bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes of Remediation Strategies Implemented by the Illinois Board of Nursing to Improve Program NCLEX Pass Rates: A Five-Year Follow-Up
Authors: Libner Joan
Published: February 2021

After noting a marked decline in National Council Licensure Examination (NCLEX) pass rates for Illinois programs, the Illinois Board of Nursing created its remediation strategies tool based on standards of two accrediting bodies for use by programs with NCLEX pass rates of less than the state-mandated 75 percent. Five-year follow-up data demonstrated a marked decrease in number and percentage of programs with unsatisfactory results, which were consistent over time. Qualitative survey data across Illinois programs further supported the tool as a valuable resource.
Academic Factors Predicting NCLEX-RN Success
Authors: Flowers Monica , Olenick Maria , Maltseva Tatayana , Simon Sharon , Diez-Sampedro Ana , Allen Lois Ryan
Published: February 2021

This retrospective study examined the relationships among 10 academic predictors and first-time success on the NCLEX-RN in a sample of 92 bachelor of science in nursing minority and culturally diverse generic/traditional students at a large minority-serving, urban, public university. Predictors included the Test of Essential Academic Skills (overall, science, and reading), science grade point average (GPA), cumulative GPA, and scores on various standardized exams: Kaplan, HESI, and ATI. Discriminant analysis found science GPA of >3.50 and ATI B of 60 or above to be the best predictors of passing NCLEX-RN. Based on statistically significant differences between NCLEX-RN pass and fail scores, good indicators of NCLEX-RN success were scores of 50 or above on Kaplan and 950 or above on HESI. Overall, the Test of Essential Academic Skills did not predict students’ NCLEX-RN outcomes.
Best practices in benzodiazepine prescribing and management in primary care
Authors: Champion Claire , Kameg Brayden N.
Published: February 2021

Despite the lack of evidence on the long-term effectiveness of benzodiazepines and their potential harmful effects, prescriptions of the drug have significantly increased in the US over the past decade. This article reviews best practices regarding primary care benzodiazepine prescriptions and how providers can best prevent and treat benzodiazepine use disorder and other harmful effects.
Beliefs related to Pap smear intention among Jamaicans
Authors: Linton Denise
Published: February 2021

Globally, most women who are diagnosed with cervical cancer do not obtain regular screening with the Pap smear/test. Women in developing countries have high cervical cancer incidence and mortality. Therefore, a qualitative research study was conducted to determine the referents, and salient and control beliefs related to Pap smear/test intention among Jamaicans.
Mental health problems among youth experiencing sex trafficking
Authors: Fazio Nicole , Lynch Jenna , Devlin Maura , Kameg Brayden
Published: February 2021

There are an estimated 4.8 million victims of sex trafficking (ST) globally, and 21% of these victims are children or adolescents. Victims of ST are at risk for mental health problems, and it is crucial for healthcare professionals to identify them and provide care.
Determining the level of evidence
Authors: Glasofer Amy , Townsend Ann B.
Published: February 2021

To support evidence-based nursing practice, the authors provide guidelines for nonresearch evidence, which includes clinical practice guidelines, consensus or position statements, literature review, expert opinion, organizational experience, case reports, community standards, clinician experience, and consumer preferences. This is the third in a three-part series.
Women on the Frontline: A Changed Workforce and the Fight Against COVID-19
Authors: Rabinowitz Loren Galler , Rabinowitz Danielle Galler
Published: February 2021

COVID-19 is a worldwide pandemic, with frontlines that look drastically different than in past conflicts: that is, women now make up a sizeable majority of the health care workforce. American women have a long history of helping in times of hardship, filling positions on the home front vacated by men who enlisted as soldiers during World War I and similarly serving in crucial roles on U.S. military bases, on farms, and in factories during World War II. The COVID-19 pandemic has represented a novel battleground, as the first in which women have taken center stage, not only in their roles as physicians, respiratory therapists, nurses, and the like, but also by serving in leadership positions and facilitating innovations in science, technology, and policy. Yet, the pandemic has exacerbated multiple pain points that have disproportionally impacted women in health care, including shortages in correctly sized personal protective equipment and uniforms, inadequate support for pregnant and breastfeeding providers, and challenges associated with work–life balance and obtaining childcare. While the pandemic has facilitated several positive advancements in addressing these challenges, there is still much work to be done for women to achieve equity and optimal support in their roles on the frontlines.
Learning From What We Do, and Doing What We Learn: A Learning Health Care System in Action
Authors: Lindsell Christopher J. , Gatto Cheryl L. , Dear Mary Lynn , Buie Reagan , Rice Todd W. , Pulley Jill M. , Hartert Tina V. , Kripalani Sunil , Harrell Frank E. , Byrne Daniel W. , Edgeworth Mitchell C. , Steaban Robin , Dittus Robert S. , Bernard Gordon R.
Published: February 2021

Different models of learning health systems are emerging. At Vanderbilt University Medical Center, the Learning Health Care System (LHS) Platform was established with the goal of creating generalizable knowledge. This differentiates the LHS Platform from other efforts that have adopted a quality improvement paradigm. By supporting pragmatic trials at the intersection of research, operations, and clinical care, the LHS Platform was designed to yield evidence for advancing content and processes of care through carefully designed, rigorous study.

