bluuebunny/crossref_metadata_2025 huggingface dataset:
821 An Unusual Pediatric PAP Compliance Obstacle, Even When the Mask Fits
Authors: Upchurch Andrew , Kasi Ajay , Harford Kelli-Lee , Leu Roberta
Published: May 2021

Introduction

Proper mask fitting is an important factor for compliant and effective use of PAP therapy. However, we present 2 patients whose masks became a barrier to PAP therapy despite a well-fitting mask.

Report of case(s)

Case 1 A 12-year-old female with ADHD, Chiari I malformation status-post decompression, and persistent mixed central and obstructive sleep apnea is managed with BPAP S/T. Despite absence of upper airway structural abnormalities, she is a mouth-breather during sleep and only tolerates full face masks. Despite ensuring a good mask fit and optimal BPAP settings to control her AHI, she sleeps with her neck hyperextended, resulting in her lower jaw pushing caudally and the mask liner slipping into her mouth. This stimulated chewing and resulted in damage to several masks. Case 2 An 8-year-old male with congenital central hypoventilation syndrome is managed with BPAP S/T during sleep. Similar to case 1, he is a mouth-breather during sleep and can only tolerate full face masks. Although his mask and headgear fit him well, he drools in sleep which results in the silicone liner slipping into his mouth, stimulating chewing. This has led to the need for replacement of several masks. Of note, drooling did not occur when he was previously using assisted ventilation via tracheostomy, and bruxism was not identified during polysomnography.

Conclusion

To our knowledge, this is the first report of PAP mask chewing, thus its incidence is unknown. We suspect that the mask liner slipping into the mouth touches the anterior surfaces of the teeth stimulating the chewing reflex. The frequency of mask chewing and consequent damage is unpredictable and often necessitates mask replacement. Insurance companies should consider this unique mask complication when determining their mask coverage policies since the typical 6-months interval for authorization of a new mask can impair the patient’s health, PAP compliance, and become an out-of-pocket financial burden for families. Although it did not occur in our patients, mask chewing may pose a potential choking hazard. Awareness of mask chewing may help in improving pediatric PAP mask development to ensure masks are safe.

Support (if any):
822 Apnea every 5 minutes
Authors: Sekhon Anupamjeet , Chiang Ambrose , Strohl Kingman , Yeh Eric
Published: May 2021

Introduction

Vagal Nerve Stimulators (VNS) are used in refractory epilepsy and depression. VNS are known to decrease airflow, oxygen saturation, and respiratory amplitude during sleep. We present a case of VNS induced OSA that was overlooked for 6 years.

Report of case(s)

A 63-year-old Caucasian female with refractory depression, hypothyroidism, and obesity presented with snoring and excessive daytime sleepiness (EDS). She had VNS implanted in a research trial for depression. She was on bupropion, duloxetine, lithium carbonate, lamotrigine, olanzapine, and levothyroxine. Polysomnography (PSG) showed moderate OSA with apnea-hypopnea index (AHI) of 25.8 and SpO2 nadir of 83%, and was titrated to bi-level positive airway pressure (PAP). She tried different masks and pressures but her leak and PAP intolerance persisted. There was no improvement in her EDS, and Armodafinil was prescribed for wake promotion. She struggled with bi-level PAP therapy for five years before being considered for hypoglossal nerve stimulator. But was turned down because of VNS presence. She was then recommended maxillomandibular advancement (MMA) but decided against it. She continued PAP therapy until a repeat PSG revealed mild to moderate OSA (AHI 10.9, RDI 17.8, and SpO2 nadir 79%), and it was noted that most of her respiratory events appeared in a regular fashion at 300-second intervals corresponding with the firing of VNS. PSG performed with VNS turned off showed no OSA (AHI 0.8 and SpO2 nadir 85%). PAP therapy was discontinued and subsequent nocturnal pulse oximetry showed normal oxygenation (ODI 15, RDI 17.8, SpO2 <88% for only 1.7 minutes). Her EDS resolved and VNS was eventually removed as per patient’s preference. She was started on a new medical therapy for depression. She continues to be asymptomatic.

Conclusion

Ascertainment bias led to delay in recognition of the cause of OSA as focus was on treatment only. Lowering the VNS frequency, increasing cycle time, turning it off during sleep or removal can improve respiratory events. The decision to do so depends on perceived benefit and harm of continuing VNS therapy. This case highlights the importance of re-evaluation of causes and treatment strategies when the standard of care is ineffective.

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831 Diagnostic and Treatment Challenges in a Child with Type 1 Narcolepsy
Authors: Nakka Sirish , Nandalike Kiran
Published: May 2021

Introduction

The diagnosis and management of Narcolepsy can be challenging in young children. We present a case of abrupt onset severe type 1 narcolepsy complicated by tactile hallucinations with stimulant medication therapy.

