bluuebunny/crossref_metadata_2025_split huggingface dataset:
PB2443 AUDIT ON NOACS (APIXABAN AND RIVAROXABAN) PRESCRIPTION IN A DISTRICT GENERAL HOSPITAL
Authors: Lovato S. , Kanakam T. , Vajia P. , Dosanjh J. , Harford D. 
Published: June 2019

Background:Oral anticoagulation therapy is the treatment of choice to prevent stroke in patients with non valvular atrial fibrillation. Non‐vitamin K antagonist oral anticoagulants (NOACs) are often used as alternative to vitamin K antagonists as they do not require INR level monitoring. Before initiating the anticoagulant therapy the risk of stroke should be evaluated using the CHA2DS2‐VASc score and the bleeding risk using the HAS‐BLED score. In our institution the most used NOACs are Apixaban and Rivaroxaban. The recommended dose for Apixaban is 5 mg bd, reduced to 2.5 mg twice bd in patients with age >80, weight < 61 kg or serum creatinine > 133 micromol/litre. The recommended dose for Rivaroxaban is 20 mg od.Aims:The aim of this study was to understand the appropriateness of NOACs use in our institution in terms of indication and dose compared to the national guidelines.Methods:We performed an audit including all new patients who attended our anticoagulation service in a period of six months and were started on either Apixaban or Rivaroxaban. To do this we evaluated if the indication for anticoagulation was appropriate, if CHA2DS2‐VASc score HAS‐BLED score were documented on the notes. We also evaluated the appropriateness of the dose adjusted for creatinine of Apixaban.Results:We included 57 patients, 29 of them were started on Apixaban and 28 on Rivaroxaban. All of the patients had a diagnosis of Non Valvular Atrial Fibrillation. CHA2DS2‐VASc score was documented in 31 patients (54%) and HAS‐BLED score in 32 patients (56%), only 22 patients (38%) had both score properly documented. Out of 31 patients 4 (13%) had a CHA2DS2‐VASc score of 0, and out of 32 patients 2 (6%) had a HAS‐BLED score >3. This mean that in 19% of the patients the anticoagulation therapy was not indicated or contraindicated, but also that in 62% of the patients the appropriateness could not be properly evaluated. Creatinine was documented only in 11 of the patients on Apixaban (38%), in all of them the dose was appropriate for renal function.Summary/Conclusion:We included 57 patients, 29 of them were started on Apixaban and 28 on Rivaroxaban. All of the patients had a diagnosis of Non Valvular Atrial Fibrillation. CHA2DS2‐VASc score was documented in 31 patients (54%) and HAS‐BLED score in 32 patients (56%), only 22 patients (38%) had both score properly documented. Out of 31 patients 4 (13%) had a CHA2DS2‐VASc score of 0, and out of 32 patients 2 (6%) had a HAS‐BLED score >3. This mean that in 19% of the patients the anticoagulation therapy was not indicated or contraindicated, but also that in 62% of the patients the appropriateness could not be properly evaluated. Creatinine was documented only in 11 of the patients on Apixaban (38%), in all of them the dose was appropriate for renal function.
Utilizing an SBAR Workshop With Baccalaureate Nursing Students to Improve Communication Skills
Authors: Stevens Natalie , McNiesh Susan , Goyal Deepika 
Published: June 2019

Abstract
This study evaluated the effectiveness of the Situation-Background-Assessment-Recommendation (SBAR) technique to reduce anxiety and increase self-confidence levels regarding health care communication among undergraduate nursing students. Baccalaureate nursing students (n = 35) completed anxiety and self-confidence questionnaires before and after an SBAR communication workshop and subsequent simulation. A statistically significant increase in postintervention self-confidence scores was noted with no significant difference in anxiety levels. The findings support the use of SBAR as an organizing tool to promote nursing students’ self-confidence during communication; however, further efforts are needed to qualitatively examine how this tool promotes these changes.
Congenital Forearm Pseudarthrosis, a Systematic Review for a Treatment Algorithm on a Rare Condition
Authors: Siebelt Michiel , de Vos-Jakobs Suzanne , Koenrades Nienke , van Nieuwenhoven Christianne A.V. , Oostenbrink Rianne , Bramer Wichor M. , Verhaar Jan A.N. , Bessems Gert J.H.J.M. , Kempink Dagmar R.J. 
Published: June 2019

Background:
A congenital forearm pseudarthrosis is a rare condition and is strongly associated with neurofibromatosis type 1. Several surgical techniques are described in the literature, but the most optimal treatment strategy remains unclear. This systematic review aims to develop a treatment algorithm that may aid in clinical decision making.