The LHS Platform provides the necessary infrastructure and governance to leverage translational, transdisciplinary team science to inform clinical and operational decision making across the health system. The process transforms a clinical or operational question into a research question amenable to a pragmatic trial. Scientific, technical, procedural, and human infrastructure is maintained for the design and execution of individual LHS projects. This includes experienced pragmatic trialists, project management, data science inclusive of biostatistics and clinical informatics, and regulatory support. Careful attention is paid to stakeholder engagement, including health care providers and the community. Capturing lessons from each new study, the LHS Platform continues to mature with plans to integrate implementation science and to complement clinical and process outcomes with cost and value considerations. The Vanderbilt University Medical Center LHS Platform is now a pillar of the health care system and leads the evolving culture of learning from what we do and doing what we learn.
Who Is Caring for Health Care Workers’ Families Amid COVID-19?
Authors: Robinson Londyn J. , Engelson Brianna J. , Hayes Sharonne N.
Published: February 2021

Amid the COVID-19 pandemic, women in medicine, including faculty, residents, medical students, and other health care workers (HCWs), are facing unparalleled challenges. The burdens of pandemic-associated increases in domestic and caregiving responsibilities, professional demands, health risks associated with contracting COVID-19, and the resulting psychosocial distress have exacerbated existing gender disparities at home, at work, and in academia. School and day care closures have created additional childcare needs, primarily for women, yet little support exists for parents and families. These increased childcare and domestic responsibilities have forced women HCWs, who make up the overwhelming majority of the workforce, to adapt their schedules and, in some cases, leave their jobs entirely.

In this article, the authors detail how COVID-19 has exacerbated existing childcare accessibility and affordability issues as well as gender disparities. They argue that unless government and health care organization support for childcare increases, families, specifically women and children, will continue to suffer. Lack of access to affordable childcare can prevent HCWs from doing their jobs, including conducting and publishing academic scholarship. This poses incalculable risks to families, science, and society. COVID-19 should serve as a call to action to all sectors, including the government and health care organizations, to prioritize childcare provision and increase support for women HCWs, both now during the pandemic and going forward.
Atrial appendage angiotensin-converting enzyme-2, aging and cardiac surgical patients: a platform for understanding aging-related coronavirus disease-2019 vulnerabilities
Authors: Wang Hao , Saha Amit K. , Sun Xuming , Kon Neal D. , Ferrario Carlos M. , Groban Leanne
Published: February 2021

Purpose of review

Hospitalizations for COVID-19 dramatically increase with age. This is likely because of increases in fragility across biological repair systems and a weakened immune system, including loss of the cardiorenal protective arm of the renin--angiotensin system (RAS), composed of angiotensin-converting enzyme-2 (ACE2)/angiotensin-(1--7) [Ang-(1--7)] and its actions through the Mas receptor. The purpose of this review is to explore how cardiac ACE2 changes with age, cardiac diseases, comorbid conditions and pharmaceutical regimens in order to shed light on a potential hormonal unbalance facilitating SARs-CoV-2 vulnerabilities in older adults.

Recent findings

Increased ACE2 gene expression has been reported in human hearts with myocardial infarction, cardiac remodeling and heart failure. We also found ACE2 mRNA in atrial appendage tissue from cardiac surgical patients to be positively associated with age, elevated by certain comorbid conditions (e.g. COPD and previous stroke) and increased in conjunction with patients’ chronic use of antithrombotic agents and thiazide diuretics but not drugs that block the renin--angiotensin system.

Cardiac ACE2 may have bifunctional roles in COVID-19 as ACE2 not only mediates cellular susceptibility to SARS-CoV-2 infection but also protects the heart via the ACE2/Ang-(1--7) pathway. Linking tissue ACE2 from cardiac surgery patients to their comorbid conditions and medical regimens provides a unique latform to address the influence that altered expression of the ACE2/Ang-(1–7)/Mas receptor axis might have on SARs-CoV-2 vulnerability in older adults.
Professionalism: microaggression in the healthcare setting
Authors: Ehie Odinakachukwu , Muse Iyabo , Hill LaMisha , Bastien Alexandra
Published: February 2021

Purpose of review

Microaggressions are daily commonplace, subtle behaviors and attitudes toward others that arise from conscious or unconscious bias. Not only can microaggressions affect one's access to power, resources, and opportunity, but they could also contribute to the persistent disparities faced by marginalized groups among healthcare professionals as well as patients.

Recent findings

Physicians, especially those in perioperative specialties, commonly have distress during their medical training. Workplace mistreatment, such as discrimination, has been commonly reported by residents across multiple specialties. Microaggressions also impact patient care as they can influence decisions of medical professionals toward a person or group of people.

This review offers education on the correlation of microaggression and unconscious bias to health disparities, provides tools to address microaggressions as a bystander, and outlines processes for institutional improvement.
Acute respiratory failure and burn patient outcomes
Authors: Maarouf Rami , Campbell Cedric
Published: February 2021

Purpose of review

Advances in the care of inhalational injuries have not kept pace with advances that have been seen in the treatment of cutaneous burns. There is not yet a standard of care for best outcomes for airway management of patients with known or suspected inhalational injuries. Clinicians must decide if to intubate the patient, and if so, whether to intubate early or late in their presentation. Unnecessary intubation affects morbidity and mortality. This review will summarize literature that highlights present practices in the treatment of patients with inhalation injuries.