Report of case(s)

A previously healthy 7-year-old African American female presented to us at the beginning of the current pandemic with one week of excessive daytime sleepiness (EDS) with associated enuresis, hyperphagia and two episodes of cataplexy. She also presented with hypnagogic hallucinations and dream enactment behaviors. She was extremely sleepy with a score of 24/24 on the Epworth Sleepiness Scale. Her neurological exam was negative except for facial twitching appearing to be cataplectic facies. Extensive work up including urine toxicology, serology and cerebrospinal fluid (CSF) tests were undertaken to rule out infectious and demyelinating conditions; the results of these tests were negative. Brain magnetic resonance imaging as well as electroencephalogram testing were unremarkable. Overnight polysomnography demonstrated short sleep latency and rapid eye movement (REM) sleep without atonia and a multiple sleep latency test showed a mean sleep latency of less than 2 minutes and 4/4 sleep onset REM periods, highly suggestive of narcolepsy. Her HLA DQB1*0602 haplotype was positive but CSF Hypocretin testing was not done. She was given a diagnosis of Narcolepsy type I and started treatment on low dose Methylphenidate and Venlafaxine to address her EDS and cataplexy, respectively. Her EDS was gradually controlled with a higher dose of Methylphenidate but she developed severe tactile hallucinations. She complained of feeling bugs crawling under her skin and could not keep her clothes on due to constant discomfort. The tactile hallucinations improved with discontinuation of methylphenidate but reappeared with introduction of a different class of stimulants. Modafinil was ineffective in controlling her EDS symptoms. Her EDS, cataplexy and enuresis were better controlled after starting her on Sodium Oxybate. She continues to suffer from moderate to severe EDS with optimally dosed Sodium Oxybate with suboptimal response to various typical and atypical stimulants.

Conclusion

This case illustrates the difficulties in diagnosing and treating pediatric narcolepsy patients and a unique challenge of tactile hallucinations with stimulant medications.

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836 Issues with Sleep Can Be Skin Deep: Management of Obstructive Sleep Apnea in Cutaneous Sarcoidosis
Authors: Okorie Ugorji , Koothirezhi Rupa , Anne Pratibha , Monceaux Brittany , Liendo Cesar , Chernyshev Oleg
Published: May 2021

Introduction

Introduction/Background: PAP Intolerance is a common initial complaint among new PAP users, with mask issues and difficulty with pressure level leading the list. In clinical practice, feelings of claustrophobia and anxiety are usually cited as the reason for PAP intolerance. Sometimes craniofacial impairments such as congenital malformations or change in facial architecture after a major accident or surgery may play a role. Our case describes our experience with a patient afflicted with severe sinonasal cutaneous Sarcoidosis.

Report of case(s)

Case Description: A 43 year old AAF with a PMH of morbid obesity, depression and cutaneous sinonasal Sarcoidosis was referred to Sleep Medicine by ENT in late May 2020 with complaints of snoring, witnessed apneas, excessive daytime sleepiness, fatigue, and non-restorative sleep for >20 years. The patient was first diagnosed with cutaneous Sarcoidosis limited to the internal sinonasal region around 2015 and managed by ENT until the lesions spread to her face. Due to this, the patient developed depression and became increasingly non-complaint with her medical regimens. As a result, her sarcoidosis and other co-morbidities worsened. Diagnostic Polysomnogram (PSG) in May 2020 showed presence of Hypopnea predominant Obstructive Sleep Apnea (OSA) with AHI 35.9 and O2 desaturation to 58%. Subsequently, the patient was placed on auto CPAP 6–20 cm H2O with a DreamWear FFM. At follow up in September 2020, her sarcoidosis had spread to her upper lip area, so she was prescribed a Fit Life mask to avoid this region. Follow up in December 2020 revealed improvement in Sarcoidosis and accompanying vast improvement in objective compliance though she reverted to using her DreamWear FFM due to “mask seal issues. An AirFit f20 mask was then given to help avoid the active lesions on her upper lip.

Conclusion: Discussion/Conclusion

In patients with compromised facial architecture, special attention must be paid to the type of mask interface used so it does not aggravate sensitive areas which may lead to poor compliance with PAP therapy. Instructions were given for her to alternate between her three masks—the Fit Life, the DreamWear FFM and the AirFit f20 FFM—in an effort to reduce irritation on her face over time.

Support (if any):
838 Not All Hypercapnia is COPD
Authors: Te Tue , Emanuel Hina , Velamuri Kanta , Singh Supriya
Published: May 2021

Introduction

Sleep breathing disorder related to isolated unilateral or bilateral diaphragmatic dysfunction (DD), in the absence of a generalized neuromuscular disorder, is not well understood and often under-recognized. There have been only a few cases reported of apneas and hypoponeas during REM sleep due to diaphragmatic dysfunction. We present here, a case of an 62 year-old man who developed acute hypercapnic respiratory failure with presumed COPD exacerbation requiring invasive ventilation.

Report of case(s)

A 62-year-old man was found on the sidewalk extremely short of breath and was intubated in the emergency department. Initial post-intubation arterial blood gas showed pH 7.1, pCO2 82, pO2 263, CO3 25.5. CXR showed no infiltrates. Echocardiography showed EFof 55%-65%. Long-term tobacco use supported the picture of COPD exacerbation. However, PFT was within normal limits. HSAT one year prior which showed severe OSA with AHI 52.6 event per hour. Patient had not pursued positive airway pressure (PAP) titration study afterward. In ICU, he was treated for presumed COPD exacerbation and successfully weaned off invasive ventilation. Inpatient PAP titration study recommended IPAP 12 and EPAP 8 cm H20. A fluoroscopy of the diaphragm was performed and showed that the right diaphragm had limited mobility. Electromyogram did not show generalized myopathy.

