screws lengthened more in prophylactic (4.8±3.4 mm) than SCFE hips (1.7±1.8 mm, P=0.027).

Conclusions:

Greater remodeling of femoral neck cam deformity occurs when treating SCFE using an FG screw. Further research is required to measure the impact of this finding on femoroacetabular impingement and degenerative arthritis. In addition, FG screws allow ongoing growth of prophylactically treated hips, while standard screws promote coxa breva.

Level of Evidence:

Level III—retrospective comparative, therapeutic study.
Late Hip Dysplasia After Normal Ultrasound in Breech Babies: Implications on Surveillance Recommendations
Authors: Morris William Z. , Mayfield Laura , Beckwith Terri , Zepeda Erica , Jo Chan-Hee , Sucato Daniel J.
Published: February 2021

Background:

There is significant controversy in the literature over rates of late-developing dysplasia following normal screening ultrasound in breech babies, with reported rates varying from 7% to 29%. The purpose of this study is to investigate the rates of radiographic dysplasia in breech babies after a normal ultrasound with a minimum of 1 year of radiographic follow-up.

Methods:

This study was an institutional review board–approved prospective study of all patients referred by their pediatrician for concern for developmental dysplasia of the hip between July 2008 and August 2014. We identified all subjects with breech presentation and excluded those with an abnormal initial examination/ultrasound or with <12 months of radiographic follow-up. Anterior-posterior pelvis films were obtained after >12 months and acetabular indices (AIs) were measured and compared with contemporary normative data. Dysplasia was diagnosed as >2 SDs above the mean.

Results:

A total of 654 patients were referred with a history of a breech presentation, and 150 (22.9%) were found to have clinical instability or sonographic evidence of dysplasia on initial presentation and were observed with serial imaging or treated. Of the remaining 504 subjects with a normal clinical examination and screening ultrasound, 133 (26.4%; 74.4% females, 25.6% males) were followed until at least 12 months of age. Of those presenting at age 12 to 14 months, the mean AI was 0.42±0.83 SD above the mean with a skew towards elevated AIs. At the final follow-up (mean: 20.7±6.7 mo), the mean AI was 0.05±0.92 SD above the mean, and only 3/133 (2.2%) patients had a dysplastic hip. No patients underwent treatment other than an observation during the study period.

Conclusions:

One in 5 breech babies have dysplasia at presentation, but late dysplasia following normal screening ultrasound may be less common than previously reported and may be due to our prolonged follow-up period. We recommend surveillance of breech babies with follow-up visits after 12 months of age since earlier visits may offer limited benefits.

Level of Evidence:

Level II—prospective prognostic study.
Etiologies and Outcomes Associated With Tacrolimus Levels Out of a Typical Range That Lead to High Variability in Kidney Transplant Recipients
Authors: Taber David J. , Hirsch Jason , Keys Alison , Su Zemin , McGillicuddy John W.
Published: February 2021

Background:

High tacrolimus intrapatient variability (tac IPV) is associated with poor outcomes in kidney transplantation, including rejection, donor-specific antibodies, and graft loss. A common cause of high tac IPV is related to patient nonadherence, but this is yet to be conclusively demonstrated.

Methods:

This was a longitudinal cohort study comprising adult kidney recipients, who received transplants between 2015 and 2017, with follow-ups through February 2020. The goal of this study was to identify the most common etiologies of tac levels outside the typical range, which lead to high tac IPV, and assess the etiology-specific associations between high tac IPV and graft outcomes. Multivariate Cox regression was used to assess time-to-event analyses.

Results:

In total, 537 adult kidney recipients were included; 145 (27%) were identified as having a high tac IPV (>40%) 3–102 months post-transplant. Common etiologies of tac levels significantly outside the standard goal range (6–12 ng/mL) leading to high tac IPV included patient nonadherence (20%), infections (19%), tac-related toxicities (17%), and undocumented issues (27%). In multivariable Cox modeling, those with high tac IPV because of nonadherence had a 3.5 times higher risk of late acute rejection (P = 0.019) and 2.2 times higher risk of late graft loss (P = 0.044). No other etiologies in the typical tac level range were significantly associated with either acute rejection or graft loss.