Recent findings

There have been promising investigations into biomarkers that can be used to quantify a patient's risk and better target therapies. Grading systems serve to better stratify the burn victim's prognosis and then direct their care. Special ventilator modes can assist in ventilating burn patients with inhalation injuries that experience difficulties in oxygenating.

Inhalational injuries are a significant source of morbidity and mortality in thermally injured patients. Treatment modalities, such as modified ventilator settings, alteration in fluid resuscitation, and a standardized grading system may improve morbidity and mortality.
The Do Not Resuscitate (DNR) order in the perioperative setting: practical considerations
Authors: Kim Christin , Keneally Ryan
Published: February 2021

Purpose of review

Addressing patients’ Do Not Resuscitate (DNR) status in the perioperative setting is important for shared patient decision-making. Although the inherently resuscitative nature of anesthesia and surgery may pose an ethical quandary for clinicians tasked with caring for the patient, anesthesiologist-led efforts need to evaluate all aspects of the DNR order and operative procedures.

Recent findings

Approximately 15% of patients undergoing surgical procedures have a preexisting DNR order (Margolis et al., 1995) [1]. American Society of Anesthesiologists (ASA) and the American College of Surgeons (ACS) do not support automatic reversal of the DNR order in the perioperative setting. Citing patient self-determination and autonomy, these societies advocate for a thoughtful discussion where a patient or legal designee may make an informed decision regarding resuscitation in the perioperative setting. Although studies have suggested increased perioperative mortality among patients with a preexisting DNR order, this data remains largely inconclusive.

Efforts must be made to address the DNR order in the perioperative setting. The fundamental tenets of medical ethics, nonmaleficence, beneficence, and patient autonomy can help to guide this oftentimes challenging discussion.
Low-Threshold Buprenorphine via Community Partnerships and Telemedicine—Case Reports of Expanding Access to Addiction Treatment During COVID-19
Authors: Levander Ximena A. , Wheelock Haven , Pope Justine , Lee Abby , Hartmann Kerith , Abuelkhair Sarah , Gregg Jessica L. , Buchheit Bradley M.
Published: February 2021

Background:

To reduce coronavirus disease 2019 (COVID-19) spread, federal agencies eased telemedicine restrictions including audio-only appointments. These changes permitted clinicians to prescribe buprenorphine to patients with opioid use disorder (OUD) without in-person or audio/video assessment. Our clinic utilized existing community collaborations to implement protocols and extend outreach. We describe 3 patients with OUD who engaged with treatment through outreach with trusted community partners and low-threshold telemedicine.

Case Presentations:

Patient 1—a 40-year-old man with severe OUD who injected heroin and was living outside. A weekend harm reduction organization volunteer the patient previously knew used her mobile phone to facilitate an audio-only intake appointment during clinic hours. He completed outpatient buprenorphine initiation. Patient 2—a 48-year-old man with severe opioid and methamphetamine use disorders who injected both and was living in his recreational vehicle. He engaged regularly with syringe services program (SSP), but utilized no other healthcare services. Initially, an SSP worker connected him to our clinic for audio-only appointment using their landline to initiate buprenorphine; a harm reduction volunteer coordinated follow-up. Patient 3—a 66-year-old man with moderate OUD used non-prescribed pill opioids without prior buprenorphine experience. He lived over 5 hours away in a rural town. He underwent virtual appointment and completed home buprenorphine initiation.

Conclusion:

These 3 cases illustrate examples of how policy changes allowing for telemedicine buprenorphine prescribing can expand availability of addiction services for patients with OUD who were previously disengaged for reasons including geography, lack of housing, transportation difficulties, and mistrust of traditional healthcare systems.
Utilization of Medications for Opioid Use Disorder Across US States: Relationship to Treatment Availability and Overdose Mortality
Authors: Krawczyk Noa , Jent Victoria , Hadland Scott E. , Cerdá Magdalena
Published: February 2021

Objective:

Availability of medications for opioid use disorder (MOUD) remains sparse. To date, there has been no national, state-by-state comparison of patient MOUD utilization relative to treatment availability and burden of overdose deaths. We aimed to quantify, for each state, the number of MOUD patients relative to (1) office-based buprenorphine providers and opioid treatment programs (OTPs) and (2) overdose deaths.

Methods:

We conducted a spatial analysis of patients receiving MOUD from OTPs or buprenorphine providers in March 2017 across all 50 states and Washington, DC. For each state, we calculated the number of patients receiving MOUD from OTPs and buprenorphine prescriptions, relative to available OTPs and buprenorphine providers; as well as ratios of number of patients receiving MOUD relative to overdose deaths.

Results:

In March 2017, 942,368 patients attended an OTP (410,288) or received a buprenorphine prescription (486,318). Patient to OTP ratio was highest in West Virginia, Delaware, Washington, DC, New Jersey, New Hampshire, Connecticut and Ohio, ranging from 91 to 193 patients per OTP in the first quintile to 430 to 648 in the fifth. Patient to buprenorphine provider ratio was highest in Kentucky and West Virginia, ranging from 3 to 7 patients per provider in the first quintile to 19 to 28 in the fifth. Median MOUD patients per overdose death was 21 (IQR:14.9–28.2). Of high overdose states, Washington, DC, New Jersey, and Ohio had the smallest number of patients on MOUD relative to deaths.