Conclusion

In conclusion, this case report describes the presentation of sleep disordered breathing seen in patients with unilateral diaphragmatic palsy. In these patients, the respiratory events seen are mainly hypopneas and desaturations, worse in REM sleep and supine position. This was an unusual presentation of a patient with untreated OSA and unilateral diaphragmatic palsy. A characteristic finding in these patients is worsening of the OSA in supine position. This has been reported in several studies and was seen in our case as well. This case underscores the need for critical thinking and diagnostic reasoning in the evaluation of a patient with hypercapnic respiratory failure and consider a wide differential and not only COPD exacerbation as the cause. Unilaterally diaphragmatic palsy is a rare cause of hypercapnic respiratory failure but must be considered when seen with obstructive sleep apnea with predominantly hypopneas and hypoxemia out of proportion of the respiratory events.

Support (if any):
847 Rapid Improvement of Pulmonary Hypertension with Adequate Ventilatory Support in Patient with Prader-Willi Syndrome
Authors: McHugh Erin , Gubichuk Megan , Malhotra Sonal
Published: May 2021

Introduction

Prader-Willi syndrome (PWS) is a genetic multi-system disorder characterized by developmental delay, hyperphagia, and often morbid obesity. Patients can have impairments in ventilatory control and are at risk for sleep disordered breathing due to craniofacial abnormalities, obesity, hypothalamic dysfunction, hypotonia and respiratory muscle weakness. This places them at higher risk for obstructive sleep apnea (OSA), hypoventilation and, if left untreated, may lead to cardiovascular complications. We present a patient with pulmonary hypertension (PH) in the setting of PWS and under supported OSA.

Report of case(s)

A 17-year-old female with PWS, obesity, type II diabetes mellitus, developmental delay and severe OSA, non-adherent to positive airway pressure (PAP) therapy, presented with 6 months of pedal edema, weight gain with acute shortness of breath, fatigue, and decreased appetite. Upon arrival she developed hypoxemic, hypercapnic respiratory failure requiring intubation. Echocardiogram two months prior to admission showed normal right ventricular size and function with normal septal configuration. Echocardiogram after intubation showed signs of PH with dilated and hypokinetic ventricles compared to prior exam, worsening tricuspid valve regurgitation, and septal bowing. Sleep history was notable for severe OSA in 2017 with obstructive apnea-hypopnea index (oAHI) of 22.6, oxygen nadir of 74%, peak transcutaneous pCO2 of 51 mmHg. Patient was lost to follow-up and as per our history, was non-adherent to PAP therapy. On admission she was started on aggressive diuresis and tadalafil. After successful extubation to BPAP and wean to room air while awake, a BPAP titration PSG was performed. It demonstrated low baseline oxygen saturations (93%), an oxygen nadir of 70%, transcutaneous CO2 peak of 57mmHg with obstructive events eliminated with BPAP of 24/14 cmH20 and hypoxemia treated with 4L supplemental oxygen. With adequate respiratory support with sleep combined with PH monotherapy, repeat echocardiogram prior to discharge showed improved systolic function and only mild septal flattening.

Conclusion

It is unclear the prevalence of PH in patients with PWS independent of OSA, however it is likely increased overall secondary to the increased prevalence of OSA. As a result, patients with PWS may benefit from routine interval echocardiogram to monitor for signs of PH.

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850 REM Sleep and ST Deviation in Acute Myocardial Infarction
Authors: Ramaniuk Aliaksandr , Carbajal-Mamani Semiramis , Hadigal Susheela , Ricaurte Basma
Published: May 2021

Introduction

Sleep stage architecture and amount of REM sleep have been associated with mortality and clinical recovery, without clear etiology. Patients recovering from critical illness frequently experience sleep disturbances, episodic arrhythmogenesis, EKG changes. This case aims to add to current field of study and describes an unusual pattern of sleep stage dependent, hypoxia independent, ST segment variation, which may benefit from further exploration and utilization of polysmongoraphy (PSG) in the immediate post acute MI period.

Report of case(s)

46 year old female with history of smoking, obesity, and diabetes presented for a sleep medicine evaluation, four days following a hospitalization for non ST elevation myocardial infarction (NSTEMI) and percutaneous coronary intervention. Her split night PSG data revealed severe obstructive sleep apnea (OSA) with apnea hypopnia index (AHI) of 131. Patient did not report acute cardiac symptoms during overnight sleep evaluation. On close observation of PSG data, the patient had grossly evident baseline ST segment depression during wake period. The ST depression persisted through stages 1 and 2 with unchanged morphology. During Stage 3, the ST segment showed progressive elevation to near the isoelectric line. During REM sleep without positive airway pressure (PAP), ST segment was noted at or near isoelectric line, even in the setting of hypoxia with saturation (Sao2) of 75%. During REM Sleep with PAP, the ST segment remained at the isoelectric line, and returning to baseline depression during wake phase while on BiPAP.

Conclusion

Residual ST segment deviation, and its resolution, are strong predictors of prognosis in patients with MI. Prior studies focused on hypoxic tolerance and sleep disordered breathing, with limited attention on specific sleep stage evaluation. REM sleep has been described as potentially having restorative effect on ischemic myocardium. Additionally, the transition period from non REM to REM sleep was reported to provide potential for myocardial restoration. PSG with cardiac monitoring remains a unique tool in further assessment of a possible association. This case aims to bring attention to the potential association of EKG ST segment variation with sleep stages, especially REM and S3, independent of hypoxia.