Conclusions:

Although high tac IPV has many causes, only high tac IPV caused by nonadherence is consistently associated with poor allograft outcomes.
A Loading Micafungin Dose in Critically Ill Patients Undergoing Continuous Venovenous Hemofiltration or Continuous Venovenous Hemodiafiltration: A Population Pharmacokinetic Analysis
Authors: Garbez Nicolas , Mbatchi Litaty C. , Maseda Emilio , Luque Sonia , Grau Santiago , Wallis Steven C. , Muller Laurent , Lipman Jeffrey , Roberts Jason A. , Lefrant Jean-Yves , Roger Claire
Published: February 2021

Background:

In this study, the authors aimed to compare the pharmacokinetics (PK) of micafungin in critically ill patients receiving continuous venovenous hemofiltration (CVVH, 30 mL·kg−1·h−1) with those of patients receiving equidoses of hemodiafiltration (CVVHDF, 15 mL·kg−1·h−1 + 15 mL·kg−1·h−1) and determine the optimal dosing regimen using the developed model.

Methods:

Patients with septic shock undergoing continuous renal replacement therapy and receiving a conventional dose of 100 mg micafungin once daily were eligible for inclusion. Total micafungin plasma concentrations from 8 CVVH sessions and 8 CVVHDF sessions were subjected to a population PK analysis using Pmetrics. Validation of the model performance was reinforced by external validation. Monte Carlo simulations were performed considering the total ratio of free drug area under the curve (AUC) over 24 hours to the minimum inhibitory concentration (MIC) (AUC0-24/MIC) in plasma.

Results:

The median total body weight (min–max) was 94.8 (66–138) kg. Micafungin concentrations were best described by a 2-compartmental PK model. No covariates, including continuous renal replacement therapy modality (CVVH or CVVHDF), were retained in the final model. The mean parameter estimates (SD) were 0.96 (0.32) L/h for clearance and 14.8 (5.3) L for the central compartment volume. External validation confirmed the performance of the developed PK model. Dosing simulations did not support the use of standard 100 mg daily dosing, except for Candida albicans on the second day of therapy. A loading dose of 150 mg followed by 100 mg daily reached the probability of target attainment for all C. albicans and C. glabrata, but not for C. krusei and C. parapsilosis.

Conclusions:

No difference was observed in micafungin PK between equidoses of CVVH and CVVHDF. A loading dose of 150 mg is required to achieve the PK/PD target for less susceptible Candida species from the first day of therapy.
Improving uptake of perinatal autopsy
Authors: Lewis Celine , Simcock Ian C. , Arthurs Owen J.
Published: February 2021

Purpose of review

Uptake of perinatal autopsy has declined in the West over the past 30 years, largely because of reduced parental acceptance of a traditional invasive autopsy. Several studies have recently investigated the decline to identify the key factors and how they may be mitigated.

Recent findings

Three main themes were identified that have been found to improve uptake of perinatal autopsy: improved communication, in particular ensuring the consent process was conducted as a conversation with time spent talking through the procedure and allowing time for questions; health professional training to ensure staff discussing autopsy with parents have adequate understanding of the procedure and are able to convey confidence and empathy; and availability of less invasive autopsy, including noninvasive as well as minimally invasive options. These should be offered alongside standard autopsy, which some parents may still prefer.

This review highlights that the discussions that take place, and the options that are available to parents, can profoundly impact whether or not they consent to autopsy investigation. Further research should focus on the impact of offering less invasive options as well as evaluating the training and support materials that have recently been developed.
SURGICAL RETINAL EXPLANTS AS A SOURCE OF RETINAL PROGENITOR CELLS
Authors: Too Lay Khoon , Shen Weiyong , Mammo Zaid , Osaadon Perach , Gillies Mark C. , Simunovic Matthew P.
Published: February 2021

Purpose:

To describe the novel observation of spontaneously migrating retinal cells from living donor surgical retinal explants that express progenitor cell markers in the absence of exogenous growth factors.

Methods:

Surgical retinal explants were harvested from 5 consecutive patients undergoing 23 G pars plana vitrectomy for the management of rhegmatogenous detachment. During surgery, equatorial flap tears were trimmed with the vitreous cutter and aspirated. Excised tissue was then regurgitated into a syringe containing balanced salt solution and immediately transferred to tissue culture. Migrating cells subsequently underwent immunohistochemical staining and their characteristics were compared with those of a spontaneously immortalized Müller stem cell line.