Conclusions:

High patient volume relative to treatment availability in overdose-burdened areas may indicate strain on MOUD providers and OTPs. Promoting greater utilization while expanding MOUD providers and programs is critical.
A Review of the Metabolism and Potential Drug-drug Interactions With Addictive Drugs
Authors: Radke Joshua , Tocki Kelly , Faine Brett A.
Published: February 2021

People who use drugs (PWUD) are at increased risk for drug-related harms such as overdose. Additionally, they are also at increased risk of secondary harms from bacterial and other infections such as hepatitis B, hepatitis C, and Human Immunodeficiency Virus. These secondary harms, along with other medical conditions, typically require treatment with prescription medications. When considering treatment options, drug-drug interactions (DDIs) must be considered, unfortunately these interactions are often overlooked with addictive drugs. Although DDIs in PWUD have been reviewed for certain drug classes and specific drugs of abuse, no comprehensive list could be found. The objective of this article is to compile a list of potential DDIs between prescription drugs and addictive drugs to create a list allowing prescribers to make more informed decisions when prescribing a medication to PWUD.
Adverse Childhood Experiences and Chronic Pain Rehabilitation Treatment Outcomes in Adults
Authors: Craner Julia R. , Lake Eric S.
Published: February 2021

Objectives:

Adverse childhood experiences (ACEs) are commonly reported by individuals with chronic pain. However, little is known about how ACE exposure influences treatment outcomes. The goal of the current study was to evaluate group and treatment-related differences among adults with varying levels of ACE exposure participating in a pain rehabilitation treatment program.

Methods:

Adult participants (N=269) were categorized as 0 ACEs (n=65), 1 to 2 ACEs (n=87), or ≥3 ACEs (n=117). Participants completed self-report measures of pain, physical functioning, and psychosocial functioning at intake and discharge from a 10-week interdisciplinary pain rehabilitation program.

Results:

ACE exposure was frequently endorsed in this sample, with the majority of participants (78.5%) reporting at least 1 form of childhood adversity. Adults in the ≥3 ACEs group reported a greater level of impairment in mental health symptoms and adjustment to chronic pain; however, all groups endorsed treatment improvements and there were no differences in response to treatment. There were also no differences between groups on measures of pain or physical functioning at intake or discharge.

Discussion:

ACE exposure appears common among treatment-seeking adults with chronic pain and is associated with increased clinical complexity. However, adults with and without exposure to ACEs endorsed significant improvements in pain and functioning following participation in an interdisciplinary pain rehabilitation program. This model of treatment may be especially well situated to address the biopsychosocial contributions to pain among those with a history of adversity.
Implementation and Evaluation of the Premature Infant Pain Profile-revised (PIPP-R) e-Learning Module for Assessing Pain in Infants
Authors: Bueno Mariana , Stevens Bonnie , Rao Megha , Riahi Shirine , Campbell-Yeo Marsha , Carrier Leah , Benoit Britney
Published: February 2021

Objectives:

The Premature Infant Pain Profile-revised (PIPP-R) is a well-established measure for infant pain assessment. The aim of this study was to evaluate the implementation and clinical utility of the PIPP-R electronic learning (e-Learning) module to promote standardized health care training for nurses.

Materials and Methods:

A descriptive mixed-methods study was conducted in 2 tertiary Neonatal Intensive Care Units in Canada. Nurses were recruited and asked to complete the PIPP-R e-Learning Module and evaluate it. A 26-item questionnaire was used to describe nurse demographics and clinical experience and to evaluate implementation success (ie, acceptability, feasibility, usability) and clinical utility.

Results:

In all, 98 nurses from 2 settings in Central and Eastern Canada participated; most were registered nurses highly experienced in neonatal nursing care. The majority had received previous training on the PIPP-R (61.2%) and routinely used it in practice (67.4%). They considered the e-Learning module as acceptable and feasible as it was easy to access (94.9%) and to navigate (94.8%). Content was considered clear (98.9%) and met users’ learning needs (99.0%). Nurses agreed that completing the module improved their understanding of neonatal pain (96.0%) and was clinically useful in improving their ability to assess pain in neonates (97.9%). The module was accessed primarily from work settings (77.8%) using desktop computers (49.0%) or tablets (28.0%) and was usually completed in a single session (75.7%).