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858 Transitions to Virtual Administration of CBT-I: Strengths & Barriers
Authors: Nguyen Anna Marie , Campbell Rebecca , Mobley Alita , Vargas Ivan
Published: May 2021

Introduction

In March 2020, the University of Arkansas Psychological Clinic began social distancing resulting in a CBT-I group (four patients, 3 trainee co-leaders) transitioning from in-person meetings to telehealth via Webex. Two co-leaders led the group while the third disseminated electronic materials and scored the patients’ online sleep diaries. Virtual administration of CBT-I had benefits and challenges.

Report of case(s)

Firstly, many of the patients were familiar with teleconferencing as their jobs also transitioned to virtual meetings and could identify environments with limited interruptions. Telehealth group etiquette such as muting audio, timely diary submission, and peer support were easily mastered. However, one patient had poor internet connection, which necessitated switching between their laptop and phone to connect and seemed to negatively impact engagement with the group. Furthermore, the clinicians were confronted with the difficult decision to continue helping troubleshoot technical issues or continue with the session. During in-person visits, co-leaders could address difficulties with sleep prescription or questions about the material; however, balancing technical issues, answering questions, and facilitating support amongst the patients via telehealth was often distracting and inefficient. From a clinician perspective, it was difficult to co-lead the group due to patients respectfully muting their mics, resulting in less contributions to discussion. Additionally, many of the administrative tasks typically completed with clinic staff after an in-person session were completed during session, making it challenging to maintain confidentiality. Presentation of visual aids was difficult as patient using cellphones to connect could not view and download files while connected to session. Finally, basic clinical techniques were impacted using the virtual platform. For instance, “sitting in silence” was less effective while maintaining eye contact with the entire group was facilitated by looking directly at the camera. Unfortunately, reading facial expressions and non-verbals was often more difficult and clinicians relied on more direct questions rather than open-ended questions.

Conclusion

These challenges provide opportunities to learn how to make CBT-I via telehealth more effective. Despite the challenges of transitioning to telepsychology, the CBT-I group was effective as evidenced by high satisfaction ratings from patients, reductions in PHQ-9 and ISI scores, SOL, WASO, and increases in sleep efficiency.

Support (if any):
A Gender Gap in Publishing? Understanding the Glass Ceiling in Pediatric Orthopaedic Surgery
Authors: Johnson Mitchell A. , Mulvey Hillary , Parambath Andrew , Anari Jason B. , Wall Lindley B. , Shah Apurva S.
Published: May 2021

Background:

Women are underrepresented across most surgical specialties and especially in the field of orthopaedic surgery. Despite pediatric orthopaedic surgery being one of the most gender diverse subspecialties in orthopaedics, women may still face barriers to academic advancement. Research presentations at national meetings and publication record are important drivers of advancement in the field of academic orthopaedic surgery. The aim of this study is to assess whether research abstracts authored by women are less likely to be published than abstracts authored by men.

Methods:

Abstracts from research podium presentations given at the Pediatric Orthopaedic Society of North America annual meetings from 2006 to 2020 were reviewed to assess research quality and determine basic study characteristics. For each abstract, author gender was determined through a search of institutional websites and professional networking websites for gender-specific pronouns. Resulting publications corresponding to the 2006 to 2018 were identified using a systematic search of PubMed and Google Scholar databases. Kaplan-Meier inverse survival analysis with log rank test were used to determine differences in publication rates based on whether the last (senior) author was female versus male. Multivariate, binary logistic regression was performed to assess factors predictive of eventual publication.

Results:

One thousand five hundred and eighty-one of 1626 (97.2%) of abstracts from 2006 to 2020 had an identifiable last author gender, with 17.8% (281/1581) female. No differences in study quality were identified across genders including sample size, level of evidence, or impact factor of journal if leading to publication. Women were more likely to author abstracts in foot, ankle, or lower extremity surgery [17.8% (50/281) vs. 12.9% (168/1300), P=0.032] and less likely to author abstracts focusing on the hip [11.0% (31/281) vs. 17.1% (222/1300), P=0.012]. Abstracts with women as the last author were significantly less likely to be published compared with abstracts with men as the last author [59.6% (143/240) vs. 67.9% (783/1154), P=0.013]. Multivariate analysis demonstrated that last author female gender was predictive of a lower likelihood of publication (odds ratio: 0.684, 95% confidence interval: 0.513-0.912, P=0.010). Women were less likely to be the last author of abstracts presented by study groups [2.1% (6/281) vs. 5.5% (71/1300), P=0.019].

Conclusion:

In pediatric orthopaedic surgery, abstracts authored by women are less likely to reach publication, despite no identifiable differences in study quality. Reasons for this discrepancy must be explored including insufficient mentorship, exclusion from study group participation, or potential bias against female researchers in the field of orthopaedic surgery.

Level of Evidence:

Level IV.
A Trend-Based Early Warning Score Can Be Implemented in a Hospital Electronic Medical Record to Effectively Predict Inpatient Deterioration
Authors: Bell David , Baker John , Williams Chris , Bassin Levi
Published: May 2021

OBJECTIVES:

To determine whether a statistically derived, trend-based, deterioration index is superior to other early warning scores at predicting adverse events and whether it can be integrated into an electronic medical record to enable real-time alerts.

DESIGN:

Forty-three variables and their trends from cases and controls were used to develop a logistic model and deterioration index to predict patient deterioration greater than or equal to 1 hour prior to an adverse event.