Results:

Spontaneously migrating cells were observed from samples taken from all 5 patients from Day 2 to 10 after transfer to culture. These cells were found to express embryonic cell markers, including paired box 6 (Pax6), sex-determining region Y-box 2 (Sox-2), nestin, cone-rod homeobox, and cyclin-dependent kinase inhibitor 1B (p27Kip1) as well as proteins consistent with early or retained differentiation down the Müller cell lineage, including glial fibrillary acidic protein and glutamine synthetase.

Conclusion:

After injury, the human equatorial retina is capable of spontaneously producing cells that demonstrate migration and that express progenitor cell markers. In addition, these cells express proteins consistent with Müller cell lineage. These initial observations support the assertion that the human retina may possess the potential for regeneration and that surgical retinal explants could also act as a ready source of retinal progenitor cells.
CYSTOID MACULAR EDEMA AFTER FOUR-POINT SCLERAL FIXATION OF INTRAOCULAR LENS
Authors: Hauser David , Ben-David David , Masarwa Dua , Jaar Richard , Arow Majd , Haas Keren , Pokroy Russell
Published: February 2021

Purpose:

To assess the incidence of cystoid macular edema (CME) associated with 4-point Gore-Tex suture intraocular lens (IOL) scleral fixation, before and after institution of routine intravitreal triamcinolone acetonide prophylaxis and long-term topical nonsteroidal anti-inflammatory drug usage.

Methods:

Consecutive patients were included after IOL implantation with concurrent pars plana vitrectomy for spontaneous IOL dislocation due to pseudoexfoliation syndrome. We compared short-term prophylactic nonsteroidal anti-inflammatory drugs only (Group A) to prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs (Group B).

Results:

Twenty-six eyes of 26 patients with pseudoexfoliation syndrome and spontaneous IOL dislocation were studied. Mean logMAR visual acuity improved from 1.27 ± 0.80 (20/375 Snellen equivalent) preoperatively to 0.46 ± 0.39 (Snellen 20/43) postoperatively (P < 0.001). Visual outcomes were similar for Groups A and B. In Group A, 10/16 eyes had CME, 4/16 had chronic CME longer than 6 months, and 1 longer than 12 months. In Group B, 1/10 had CME (which was both chronic and refractory).

Conclusion:

In eyes with pseudoexfoliation syndrome and spontaneous IOL dislocation, 4-point Gore-Tex suture IOL ab externo fixation yielded good visual outcomes, although CME was observed more than reported elsewhere. Prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs seem to reduce the risk of postoperative CME.
Exacerbation of Granular Corneal Dystrophy Type 2 After Small Incision Lenticule Extraction
Authors: Kwak Jay Jiyong , Yoon Sook Hyun , Seo Kyoung Yul , Kim Tae-im , Lee Hyung Keun , Stulting R. Doyle , Kim Eung Kweon
Published: February 2021

Purpose:

To report the outcome of unilateral small incision lenticule extraction (SMILE) in a patient with granular corneal dystrophy type 2 (GCD2).

Methods:

Slit-lamp photography and Fourier domain optical coherence tomography were used to document the clinical course and appearance of the corneas in a patient with genetically determined GCD2 who underwent unilateral SMILE in the right eye.

Results:

Slit-lamp examination of a 23-year-old woman revealed 2 faint opacities at the surgical interface approximately 2 months after the SMILE procedure had been performed on her right eye. Nine and 3 typical GCD2 deposits located immediately beneath the Bowman layer were observed in the right and left corneas, respectively. Over time, the deposits at the interface increased in size, density, and number in the right eye. Fourier domain optical coherence tomography performed 33 months after the SMILE procedure revealed deposits at the SMILE interface that were distinct from those located immediately beneath the Bowman layer. The severity of disease exacerbation was less in this patient than what is typically observed in others who have undergone laser-assisted in situ keratomileusis or photorefractive keratectomy.