Discussion:

Nurses’ evaluation of the PIPP-R e-Learning module was overwhelmingly positive. The module was perceived as easy to implement, clinically useful, and was considered as a promising online educational tool. Further testing in clinical practice is needed to build on the results of this study and support the importance of dissemination of this module for standardized training purposes.
Commonalities in Nursing Perspectives Among 6 Countries/Regions
Authors: Im Eun-Ok , Sakashita Reiko , Lin Chia Chin , Oh Eui Geum , Tsai Hsiu-Min , Kunaviktikul Wipada , Huang Lian-Hua , Wang Hsiu-Hung , McCauley Linda
Published: February 2021

The purpose of this article is to identify the commonalities in nursing perspectives among 6 countries/regions (United States, South Korea, Taiwan, Japan, Hong Kong, and Thailand). Nine leaders from the 6 countries/regions reflected on what nursing perspectives were in their own countries/regions and provided exemplars/cases from their own experiences and literature reviews. The data were analyzed using a content analysis. Seven themes were extracted: (a) “embedded in cultural and historical contexts”; (b) “based on philosophical pluralism”; (c) “women-centered perspectives”; (d) “care-oriented holistic views”; (e) “ethical and humane views”; (f) “respecting and advocating”; and (g) “considering diversities.”
Developmental Outcomes in Early-Identified Children Who Are Hard of Hearing at 2 to 3 Years of Age
Authors: Stika Carren J. , Eisenberg Laurie S. , Carter Alice S. , Johnson Karen C. , Hammes Ganguly Dianne M. , Henning Shirley C. , DesJardin Jean L.
Published: February 2021

Objectives:

This study examined the psychosocial, adaptive behavior, and language outcomes of young children who are hard of hearing (HH) without additional disabilities or neurocognitive impairments. Relations between early developmental outcomes and child and parent demographic variables, and parenting stress and self-efficacy were also explored.

Design:

Participants were 39 children with early identified, permanent mild to severe hearing loss, between the ages of 2 and 3 years, and a comparison group of 47 children with normal hearing (NH). Developmental outcomes were measured using clinician-administered standardized tests and parent-completed behavior rating instruments specific to language, psychosocial functioning, and adaptive behavior. Mothers completed self-report measures that assess parenting stress and maternal self-efficacy.

Results:

The children who are HH were similar to the children with NH in terms of their psychosocial functioning and adaptive behavior, with the exception of their socialization skills. As a group, the children who are HH performed significantly worse than their peers with NH on all measures of language ability. Among the children who are HH, maternal self-efficacy showed a strong positive correlation with adaptive behavior outcomes; however, it failed to contribute unique variance above that explained by language ability and gender. Maternal self-efficacy was also significantly correlated with better psychosocial outcomes, but only parenting stress proved to be a significant predictor of child behavioral problems once other variables considered were in the model.

Conclusions:

Early-identified young children who are HH can demonstrate age-appropriate development in multiple domains, including language, psychosocial, and adaptive behavior. However, mild to severe hearing loss places young children with no additional disabilities or neurocognitive impairments at risk for language delays. Although the children who are HH demonstrated no more emotional or behavioral problems than their same-age peers with NH, results suggest that language delays increase their vulnerability for delays in various aspects of social competence.
Phantom pain decreases with vibrating silicone liner in lower limb amputee: a prospective study
Authors: Farahmand Behshid , Turkeman Omid , Saghafi Marzieh , Yazdani Meria , Bagherzadeh Cham Masumeh
Published: February 2021

Background:

The purpose of this study was to design, construct, and evaluate the effectiveness of a vibrating silicone liner on the phantom pain of traumatic below-knee amputees.

Methods:

Twelve unilateral below-knee amputees who had phantom pain and did not use another treatment participated in this study. The patients were asked to use vibrating silicone liners for three 10-minute sessions daily for 30 days. The severity of pain was evaluated by the short form of the McGill Pain Questionnaire before and after 30 days of using the vibrating silicone liner.

Results:

The mental aspect of pain intensity, pain intensity based on visual analog scale (VAS), momentary pain intensity, and overall pain intensity decreased significantly after 30 days of using the vibrating silicone liner (P<0.05). Also, there was a significant correlation between initial pain score and psychological aspect of pain (P=0.007).

Conclusions:

Using a vibrating silicone liner for three 10-minute sessions daily for a period of 30 days had a significant effect on the reduction of all the components of phantom pain in the patients who were included in this study. It seems that the vibrating silicone liner reduced phantom pain by creating heat, controlling gate of pain in the spinal cord, and psychological effects.

Level of Evidence:

Level II
Interstitial lung disease throughout the rheumatoid arthritis disease course
Authors: McDermott Gregory C. , Doyle Tracy J. , Sparks Jeffrey A.
Published: February 2021

Purpose of review

To summarize the current understanding of rheumatoid arthritis-associated interstitial lung disease (RA-ILD) throughout the rheumatoid arthritis (RA) disease course from preclinical to established disease.

Recent findings

ILD is a serious extra-articular manifestation of RA. Multiple studies have demonstrated a high prevalence of both subclinical and clinical ILD throughout the RA disease course. Investigations of patients without RA have demonstrated an association between RA-related autoantibodies like anticitrullinated protein antibodies (ACPA) and interstitial abnormalities on lung imaging. A significant proportion of RA-ILD patients develop ILD prior to articular manifestations, suggesting that the lung plays a central role in RA development, perhaps through ACPA production. RA-ILD also occurs in early RA, when exuberant autoantibody production and systemic inflammation may propagate pulmonary disease activity. In patients with established RA, a high burden of subclinical and clinical ILD results in significant morbidity, mortality, and healthcare expenditure. Multiple epidemiologic and genetic risk factors, as well as serum biomarkers, have been associated with RA-ILD.