SETTING:

Two large Australian teaching hospitals.

PATIENTS:

Cases were considered as patients who suffered adverse events (unexpected death, unplanned ICU transfer, urgent surgery, and rapid-response alert) between August 1, 2016, and April 1, 2019.

INTERVENTIONS:

The logistic model and deterioration index were tested on historical data and then integrated into an electronic medical record for a 6-month prospective “silent” validation.

MEASUREMENTS AND MAIN RESULTS:

Data were acquired from 258,732 admissions. There were 8,002 adverse events. The addition of vital sign and laboratory trend values to the logistic model increased the area under the curve from 0.84 to 0.89 and the sensitivity to predict an adverse event 1–48 hours prior from 0.35 to 0.41. A 48-hour simulation showed that the logistic model had a higher area under the curve than the Modified Early Warning Score and National Early Warning Score (0.87 vs 0.74 vs 0.71). During the silently run prospective trial, the sensitivity of the deterioration index to detect adverse event any time prior to the adverse event was 0.474, 0.369 1 hour prior, and 0.327 4 hours prior, with a specificity of 0.972.

CONCLUSIONS:

A deterioration prediction model was developed using patient demographics, ward-based observations, laboratory values, and their trends. The model’s outputs were converted to a deterioration index that was successfully integrated into a live hospital electronic medical record. The sensitivity and specificity of the tool to detect inpatient deterioration were superior to traditional early warning scores.
Academic and Nonacademic Predictors of BSN Student Success on the HESI Exit Exam
Authors: Moore Leslie C. , Goldsberry Jennifer , Fowler Catherine , Handwerker Sarah
Published: May 2021

First-time success rate on the NCLEX-RN examination has significant implications for BSN students, faculty, and schools of nursing. Many nursing programs utilize standardized examinations such as the HESI Exit Exam to quantify student success on knowledge of nursing concepts and to prepare students for success on the NCLEX-RN. Nursing faculty must be able to identify predictors of student success early in the nursing program in order to offer appropriate support and remediation. The purpose of this retrospective, correlational study was to determine predictive variables of BSN student success on the HESI Exit Exam in a southeastern university. Students who reported higher test anxiety scored significantly lower on the HESI Exit Exam. Higher medical-surgical I HESI examination scores, higher medical-surgical II HESI examination scores, higher obstetrics HESI examination scores, and higher final grade point average were significant predictors of students' HESI Exit Exam scores and accounted for 39% of the variance in the scores. Results from this study suggest implementing remediation based on HESI Specialty Exam scores and interventions aimed at reducing test anxiety.
Feasibility of Wearable Universal Serial Bus Utilization to Support Clinical Trial Participant Safety Management
Authors: Johnson Elizabeth , Carrington Jane M.
Published: May 2021

Clinical trials are exploratory in nature and thus present a degree of risk for those individuals who participate in the trial. Risks include adverse events, which are undesirable experiences that arise from use of investigational products or devices that may cause participant injury or withdrawal from the clinical trial. The prevention of adverse events is a challenge given the lack of interoperability among organizational electronic health records and reliance on wallet cards to communicate safety-related information, leaving the burden of describing research-related information to external providers on the trial participant. This potential for ineffective communication propagates further risk of contraindicated medication administration and misaligned care management, which can negatively impact the trial participant's opportunity to safely engage in novel therapeutic research. This pilot, qualitative descriptive study explores a mobile, low-technology solution in the form of a wearable universal serial bus device to house deidentified, critical research-related information for clinical trial participants to wear and give external providers such that trial constraints on care management are effectively communicated. Eight participants wore a commercial universal serial bus device for 72 hours and described the meaning surrounding the participants' daily wearing of the universal serial bus bracelet via semistructured interviews. Four themes emerged: application to clinical trial participants, societal perception of wearing device, healthcare operations/workflow impact, and wearability of the universal serial bus device. Thematic findings included recommendations for device design improvements as well as key considerations for provider identification of the device.
Baseline Plasma Inflammatory Profile Is Associated With Response to Neoadjuvant Chemotherapy in Patients With Pancreatic Adenocarcinoma
Authors: Chopra Asmita , Zamora Ruben , Vodovotz Yoram , Hodges Jacob C. , Barclay Derek , Brand Randall , Simmons Richard L. , Lee Kenneth K , Paniccia Alessandro , Murthy Pranav , Lotze Michael T. , Boone Brian A. , Zureikat Amer H.
Published: May 2021