Conclusions:

SMILE is contraindicated in patients with GCD2, as are other corneal refractive surgical procedures. This case highlights the importance of genetic testing before the performance of refractive corneal procedures—especially for patients with corneal opacities on preoperative slit-lamp examination or a family history of corneal disease compatible with that of a corneal dystrophy.
Educational and Electronic-Based Tools to Mitigate the Risk of Transfusion Adverse Events
Authors: Ding Jennifer , Krey Rebecca , Malone Laura , Merrill VeRonika , Krouss Mona , O'Brien Jennifer , Fontaine Magali J.
Published: February 2021

The transfusion of blood products is a widely used practice but comes with the risk of transfusion-associated adverse events and fatalities. The primary aim of this study was to evaluate if strict adherence to transfusion guidelines would lead to a decrease in the rate of transfusion reactions that occurred when blood products were given outside of established indications. Hospital-wide educational programs and dedicated electronic transfusion order sets were used to encourage adherence to guidelines. A secondary aim of this study was to evaluate if a decrease in the incidence of transfusion reactions also lead to a decrease in associated healthcare costs.
Improving Management of Type 2 Diabetes Mellitus in Hospitalized Adults: A Quality Initiative
Authors: Wahlberg Elizabeth A. , Muthukrishnan Preetika , Burnett Maria , Barrett Kaitlyn V. , Gilbert Matthew , Repp Allen B.
Published: February 2021

The American Diabetes Association recommends scheduled basal and nutritional insulin doses as the preferred treatment for noncritically ill hospitalized patients with type 2 diabetes; however, the adoption of these practices remains suboptimal. We sought to understand current diabetes management practices and improve glycemic control in patients with type 2 diabetes on the Hospital Medicine Services at our academic medical center. We surveyed resident and attending physicians to understand barriers to guideline-based practice. We conducted educational sessions, developed pocket-card decision aids, encouraged discussion on rounds, and provided periodic performance feedback to attending physicians. Results of the barriers survey identified “fear of causing hypoglycemia” as the most common barrier to guideline-based practice. Compared with the preintervention 12-month period, these interventions were associated with doubling of the use of guideline-based insulin therapy regimens, a significant reduction in the rate of severe hyperglycemia days, and a nonsignificant reduction in the rate of hypoglycemia days over a 12-month period. These results demonstrate that a simple, low-cost intervention can be associated with an increase in guideline-concordant insulin ordering with improvement in glycemic outcomes for patients with type 2 diabetes.
Weather and COVID-19 Deaths During the Stay-at-Home Order in the United States
Authors: Karimi Seyed M. , Majbouri Mahdi , DuPré Natalie , White Kelsey B. , Little Bert B. , McKinney W. Paul
Published: February 2021

Objective:

To estimate the association between weather and COVID-19 fatality rates during US stay-at-home orders.

Methods:

With a county-level longitudinal design, this study analyzed COVID-19 deaths from public health departments’ daily reports and considered exposure as the 18 to 22 day-period before death. Models included state-level social distancing measures, Census Bureau demographics, daily weather information, and daily air pollution. The primary measures included minimum and maximum daily temperature, precipitation, ozone concentration, PM2.5 concentrations, and U.V. light index.

Results:

A 1 °F increase in the minimum temperature was associated with 1.9% (95% CI, 0.2% to 3.6%) increase in deaths 20 days later. An ozone concentration increase of 1 ppb (part per billion) decreased daily deaths by 2.0% (95% CI, 0.1% to 3.6%); ozone levels below 38 ppb negatively correlated with deaths.

Conclusions:

Increased mobility may drive the observed association of minimum daily temperature on COVID-19 deaths.
Implementing New Working Practices Through a Structured Support Model for Systematic Work Environment Management
Authors: Molin Fredrik , Hellman Therese , Svartengren Magnus
Published: February 2021

Objective:

To describe factors that facilitate and hinder implementation of a structured support model focusing on psychosocial work environment in Swedish municipalities.

Methods:

This qualitative study was conducted in six Swedish municipalities. In total, 63 semi-structured interviews and focus groups were conducted with key stakeholders in the municipalities during a 2-year period. The consolidated framework for implementation research (CFIR) was used for data analysis.

Results:

Findings suggest that the support model needs to have an easy enough structure to understand and use, and it must be immediately applicable for work groups and employees. An important factor for facilitating implementation was the support from first-line managers and upper management.

Conclusions:

Upper management need to be committed to the model and communicate clearly to lower levels of the implementing organization on the purpose and objectives of the model.
Developing a Curriculum on Transgender Health Care for Physician Assistant Students
Authors: Hart Bethany G. , Kindratt Tiffany B. , Vasudevan Anita , Garcia Antonio D. , Pagels Patti , Orcutt Venetia , Lau May C.
Published: February 2021

Purpose

Our goal was to (1) evaluate physician assistant (PA) students' knowledge, skills, and attitudes toward transgender patients, (2) develop and deliver a lecture on transgender health care, and (3) determine changes in knowledge, skills, and attitudes postlecture.