Methods:
The PROSPERO registration number for this study was CRD42018099602 and adheres to the PRISMA guidelines for systematic reviews. Embase, MEDLINE, Cochrane Central, Web of Science, and Google Scholar databases were searched for published studies reporting on congenital forearm pseudarthrosis not related to other underlying pathologies like bacterial infection or fibrous dysplasia. Results were not restricted by date or study type, only English literature was allowed. Studies were assessed for quality using the critical appraisal checklist for case reports from the Joanna Briggs Institute. Patient characteristics, underlying disease, type of surgery, union rate, and functional outcome were extracted from included studies.

Results:
Of 829 studies identified, 47 were included in this review (17 case series and 30 case reports, a total of 84 cases). A one-bone forearm procedure showed highest union rates (92%), however, it results in loss of forearm rotation. Free vascularized fibula grafting showed high union rates (87%) and was related to good functional outcome of elbow flexion and forearm rotations. Other procedures showed disappointing outcomes.

Conclusions:
Congenital forearm pseudarthrosis is best treated with a free vascularized fibula grafting, a one-bone forearm procedure should be used as a salvage procedure. Evidence extracted from the case reports was sufficient to generate a treatment algorithm to be used in clinical pediatric practice.

Level of Evidence:
Level IV—therapeutic.
Causes of Death in Status Epilepticus
Authors: Hawkes Maximiliano A. , English Stephen W. , Mandrekar Jay N. , Rabinstein Alejandro A. , Hocker Sara 
Published: June 2019

Objectives:
To determine the causes of death in patients with status epilepticus. To analyze the relative contributions of seizure etiology, seizure refractoriness, use of mechanical ventilation, anesthetic drugs for seizure control, and medical complications to in-hospital and 90-day mortality, hospital length of stay, and discharge disposition.

Design:
Retrospective cohort.

Setting:
Single-center neuroscience ICU.

Participants:
Patients with status epilepticus were identified by retrospective search of electronic database from January 1, 2011, to December 31, 2016.

Interventions:
Review of electronic medical records.

Measurements and Main Results:
Demographics, clinical characteristics, treatments, and outcomes were collected. Univariable and multivariable logistic regression analysis were used to determine whether the use of anesthetic drugs, mechanical ventilation, Status Epilepticus Severity Score, refractoriness of seizures, etiology of seizures, or medical complications were associated with in-hospital, 90-day mortality or discharge disposition. Among 244 patients with status epilepticus (mean age was 64 yr [interquartile range, 42–76], 55% male, median Status Epilepticus Severity Score 3 [interquartile range, 2–4]), 24 received anesthetic drug infusions for seizure control. In-hospital and 90-day mortality rates were 9.2% and 19.2%, respectively. Death was preceded by withdrawal of life-sustaining treatment in 19 patients (86.3%) and cardiac arrest in three (13.7%). Only Status Epilepticus Severity Score was associated with in-hospital and 90-day mortality, whereas the use of anesthetic drugs for seizure control, mechanical ventilation, medical complications, etiology, and refractoriness of seizures were not. Hospital length of stay was longer in patients with medical complications (p = 0.0091), refractory seizures (p = 0.0077), and in those who required anesthetic drugs for seizure control (p = 0.0035). Patients who had refractory seizures were less likely to be discharged home (odds ratio, 0.295; CI, 0.143–0.608; p = 0.0009).

Conclusions:
In this cohort, death primarily resulted from the underlying neurologic disease and withdrawal of life-sustaining treatment and not from our treatment choices. Use of anesthetic drugs, medical complications, and mechanical ventilation were not associated with in-hospital and 90-day mortality.
Oral Gabapentinoids and Nerve Blocks for the Treatment of Chronic Ocular Pain
Authors: Small Leslie R. , Galor Anat , Felix Elizabeth R. , Horn Danielle B. , Levitt Roy C. , Sarantopoulos Constantine D. 
Published: June 2019

Purpose:
There is a recognition that nerve dysfunction can contribute to chronic ocular pain in some individuals. However, limited data are available on how to treat individuals with a presumed neuropathic component to their ocular pain. As such, the purpose of this study was to examine the efficacy of our treatment approaches to this entity.