Despite its increased application in pancreatic ductal adenocarcinoma (PDAC), complete response to neoadjuvant therapy (NAT) is rare. Given the critical role of host immunity in regulating cancer, we sought to correlate baseline inflammatory profiles to significant response to NAT. PDAC patients receiving NAT were classified as responders (R) or nonresponders (NR) by carbohydrate antigen 19-9 response, pathologic tumor size, and lymph node status in the resected specimen. Baseline (treatment-naive) plasma was analyzed to determine levels of 27 inflammatory mediators. Logistic regression was used to correlate individual mediators with response. Network analysis and Pearson correlation maps were derived to determine baseline inflammatory mediator profiles. Forty patients (20R and 20NR) met study criteria. The R showed significantly higher overall survival (59.4 vs. 21.25 mo, P=0.002) and disease-free survival (50.97 vs. 10.60 mo, P=0.005), compared with NR. soluble interleukin-2 receptor alpha was a significant predictor of no response to NAT (P=0.045). Analysis of inflammatory profiles using the Pearson heat map analysis followed by network analysis depicted increased inflammatory network complexity in NR compared with R (1.69 vs. 1), signifying a more robust baseline inflammatory status of NR. A panel of inflammatory mediators identified by logistic regression and Fischer score analysis was used to create a potential decision tree to predict NAT response. We demonstrate that baseline inflammatory profiles are associated with response to NAT in PDAC, and that an upregulated inflammatory status is associated with a poor response to NAT. Further analysis into the role of inflammatory mediators as predictors of chemotherapy response is warranted.
In-hospital Complications Are More Likely to Occur After Reverse Shoulder Arthroplasty Than After Locked Plating for Proximal Humeral Fractures
Authors: Köppe Jeanette , Stolberg-Stolberg Josef , Rischen Robert , Faldum Andreas , Raschke Michael J. , Katthagen J. Christoph
Published: May 2021

Background

Currently, there seems to be a paradigm change in the surgical treatment of proximal humeral fractures in patients aged 65 years and older, with a considerable increase in the use of reverse total shoulder arthroplasty (RTSA) compared with angular stable internal fixation (locking plate fixation). However, even among shoulder specialists there is controversy regarding the best treatment strategy.

Questions/purposes

To evaluate for (1) a greater risk of in-hospital major adverse events, (2) a greater risk for in-hospital surgical complications, and (3) a greater risk of 30-day mortality, locking plate fixation and RTSA were compared for the treatment of proximal humerus fractures of patients aged 65 years and older after controlling for potentially confounding variables in a large-database analysis.

Methods

Health claims data of the largest German insurance company including approximately one-third of the population (26.5 million policyholders) between 2010 and 2018 were analyzed. This database was chosen because of its size, nationwide distribution, and high quality/completeness. In total, 55,070 patients (≥ 65 years of age) treated with locking plate fixation (75% [41,216]) or RTSA (25% [13,854]) for proximal humeral fracture were compared. As primary endpoints, major adverse events (including acute myocardial infarction, stroke, organ failure, resuscitation, and death) and surgical complications (infection, hematoma, loss of reduction, dislocation, and revision surgery) were analyzed. The risk of all endpoints was analyzed with multivariable logistic regression models in the context of comorbidities to address existing group differences.

Results

After controlling for potentially confounding variables such as age, sex, and risk profile, RTSA was associated with a higher risk for major adverse events (OR 1.40 [95% CI 1.29 to 1.53]; p < 0.001) and surgical complications (OR 1.13 [95% CI 1.05 to 1.21]; p < 0.01) compared with locking plate fixation. There was no evidence for an increase in mortality (OR 0.98 [95% CI 0.86 to 1.12]; p = 0.81).

Conclusion

The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with RTSA for proximal humeral fractures in patients 65 years and older. Treatment decisions should be based on individual risk estimation to avoid potential harmful events. Future studies must include long-term outcomes and quality of life to enlighten these findings in a broader context.

Level of Evidence

Level III, therapeutic study.
Social Distancing and SARS-CoV-2 Transmission Potential Early in the Epidemic in Finland
Authors: Auranen Kari , Shubin Mikhail , Karhunen Markku , Sivelä Jonas , Leino Tuija , Nurhonen Markku
Published: May 2021

Background:

Information about social mixing patterns under heavy social distancing is needed to model the impact of nonpharmaceutical interventions on SARS-CoV-2 transmission.

Methods:

We conducted a survey on daily person-to-person contacts during the early phase of the SARS-CoV-2 epidemic in Finland, one month after strong social distancing measures had been introduced nationwide. We defined a contact as exchange of at least a few words in proximity of another person. We also considered physical (“skin-to-skin”) contacts separately. Based on 3,171 reported contacts by 1,320 participants of 1–79 years of age, we estimated age-stratified contact matrices essential in modeling virus transmission.

Results:

Compared with contacts during prepandemic conditions, as learned from the Finnish part of the Polymod study, there was a 72% (95% credible interval, CI = 71, 74) reduction in the daily number of all contacts and a 69% (95% CI = 66, 73) reduction in the daily number of physical contacts in April 2020. The largest reduction, of almost 90%, occurred in physical contacts by individuals more than 70 years of age. The estimated reduction in the transmission potential of the virus attributable solely to reduced contact frequencies varied between 59% (whole population; physical contacts; 95% CI = 52, 68) and 77% (over 20-year olds; physical contacts; 95% CI = 70, 89).

Conclusions:

We surmise that the large reduction in the daily numbers of social contacts in the early part of the SARS-CoV-2 epidemic in Finland was likely a major contributor to the steady decline of the epidemic in the country since early April.
Non-Respiratory Droplet Transmission of COVID-19 in the Isolation Ward of a Secondary Hospital in Oman
Authors: Al Mayahi Zayid K. , Al Kindi Nawal , Al Shaqsi Nasser , Al Hattali Noaman , Al Hattali Azza , Salim Khalid , Beatty Mark
Published: May 2021

Front-line health care workers are among the most vulnerable groups at risk for acquiring COVID-19, yet the exact mechanisms of how infections occur in health care settings are yet to be identified.

Objectives

To review the epidemiologic and environmental factors surrounding a cluster of nosocomially acquired COVID-19 cases with possible non respiratory droplet transmission indicating the importance of strict adherence with isolation procedures for patients and staff.