Methods

A 32-item survey was developed and emailed to PA students. Students were then invited to a 2-hour lecture on transgender-specific psychosocial topics and clinical skills plus medical treatment for gender dysphoria. Lecture attendees retook the survey after 2 weeks.

Results

Initial mean self-assessment scores regarding clinical knowledge and skills were below 3 on a 7-point Likert scale. All measures improved following the lecture (p < .001 for all). Overall, 86.7% of students were interested in the addition of transgender health into their didactic curriculum.

Conclusions

Our results illustrate insufficient student competence in transgender medicine. Our proposed transgender curriculum may be a useful guide for educators wanting to integrate this topic into their instruction.
Does the Length of Student Physical Therapists' Clinical Educational Experiences Matter?
Authors: Wolden Mitch , Gusman Lori N. , Drevyn Elsa , Flom-Meland Cindy
Published: February 2021

Introduction/Review of Literature.

Clinical educational experiences (CEEs) comprise approximately 30% of the total credit hours in the Doctor of Physical Therapy (DPT) curriculum and are essential to the clinical learning and performance of DPT students to achieve entry-level competence. There are no established standards in DPT education for the length and timing of CEEs to optimize students' clinical learning and performance. The purpose of our investigation was to assess the development of DPT students' clinical learning and performance at 3 DPT programs during 6-, 8-, 9-, and 16-week CEEs.

Methods.

An analysis of variance was conducted to assess the changes in DPT students' clinical learning and performance based on the following: (1) the length of CEEs, (2) the effect of the length and timing of CEEs, and (3) the length of the final CEEs.

Subjects.

Midterm and final evaluation Physical Therapist Clinical Performance Instrument data were analyzed from 707 DPT students' CEEs.

Results.

The average change in DPT students' clinical learning and performance during CEEs was as follows: 6 weeks = 3.13 (SD = 2.3), 8 weeks = 3.20 (SD = 2.6), 9-weeks = 3.30 (SD = 2.5), and 16 weeks = 2.56. Significant difference in DPT students' clinical learning occurred during the 8-week (P = .03; P = .04) and 9-week (P = .04; P = .01) CEEs compared with the early 6-week CEEs and 16-week CEEs, respectively.

Discussion and Conclusion.

The greatest change in DPT students' clinical learning and performance occurred during 8- and 9-week CEEs and between the first and third full-time CEEs. Given the increasing costs of DPT education and student debt, the length of CEEs required to meet CAPTE standards and program goals should be further investigated.
The redesign of an advanced practice registered nurse professional evaluation process and tool at a midwest academic medical center: A pilot project
Authors: Kamm Alaine M. , Howard-Ruben Josie A. , Carlson Elizabeth A.
Published: February 2021

Background:

Inconsistency and a lack of clarity exist regarding the advanced practice registered nurse peer review process in hospitals throughout the country.

Local problem:

The current APRN peer review process in place for over a decade at an academic medical center has never been evaluated, and neither fulfills ongoing professional practice evaluation requirements nor meets the expectations of peer review.

Methods:

Pre–post intervention quality improvement project (Standards for Quality Improvement Reporting Excellence checklist).

Interventions:

Using current professional standards and guidelines that meet the requirements for ongoing professional practice evaluation and nursing peer review, a redesigned process and tool was created and piloted in three specialty groups of nurse practitioners (NPs) at the medical center. Satisfaction before and after the pilot survey was measured using a Likert-type scale, and results were compared and analyzed following the completion of the pilot survey.

Results:

The posttest measure revealed a statistically significant improvement in satisfaction with the redesigned professional evaluation tool compared with the prepilot peer review tool.