Methods:
A retrospective review of treatments and outcomes in individuals with chronic ocular pain that failed traditional therapies.

Results:
We started eight patients on an oral gabapentinoid (gabapentin and/or pregabalin) as part of their pain regimen (mean age 46 years, 50% women). Two individuals reported complete ocular pain relief with a gabapentinoid, in conjunction with their topical and oral medication regimen. Three individuals noted significant improvements, one slight improvement, and two others no improvement in ocular pain with gabapentin or pregabalin. We performed periocular nerve blocks (4 mL of 0.5% bupivacaine mixed with 1 mL of 80 mg/mL methylprednisolone acetate) targeting the periocular nerves (supraorbital, supratrochlear, infratrochlear, and infraorbital) in 11 individuals (mean age 54 years, 36% women), 10 of whom had previously used a gabapentinoid without ocular pain improvement. Seven individuals experienced pain relief after nerve blocks that lasted from hours to months and four failed to benefit. Five of the individuals who experienced pain relief underwent repeat nerve blocks, weeks to months later.

Conclusions:
Approaches used to treat chronic pain outside the eye can be applied to ocular pain that is not responsive to traditional therapies.
Complex Stenoses and CT Features of the Nasolacrimal Canal in Congenital Nasolacrimal Duct Obstruction
Authors: Fayet Bruno , Racy Emmanuel , Bordonné Corinne , Katowitz James A. , Katowitz William R. , Brémond-Gignac Dominique 
Published: June 2019

The authors describe hard contact palpation during probing for CLNDO and its relationship to anatomic location and etiologies of obstruction in the nasolacrimal canal by CT imaging.

Purpose:
To study the CT appearance of the nasolacrimal canal (NLC) in cases of congenital nasolacrimal duct obstruction (CNLDO) where there is a tactile sensation of a hard contact (HC) stop in the duct preventing stent intubation.

Methods:
The authors retrospectively reviewed all consecutive cases of chronic CNLDO observed between 2003 and 2018 in which an apparent HC obstruction prevented nasolacrimal intubation. CT scans were reviewed to determine the cause of probing failure: distal stenosis, loss of parallelism of the NLC walls, abnormal angulations or an adjacent obstacle blocking tear outflow.

Results:
Nine patients (12 sides) met the following criteria: CNLDO + HC + probing failure. The mean age at the time of the first HC was 3.9 years (range: 0.8–8.1 years) and at the time of a second confirmation of HC with subsequent dacryocystorhinostomy was 7.8 years (range: 4.1–9.2 years). Nasolacrimal duct opacification was noted in 33% of cases (4/12). Abnormalities of the NLC occurred in 8 of the 12 cases of CNLDO (8/12 = 66.6%) and on the asymptomatic side in 1 case (1/6 = 16.6%). A canine tooth bud situated in the same plane as the NLC was observed in 9 cases of CNLDO (9/12 = 75%) and on the asymptomatic side in 2 cases (2/6 = 33.3%).

Conclusions:
HC noted during probing is a sensitive but relatively nonspecific sign which, nevertheless, does indicate either a complex obstruction or at least potential intubation difficulties. As confirmed by CT imaging, a significant anatomical variant is not necessarily predictive of epiphora, but nevertheless may complicate the intubation procedure.
Diagnostic Utility and Safety of Endobronchial Ultrasound–guided Transbronchial Needle Aspiration in the Elderly
Authors: Dhooria Sahajal , Sehgal Inderpaul S. , Gupta Nalini , Prasad Kuruswamy T. , Aggarwal Ashutosh N. , Agarwal Ritesh 
Published: June 2019

Background:
There is limited evidence regarding the effect of age on the specimen adequacy, positivity rate of specimen on cytology (PR), and safety of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA). The aim of this study was to investigate the utility of EBUS-TBNA in the elderly.

Methods:
This was a retrospective study of subjects who underwent EBUS-TBNA. We compare the specimen adequacy, PR, and the incidence of complications in the elderly (age 65 y and above) versus the younger subjects (age younger than 65 y). A multivariate logistic regression analysis was performed to identify the factors affecting the diagnostic yield.