Subclinical and clinical ILD occur frequently in preclinical, early, and established RA and may play a key role in RA-related autoantibody production and disease progression. Further studies are needed to better understand the risk factors, prognosis, and potential therapies for RA-ILD.
Glucocorticoid and opioid use in rheumatoid arthritis management
Authors: Moore Meriah N. , Wallace Beth I.
Published: February 2021

Purpose of review

Glucocorticoids and opioids are longstanding, common treatments for rheumatoid arthritis (RA) symptoms. High-quality clinical trials have established that glucocorticoids improve outcomes in RA, but debate continues as to whether their benefits outweigh their risks. We reviewed recent studies on patterns of glucocorticoid and opioid prescribing in RA, and associated harms.

Recent findings

At present, a large proportion of RA patients remain on glucocorticoids and/or opioids long-term. Likelihood and risk of both glucocorticoid and opioid exposure vary across the population, and are influenced by provider factors. Opioids are also associated with delays in disease-modifying treatment initiation. Recent evidence increasingly demonstrates toxicity associated with even low-dose glucocorticoids (≤7.5 mg/day). Up to two-thirds of RA patients may be able to discontinue chronic low-dose glucocorticoids without flare or adrenal insufficiency. These new data have led to changes in clinical practice guidelines for glucocorticoid use in RA.

Although low-dose and short-term glucocorticoid use is extremely common and effective in RA management, increasing evidence of toxicity has led experts to begin recommending that such exposure be minimized. Despite a lack of data to suggest opioids improve RA disease activity, they are used commonly, continued long-term, and associated with delayed effective therapy.
Postoperative Myocardial Reinfarction Following Lumbar Spine Surgery
Authors: Harwin Brett , Roberts Sidney , Formanek Blake , Wang Jeffrey C. , Buser Zorica
Published: February 2021

Study Design:

This study was a retrospective cohort database study which looked at the relationship between myocardial reinfarction following lumbar spine surgery.

Objective:

Current study aimed to determine the risk of reinfarction associated with the time between initial myocardial infarction (MI) and lumbar spine surgery, type of lumbar surgical procedure, and other risk factors.

Summary of Background Info:

Several studies have demonstrated a strong temporal pattern between postoperative reinfarction rate and the period between previous MI and surgery. To the best of our knowledge, no study has looked specifically at the temporal relationship between previous MI, lumbar spine surgery and incidence of postoperative myocardial reinfarction.

Materials and Methods:

The Humana database was analyzed from Q1 2007 through Q3 2016 and the Medicare database was analyzed from Q1 2005 through Q4 2014. Patients were placed into 1 of 5 groups based on time between MI and surgery: 0–3, 4–6, 7–12, 13–24, and 25+ months. Reinfarction rates were determined in these groups. Age, sex, and type of surgery were analyzed to determine association with postoperative reinfarction rates.

Results:

There was a strong correlation between postoperative myocardial reinfarction and lumbar spine surgery occurring 0–3 months after the patient’s initial MI (P<0.01). Those patients had a risk ratio >3 (P<0.01) compared with patients who underwent lumbar spine surgery after an interval >3 months between initial MI and lumbar spine surgery. In addition, spinal fusion procedures were associated with a greater risk of postoperative myocardial reinfarction than nonfusion procedures.

Conclusion:

In both databases, there was a clinically relevant and statistically significant increase in myocardial reinfarction in patients who experienced an MI 0–3 months before lumbar spine surgery. We believe that the current study helps in treatment planning for patients with a history of MI who are considering spine surgery.

Level of Evidence:

Level III.
One-Year Outcomes of Chiari Type 1 Malformation and Syringomyelia Treated With Posterior Fossa Decompression
Authors: Han Shiyuan , Gao Jun , Li Zhimin , Wang Xin , Li Yongning
Published: February 2021

Study Design:

This was a retrospective cohort study.

Objective:

The objective of this study was to evaluate posterior fossa structural differences between Chiari type 1 malformation with and without syringomyelia, and assess data of the improvement of syringomyelia after different surgical options.

Summary of Background Data:

Syringomyelia is among the most common concomitant complications of Chiari malformation (CM). However, posterior fossa decompression cannot definitely make the syringomyelia disappear even in the long term. Also, there are no universal criteria defining improvement in syrinx.

Materials and Methods:

All admitted CM patients at our institution from 2013 to 2018 with a 1-year follow-up were analyzed. Patients without syringomyelia were compared with those who had syringomyelia. Patients were divided into 3 groups according to the procedures performed: posterior fossa decompression versus posterior fossa decompression with duralplasty (PFDD) versus PFDD plus obex unblocking. Divergent prognosis of syringomyelia was defined as a 3-category ordinal variable. A multivariable ordinal regression model was used to estimate the relationship between patient variables and increased odds for better resolution of syringomyelia.

Results:

No significant linear difference in bony structure was found between syringomyelia and nonsyringomyelia patients. Among syringomyelia patients, the regression analysis demonstrated that patients with shorter posterior fossa height (P=0.032), lower Pavlov ratio (P=0.029), and obex unblocking (vs. PFDD, P<0.001; vs. posterior fossa decompression, P=0.037) were more likely to gain a better resolution of syringomyelia.