Conclusions:

The redesign project demonstrated that using current professional standards and guidelines, a comprehensive process and tool for professional evaluation and peer review is achievable across NP specialties.
Promoting adherence to bone-loading exercises in postmenopausal women with low bone mass
Authors: Waltman Nancy , Cole Melissa A. , Kupzyk Kevin A. , Lappe Joan M. , Mack Lynn R. , Bilek Laura D.
Published: February 2021

Background:

We recently completed a parent study (Bone Loading Exercises versus Risedronate on Bone Health in Post-menopausal Women [NIH# R01NR015029]) examining bone-loading exercises to prevent bone loss in postmenopausal women with low bone mass. Forty-three million US women have low bone mass and increased risk for fractures. Bone-loading exercises (weight-bearing and resistance training) can preserve bone mass and decrease risk of fractures. However, multiple barriers prevent women from exercising and adherence rates are low.

Purpose:

This secondary analysis of the parent study (a) examined barriers specific to women participating in bone-loading exercises; (b) described effectiveness of self-efficacy strategies used in the parent study for increasing confidence in knowledge and reducing barriers; and (c) applied study findings and principles of self-efficacy and self-regulation in development of guidelines for promoting adherence to exercises.

Methods:

Seventy-two women were randomized to the exercise group and completed 12 months of exercises. Instruments for self-efficacy were completed at 2 weeks and barriers interference at 6 months. Percent adherence was measured as the number of exercise sessions attended divided by the number prescribed.

Results:

In the 12-month study, average adherence to exercises was 58.9%. Lower adherers reported lack of self-regulation skills such as “lack of time” as the most frequent barriers to exercise.

Implications for practice:

Guidelines developed included promotion of skills for self-regulation (such as regulation of time) as well as self-efficacy to improve adherence rates. Nurse practitioners may be the most motivated of all providers to use guidelines promoting exercise for women in their clinical practice.
The role of computed tomography scan in the diagnosis of COVID-19 pneumonia
Authors: Axiaq Ariana , Almohtadi Ahmad , Massias Samuel A. , Ngemoh Dorette , Harky Amer
Published: February 2021

Purpose of review

To summarize current literature evidence on the role of computed tomography (CT) scan in the diagnosis and assessment of coronavirus disease 2019 (COVID-19) pneumonia.

Recent findings

Recent guidelines on the use of CT scans in COVID-19 vary between countries. However, the consensus is that it should not be used as the first line; a notion supported by the WHO. Currently, several investigations are being used including reverse transcription PCR testing, chest radiographs, and ultrasound scans, and CT scans. They are ideally performed later during the disease process as the sensitivity and specificity are highest by that time. Typical COVID-19 features on CT scans vary but include vascular enlargement, ground-glass opacities, and ground glass opacification together with consolidation.

Since COVID-19 was declared as a global pandemic, there was a push towards identifying appropriate diagnostic tests that are both reliable and effective. There is a general agreement that CT scans have a high sensitivity but low specificity in diagnosing COVID-19. However, the quality of available studies is not optimal, so this must always be interpreted with the clinical context in mind. Clinicians must aim to weigh up the practicalities and drawbacks of CT scans when considering their use for a patient. The ease and speed of use of CT scans must be balanced with their high radiation doses, and infection control considerations.
Intestinal failure in Finland: prevalence and characteristics of an adult patient population
Authors: Pohju Anne K. , Pakarinen Mikko P. , Sipponen Taina M.
Published: February 2021

Objectives

Details of intestinal failure in the Finnish adult population are unknown. This study aimed to specify the intestinal failure prevalence and to clinically characterize the patient population in Finland.

Methods

All Finnish healthcare units with the potential of providing parenteral support received an electronic survey to report whether they had patient(s) aged ≥18 years on long-term (≥120 days) parenteral support due to intestinal failure. Patient details came from patient records. IBM SPSS v.25 was used to analyze descriptive statistics.

Results

Of the 74 patients, 52 were included after confirming parenteral support indication from the records. The adult intestinal failure prevalence for 2017 was 11.7 per million, 95% confidence interval: 8.9–15.3. Most patients were women (69%), and the median age was 62 (45–72) years. Short bowel syndrome was the most frequent intestinal failure mechanism (73%), and surgical complication the most frequent underlying diagnosis (29%). Of patients, 66% represented the clinical classification category parenteral nutrition 1 or parenteral nutrition 2. Median Charlson Comorbidity Index was one (0–2.8); hypertension (37%) and diabetes (23%) were the most frequent comorbidities. Patients received seven (3.5–7) parenteral support infusions weekly, and eight patients (15%) were on fluids and electrolytes only. The median duration of parenteral support was 27.5 (11.3–57.3) months. Ten patients ceased parenteral support during 2017 after a median of 20.0 (9.0–40.3) parenteral support months. Eight weaned off parenteral support, one ran out of catheter sites, and one died.