Methods

Contact and environmental investigations were completed to determine the source and possible routes of hospital transmission of COVID-19.

Results

Seven cases of COVID-19 occurred in the COVID-19 isolation ward of a secondary hospital from 12/04/2020 to 01/05/2020. Analysis also included first four COVID-19 patients admitted to this facility. Epidemiologic links included exposure to massive bowel movements of two infected patients in adjoining rooms on the same day. Serious gaps in infection control practices lead to further spread the virus and cross infection between the staff.

Conclusion

Despite preparedness to combat pandemics, the infection control precautions taken at this facility were found not sufficient to prevent nosocomial spread of COVID-19. Issues were identified with compliance, enforcement, and failure to update to the most current guidance. Urgent review of ongoing hygiene and isolation practices in hospitals of this type is indicated. Further studies are required to better understand the role of fecal oral transmission and environmental contamination in the transmission of COVID-19.
Cultural Perspectives on Pain Assessment and Opioid Use: International Neuroscience Nursing Research Symposium Conference Proceedings
Authors: Bautista Cynthia , Amatangelo Mary P. , Baby Priya , Cassier-Woidasky Anne-Kathrin , Dycus Kaleigh , Edoh Esther I. , Green Theresa , Ilano Karen Czarina S. , Kemboi Mary , Littlejohns Linda , Martinez Rudolf Cymorr Kirby P. , Mastamet Gladys , Perera Anjali , Ramazanu Sheena , Ribeiro Rennan Martins , Serondo Diana Jean F. , Sila Faith , Strayer Andrea , Soriano Gil P. , Wessol Jennifer L.
Published: May 2021

INTRODUCTION: In August of 2020, the 4th International Neuroscience Nursing Research Symposium was held. The purpose of the symposium was to share neuroscience nursing research from around the world. One of the topics thought most notable that stimulated a crucial conversation was how different countries assessed pain and their use of opioids for pain management. BACKGROUND: Neuroscience nurses are global. What is not known is their experience with and what challenges exist with pain management for human beings in their country. Crossing geographic and cultural boundaries, pain affects all human beings. Each culture has unique values and beliefs regarding pain. Patient barriers, pivotal in this article, included poverty, poor health literacy, opioid phobia, and cultural as well as social beliefs. RESULTS: Neuroscience nurses from Australia, Brazil, Germany, Singapore, India, Ghana, Kenya, Philippines, South Africa, and the United States each collaborated to provide a short summary of assessing pain and use of opioids for pain management for the neuroscience patient. CONCLUSION: Neuroscience patients have varying degrees of pain based on many factors. Various countries have religious, spiritual, and cultural traditions that influence the reporting and management of pain. Pain assessment and management can be challenging, especially for the neuroscience nurses around the world.
Relationships Among Phantom Limb Pain, Peripheral Sensations, and Cognition in People with Lower-Limb Loss
Authors: Wong Christopher K. , Wong Caitlin K.
Published: May 2021

Introduction

After amputation, altered sensory input leads to cortical reorganization that partly explains phantom limb pain (PLP). However, many factors impact the PLP phenomenon, and modern conceptualizations of chronic pain including PLP integrate both peripheral inputs and central interpretation. Clinicians without functional MRI could benefit from clinical measures related to PLP to assess clinical presentations. The purpose of this pilot study was to identify peripheral sensation and cognition measures related to PLP to inform outcome measure selection in future PLP research.

Methods

This cross-sectional analysis included people with PLP of any age, sex, and amputation cause or level. Assessments included patient-reported residual limb pain and PLP using the Prosthesis Evaluation Questionnaire, peripheral sensation measures (light touch, temperature, vibration, two-point discrimination), and cognition measures (laterality recognition, trail making, clock drawing). Unadjusted Spearman ρ coefficients were reported.

Results

Eleven volunteers (48.5 ± 13.2 years) with lower-limb amputations (seven transtibial) of various causes (nine medical) participated. More severe PLP symptoms were associated with impaired peripheral sensation (light touch, ρ = 0.514; temperature, ρ = 0.756) and poorer cognition (laterality recognition, ρ = 0.524; trail making, ρ = 0.565). Residual limb pain was not correlated with cognition measures (ρ < 0.4).

Conclusions

This pilot study identified clinical measures assessing cognition and peripheral sensation impairments associated with worse PLP symptoms. Phantom limb pain was related to temperature and light touch sensation measures, but two-point discrimination was not associated with PLP consistent with past research. Laterality recognition was associated with PLP per prior research, and the association of PLP with the Trail Making Test in this pilot study suggests that the Trail Making Test may be an additional cognition measure potentially useful in future clinical research to document the PLP experience.
A Higher Playing Standard, Bowling, and Intermittent Helmet Use Are Related to a Greater Odds of Injury or Concussion in Cricket
Authors: Filbay Stephanie R. , Bullock Garrett S. , Sanchez-Santos Maria T. , Arden Nigel K. , Peirce Nicholas
Published: May 2021

Objective:

To determine if playing position, a higher playing standard, and nonhelmet use are related to an increased odds of joint-specific injury and concussion in cricket.

Design:

Cross-sectional cohort.

Participants:

Twenty-eight thousand one hundred fifty-two current or former recreational and high-performance cricketers registered on a national database were invited to participate in the Cricket Health and Wellbeing Study. Eligibility requirements were aged ≥18 years and played ≥1 cricket season.