Conclusions:

Syringomyelia of CM patients may not simply originate from single linear anatomic variation. Patients with shorter posterior fossa height and lower Pavlov ratio received better syringomyelia resolution. Also, unblocking the obex received better syringomyelia resolution compared with duraplasty alone and bony decompression alone with the avoidance of increased postoperative complications and worse clinical outcomes.
Incidence and Risk Factors for Postoperative Venous Thromboembolic Events in Patients Undergoing Cervical Spine Surgery
Authors: Bui Annelise , Lashkari Nassim , Formanek Blake , Wang Jeffrey C. , Buser Zorica , Liu John C.
Published: February 2021

Study Design:

This was a retrospective database study.

Objective:

The objective of this study was to investigate preoperative risk factors and incidence of venous thromboembolic events (VTEs) after cervical spine surgery.

Summary of Background Data:

VTEs are preventable complications that may occur after spinal procedures. Globally, VTEs account for a major cause of morbidity and mortality. Preoperative risks factors associated with increased VTE incidence after cervical spine surgery have not been well-characterized.

Materials and Methods:

Patients undergoing anterior cervical discectomy and fusion (ACDF); posterior cervical fusion (PCF); discectomy; and decompression from 2007 to 2017 were identified using the PearlDiver Database. International Classification of Diseases (ICD) Ninth and 10th Revision codes were used to identify VTEs at 1 week, 1 month, and 3 months postoperative as well as preoperative risk factors.

Results:

Risk factors with the highest incidence of VTE at 3 months were primary coagulation disorder [ACDF=7.82%, odds ratio (OR)=3.96; decompression=11.24%, OR=3.03], central venous line (ACDF=5.68%, OR=2.11; PCF=12.58%, OR=2.27; decompression=10.17%, OR=2.80) and extremity paralysis (ACDF=6.59%, OR=2.73; PCF=18.80%, OR=2.99; decompression=11.86, OR=3.74). VTE incidence at 3 months for populations with these risks was significant for all surgery types (P<0.001) with the exception of patients with primary coagulation disorder who underwent PCF. Tobacco use had the lowest VTE incidence for all surgery types.

Conclusions:

The total cumulative incidence of VTEs at 3-month follow-up was 3.10%, with the highest incidence of VTEs occurring within the first postoperative week (0.65% at 1 wk, 0.61% at 1 mo, 0.53% at 3 mo for ACDF; 2.56% at 1 wk, 1.93% at 1 mo, 1.45% at 3 mo for PCF; 1.37% at 1 wk, 0.93% at 1 mo, 0.91% at 3 mo for decompression). Several preoperative risk factors were found to be significant predictors for postoperative VTEs and can be used to suggest those at increased risk as well as decrease the incidence of preventable VTEs after cervical spine surgery.

Level of Evidence:

Level III.
Accuracy of Subaxial Cervical Pedicle Screw Placement Using Direct Visualization Versus Computed Tomography–Based Navigation
Authors: Farber S. Harrison , Godzik Jakub , Hlubek Randall J. , Zhou James J. , Walker Corey T. , Kakarla U. Kumar , Uribe Juan S. , Turner Jay D.
Published: February 2021

Study Design:

Retrospective analysis of operative data from cadaveric cervical spines.

Objective:

To evaluate the accuracy of neuronavigation compared with laminotomy with direct visualization (DV) of the pedicle for placement of subaxial pedicle screws.

Summary of Background Data:

Subaxial pedicle screws provide superior fixation compared with other posterior cervical fixation strategies. However, high accuracy is required for safe placement, given the proximity of critical neurovascular structures. Computed tomography (CT)–based neuronavigation has increased in popularity for placement of spinal implants, including subaxial pedicle screws. However, the accuracy of the technique for this application has not been extensively evaluated.

Methods:

Six fresh-frozen cadaveric spines (occiput to T2) were prepared. Pedicle screws were placed from C3 to C7 on either side using either the DV or neuronavigation technique (alternating sides between specimens). Pedicles with diameters <4 mm were excluded. For the DV technique, a hemilaminotomy was performed for DV of pedicle borders and to determine appropriate screw medialization and trajectory. Neuronavigation screws were placed using CT-based navigation with a reference frame mounted on the C2 spinous process. Screw position was evaluated using postoperative CT, and breaches were classified using the Neo classification.

Results:

Fifty pedicle screws were placed at 25 levels in 6 cadaveric spines; 25 screws each were placed using neuronavigation or DV. No significant difference in accuracy was found between the 2 techniques. Three (12%) breaches occurred in the DV group, and 9 (36%) breaches occurred in the neuronavigation group (P=0.10). The breaches were evenly distributed across all levels. There were no high-grade breaches with DV and only 1 (4.0%) with neuronavigation (P>0.99). Average pedicle cortical and medullary bone widths were higher for levels with no breach (P=0.009 and P=0.02, respectively).

Conclusions:

High accuracy can be achieved with both neuronavigation and DV for placement of subaxial cervical pedicle screws in cadavers.
A Retrospective Analysis of Superior Facet Joint Violation Between Open and Minimally Invasive Transforaminal Lumbar Interbody Fusion and its Relation to Adjacent Segment Disease
Authors: Maharjan Sujan , Zeng Zhili , Yu Yan , Cheng Liming
Published: February 2021

Study Design:

A retrospective study.