Conclusion

Prevalence and patient characteristics of adult intestinal failure in Finland are similar to those in other Western countries.
Geographic Variation of Statin Use Among US Nursing Home Residents With Life-limiting Illness
Authors: Mack Deborah S. , Baek Jonggyu , Tjia Jennifer , Lapane Kate L.
Published: February 2021

Background:

Medically compromised nursing home residents continue to be prescribed statins, despite questionable benefits.

Objective:

To describe regional variation in statin use among residents with life-limiting illness.

Research Design:

Cross-sectional study using 2016 Minimum Data Set 3.0 assessments linked to Medicare administrative data and health service utilization area resource files.

Setting:

Nursing homes (n=14,147) within hospital referral regions (n=306) across the United States.

Subjects:

Long-stay residents (aged 65 y and older) with life-limiting illness (eg, serious illness, palliative care, or prognosis <6 mo to live) (n=361,170).

Measures:

Prevalent statin use was determined by Medicare Part D claims. Stratified by age (65–75, 76 y or older), multilevel logistic models provided odds ratios with 95% confidence intervals.

Results:

Statin use was prevalent (age 65–75 y: 46.0%, 76 y or more: 31.6%). For both age groups, nearly all resident-level variables evaluated were associated with any and high-intensity statin use and 3 facility-level variables (ie, higher proportions of Black residents, skilled nursing care provided, and average number of medications per resident) were associated with increased odds of statin use. Although in residents aged 65–75 years, no associations were observed, residents aged 76 years or older located in hospital referral regions (HRRs) with the highest health care utilization had higher odds of statin use than those in nursing homes in HRRs with the lowest health care utilization.

Conclusions:

Our findings suggest extensive geographic variation in US statin prescribing across HRRs, especially for those aged 76 years or older. This variation may reflect clinical uncertainty given the largely absent guidelines for statin use in nursing home residents.
Clinical relevance of incidental focal breast uptake on fluorine-18 fluorodeoxyglucose PET/computed tomography studies: an experience in a high-load center of Spain
Authors: Wakfie-Corieh Cristina Gamila , Rodríguez Rey Cristina , Ortega Candil Aida , Ferrando-Castagnetto Federico , Valhondo-Rama Raquel , Ruiz Tolón Mercedes , Pascual Martin Alejandro , Carreras Delgado José Luis
Published: February 2021

Aim

We aimed to determine the frequency and clinical significance of breast incidental uptake (BIU) detected through fluorine-18 fluorodeoxyglucose (18F-FDG) PET/computed tomography (CT) in a single, high-load center.

Patients and methods

In this retrospective study, we analyzed a total of 13 763 PET/CT studies performed from January 2017 to January 2020. After excluding 3148 scans, the maximum standardized uptake value (SUVmax) and maximum diameter (cm) of each BIU were measured. Clinical management, ultrasound/mammography and pathology reports were analyzed.

Results

We found BIU in 27 scans of 26 patients (0.3% of the studies). Mean age was 62.2 years and 88.5% were women; 84.6% underwent PET/CT for oncological indications. Ultrasound/mammography was consequently performed in 23 patients (88.5%), and histological correlations were available for Breast Imaging Reporting and Data System categories 4 and 5. Finally, lesions were benign in 14 patients (60.9%; two of them with low/intermediate risk of malignancy) and malignant in nine patients (39.1%). The remaining three patients had no ultrasound/mammography reports. Mean SUVmax of benign and malignant lesions were 2.6 ± 1.4 and 5.8 ± 3.5, respectively (P = 0.002). Considering a SUVmax cut-off value of 4.0, the sensitivity and specificity for differentiating benign vs. malignant lesions were 67 and 93%, respectively. Benign lesions were smaller than malignant in CT (maximum diameter:1.3 ± 0.5 cm vs. 2.0 ± 1.0 cm, P = 0.02).

Conclusion

Although BIU detected by 18F-FDG PET/CT is infrequently found, the risk of malignancy remains very high (39.1%). Both SUVmax and maximum diameter were greater in malignant than in benign lesions. An exhaustive study with ultrasound/mammography and selective histopathological correlation is mandatory after BIU findings, even in small lesions.