Independent Variables:

Main playing position (bowler/batter/all-rounder), playing standard (high-performance/recreational), and helmet use (always/most of the time/occasionally/never).

Main Outcome Measures:

Cross-sectional questionnaire data included cricket-related injury (hip/groin, knee, ankle, shoulder, hand, back) resulting in ≥4 weeks of reduced exercise and self-reported concussion history. Crude and adjusted (adjusted for seasons played) odds ratios and 95% confidence interval (CIs) were estimated using logistic regression.

Results:

Of 2294 participants (59% current cricketers; 97% male; age 52 ± 15 years; played 29 ± 15 seasons; 62% recreational cricketers), 47% reported cricket-related injury and 10% reported concussion. Bowlers had greater odds of hip/groin [odds ratio (95% CI), 1.9 (1.0-3.3)], knee [2.0 (1.4-2.8)], shoulder [2.9 (1.8-4.5)], and back [2.8 (1.7-4.4)] injury compared with batters. High-performance cricketers had greater odds of injury and concussion than recreational cricketers. Wearing a helmet most of the time [2.0 (1.4-3.0)] or occasionally [1.8 (1.3-2.6)] was related to higher odds of self-reported concussion compared with never wearing a helmet. Concussion rates were similar in cricketers who always and never wore a helmet.

Conclusions:

A higher playing standard and bowling (compared with batting) were associated with greater odds of injury. Wearing a helmet occasionally or most of the time was associated with higher odds of self-reported concussion compared with never wearing a helmet.
Realizing the Value of Nursing Through Innovative Regulation
Authors: Benton Kristin K. , Thomas Katherine A.
Published: May 2021

Nursing regulation is a specialty area of nursing practice that some may perceive as only performing licensing and disciplinary functions. However, highly effective boards strive to meet their mission of public protection through continuous innovation. This article describes several innovative programs initiated by a board of nursing. Among the examples include regulatory waivers during the pandemic, collaborations with stakeholder organizations, a resource for nursing peer-review committees, and an alternative remediation option for practice breakdown. With strong leadership and committed teams, regulation can both protect the public and play a part in actualizing the value of nursing.
Nurse Practitioner Student Perceptions of a Multimodal Telemedicine Clinical Course
Authors: Burt Leah , Kilroy Sue
Published: May 2021

Background

Telemedicine facilitates access to care that is both efficacious and highly satisfactory to patients. As primary health care providers, nurse practitioners (NPs) need to be educated to deliver health care within various settings. With the rapid expansion of telemedicine, NP educational authorities have charged educators to address essential telemedicine-based competencies.

Purpose

Innovative approaches to integrating telemedicine competencies into NP curricula have yet to be established in nursing education.

Methods

Multifocal curricular changes were integrated into an NP clinical course. Students engaged in self-directed learning modules and multiple simulation training sessions and rotated through telemedicine clinical practicums.

Results

Experiences were perceived as realistic and complementary, learning meaningful, and applicability broad and far-reaching. Telemedicine-focused simulation training sessions were viewed as highly satisfactory, and students were confident in simulation-derived learning.

Conclusions

Nursing educators should integrate multimodal telemedicine experiences into curricula, addressing multiple learning phases through experientially designed simulation trainings.
Reducing Disparities: A Virtual Quality Improvement Collaborative Resulted in Better Health Outcomes for 4 Target Populations Disproportionately Affected by HIV
Authors: Steinbock Clemens M. , Chung Rakkoo , Lee Jennifer E. , Leung Shu-Yin John , Kolesar Charles , Tesoriero James
Published: May 2021

Context:

Although viral suppression rates have recently increased among people with HIV, specific populations still experience disparities in health outcomes, a priority in the national response to end the HIV epidemic.

Purpose:

The end+disparities ECHO Collaborative, a quality improvement initiative among HIV providers in the United States from June 2018 to December 2019, created virtual communities of practice to measurably increase viral suppression rates in populations disproportionately affected by HIV: men who have sex with men of color, Black/African American and Latina women, youth aged 13 to 24 years, and transgender people.

Methods:

Participating Ryan White HIV/AIDS Program–funded providers prioritized their improvement efforts to focus on one target population and joined virtual affinity sessions with other providers focused on that population for guidance by subject matter experts and exchanges with peer providers. During 9 submission cycles, providers reported their viral suppression data for the preceding 12 months.

Main Outcome Measures:

The principal outcome measures were changes in viral suppression rates among 4 target populations and changes in viral suppression gaps compared with the rest of HIV-infected patients served by the same agency.

Results:

A total of 90 providers were included in the data analyses with an average of 110 775 reported patients, out of which 19 442 represented the targeted populations. The average viral suppression rates for agency-selected populations increased from 79.2% to 82.3% (a 3.9% increase), while the remaining caseload increased at a lower rate from 84.9% to 86.1% (a 1.4% increase). The viral suppression gap was reduced from 5.7% to 3.8%, a 33.5% reduction. Improvements were found across all target populations.

Conclusions:

The collaborative demonstrated improved health outcomes and reductions in HIV-related health disparities, moving toward ending the HIV epidemic. The model of utilizing low-cost videoconferencing technologies to create virtual communities of learning is well suited to mitigate other disease-related disparities, nationally and abroad.