Objective:

The aim was to analyze the superior facet joint violation (SFV) between open transforaminal lumbar interbody fusion (open-TLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and its effect on the superior and inferior adjacent segment disc height, segmental lordosis, lumbar lordosis, and facet joint degeneration.

Summary of Background Data:

We compared SFV between open-TLIF and MIS-TLIF and its correlation with different factors as well as its effect on adjacent segment disease.

Materials and Methods:

We retrospectively studied data of patients undergoing single level TLIF surgery from January 2013 to February 2016 in single institutional hospital. Axial and coronal postoperative computed tomography scan images were used to analyze SFV. In secondary analysis patients were divided into nonfacet violation group (NSFVG) and facet violation group (SFVG) and compared the changes on the superior and inferior adjacent level disc height, segmental lordosis, lumbar lordosis, and facet joint degeneration.

Results:

Mean SFV grade was significantly greater in MIS-TLIF compared with open-TLIF (odds ratio: 0.638, confidence interval: 0.431-0.944; P=0.025). There was more grade 2 (10.71% vs. 5.60%) and grade 3 (4.46% vs. 1.29%) SFV in MIS-TLIF. Patient with age below 60 and body mass index (BMI) >30 kg/m2 in MIS-TLIF were more prone to high-grade SFV compared with open-TLIF. Further, logistic regression showed patients with BMI ≥30 kg/m2 has 7.137 increased odds of high-grade SFV (95% confidence interval: 3.261-15.618; P=0.000) compared with patients with BMI <30 kg/m2. Compared with NSFVG, SFVG has more SFV (0.096±0.244 vs. 0.177±0.317; P=0.012) and less improvement in lumbar visual analog scale scores −0.65±0.073 versus −0.67±0.074 (P=0.006).

Conclusion:

MIS-TLIF has more high-grade SFV as well as overall mean SFV in comparison to open-TLIF with BMI >30 kg/m2 and location of pedicle screw as an independent risk factor for SFV and risk of adjacent segment disease increases with SFV.

Level of Study:

Level III.
The Modified Posteromedial Approach to Posterior Malleolar Fractures
Authors: Hube Laurent Maximiliano , Urbina Bahamonde Christian , Vargas Gallardo Fernando , Bravo Gallardo Francisco , Parra Henrriquez Mauricio , Lagos Sepúlveda Leonardo , Bastías Soto Christian
Published: February 2021

Posterior malleolus fractures are known to be caused by a combination of rotation and impaction, resulting in a wide variety of fractures, as published by Bartonicek. Among them is the subgroup known as the “posterior pilon variant,” in which the axial impaction mechanism plays a fundamental role. There is no consensus regarding appropriate surgical approaches for these fractures. We describe a posteromedial modified approach, as an alternative to treat posterior pilon malleolar fractures. This approach can be performed safely, with low complication rates and generally with favorable outcomes.

Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
High-Sensitivity Estimate of the Incidence of New-Onset Atrial Fibrillation in Critically Ill Patients
Authors: McIntyre William F. , Belley-Côté Emilie P. , Vadakken Maria E. , Rai Anand S. , Lengyel Alexandra P. , Rochwerg Bram , Bhatnagar Akash K. , Deif Bishoy , Um Kevin J. , Spence Jessica , Connolly Stuart J. , Bangdiwala Shrikant I. , Rao-Melacini Purnima , Healey Jeff S. , Whitlock Richard P.
Published: February 2021

Objective:

To estimate the incidence of new-onset atrial fibrillation in critically ill patients.

Design:

Prospective cohort.

Setting:

Medical-surgical ICU.

Subjects:

Consecutive patients without a history of atrial fibrillation but with atrial fibrillation risk factors.

Interventions:

Electrocardiogram patch monitor until discharge from hospital or up to 14 days.

Measurements and Main Results:

A total of 249 participants (median age of 71 yr [interquartile range] 64–78 yr; 35% female) completed the study protocol of which 158 (64%) were admitted to ICU for medical illness, 78 (31%) following noncardiac surgery, and 13 (5%) with trauma. Median Acute Physiology and Chronic Health Evaluation II score was 16 (interquartile range, 12–22). Median duration of patch electrocardiogram monitoring, ICU, and hospital lengths of stay were 6 (interquartile range, 3–12), 4 (interquartile range, 2–8), and 11 days (interquartile range, 5–23 d), respectively.

Atrial fibrillation ≥ 30 seconds was detected by the patch in 44 participants (17.7%), and three participants (1.2%) had atrial fibrillation detected clinically after patch removal, resulting in an overall atrial fibrillation incidence of 18.9% (95% CI, 14.2–24.3%).

Total duration of atrial fibrillation ranged from 53 seconds to the entire monitoring time. The proportion of participants with ≥1 episode(s) of ≥6 minute, ≥1 hour, ≥12 hour and ≥24 hour duration was 14.8%, 13.2%, 7.0%, and 5.3%, respectively. The clinical team recognized only 70% of atrial fibrillation cases that were detected by the electrocardiogram patch.

Conclusions:

Among patients admitted to an ICU, the incidence of new-onset atrial fibrillation is approximately one in five, although approximately one-third of cases are not recognized by the clinical team.