Results:
Of the 1816 subjects, 258 (14.2%) were elderly. The specimen adequacy was similar between the old and the young (93.5% vs. 96.3%, P=0.053). The PR in the elderly (48.8%) was lower (P<0.001) than the younger subjects (66.7%). Among those with a definite diagnosis made on EBUS-TBNA, 55.4% of the older subjects had malignancy, while 82.4% of the young had granulomatous disorders. The incidence of complications was similar in the 2 groups (3.9% vs. 4.4%, P=0.87). The specimen adequacy, PR and complications were also similar among the different age groups within the older population (65 to 69, 70 to 74, 75 to 79, and 80 y and above). On multivariate logistic regression analysis, older age, the number of lymph nodes sampled, the lymph node size, and needle reuse influenced the PR.

Conclusion:
EBUS-TBNA appears to have a similar specimen adequacy and safety but a lower PR in the elderly as compared with the younger individuals.
When a Child Dies in the PICU: Practice Recommendations From a Qualitative Study of Bereaved Parents*
Authors: Butler Ashleigh E. , Copnell Beverley , Hall Helen 
Published: June 2019

Objectives:
Around the world, the PICU is one of the most common sites for hospitalized children to die. Although ensuring the best possible care experience for these children and their families is important, clear recommendations for end-of-life and bereavement care, arising from the parents themselves, remain limited within current literature. This report aims to describe bereaved parents’ recommendations for improvements in end-of-life care and bereavement follow-up when a child dies in intensive care.

Design:
Thematic analysis of incidental data from a larger grounded theory study.

Setting:
Four Australian PICUs.

Subjects:
Twenty-six bereaved parents participated in audio-recorded, semi-structured interviews in 2015–2016. Interviews explored their experiences of having a child die in intensive care and their experiences of end-of-life care and bereavement follow-up. Data pertaining to this report were analyzed via thematic analysis.

Interventions:
None.

Measurements and Main Results:
Bereaved parents identified several areas for care delivery and improvement across three time periods: during hospitalization; during the dying phase; and during bereavement. During hospitalization, parents’ recommendations focused on improved communication, changes to the physical environment, better self-care resources, and provision of family support. During the dying phase, parents suggested private, de-medicalized rooms, familiar staff members, and support to leave the hospital. Recommendations for care after death focused mainly on the provision of ongoing support from the hospital or local bereavement services, as well as improved information delivery.

Conclusions:
Findings from this study offer many concrete recommendations for improvements in care both during and after a child’s death. These recommendations range from simple practice changes to larger organizational modifications, offering many potential avenues for change and improvement both on an individual healthcare provider level and within individual PICUs.
Long-Term Follow-Up of Longevity and Diffusion Pattern of Hyaluronic Acid in Nasolabial Fold Correction through High-Frequency Ultrasound
Authors: Qiao Ju , Jia Qian-Nan , Jin Hong-Zhong , Li Feng , He Chun-Xia , Yang Jun , Zuo Ya-Gang , Fu Lan-Qin 
Published: June 2019

Background:
Injectable hyaluronic acid fillers have been widely applied in the clinical treatment of facial wrinkles. However, further information and clinical evidence concerning dermal changes and hyaluronic acid filler longevity after injection and diffusion pattern are limited.

Methods:
The authors evaluated the longevity and diffusion pattern of two hyaluronic acid fillers generated by different cross-linking technologies used in the treatment of nasolabial folds using high-frequency ultrasound. Forty-one subjects were treated with Restylane 2 and the remaining 41 were treated with Dermalax DEEP. Wrinkle severity rating scale score and high-frequency ultrasound evaluation of nasolabial folds were performed before and after the injection of hyaluronic acid filler. The ultrasound images were acquired and analyzed to determine dermal thickness and the shape and distribution of hyaluronic acid filler.

Results:
At 2 and 24 weeks from baseline, increased dermal thickness induced by hyaluronic acid filler treatment was not significantly different between groups. At 48 weeks after injection, increased dermal thicknesses of the Restylane 2 group (0.14 ± 0.12 mm) were much lower than those of the Dermalax DEEP group (0.20 ± 0.13 mm). Ultrasound examination revealed that hyaluronic acid materials form well-demarcated and hypoechogenic areas. Restylane 2 tended to form a more diffuse pattern, with multiple smaller bubbles, whereas Dermalax DEEP developed into a more localized configuration, with larger clumps.

Conclusions:
This study is the first long-term assessment of nasolabial fold correction that reveals the performance of different hyaluronic acid materials in vivo and validates high-frequency ultrasound as a simple and rapid modality. Hyaluronic acid fillers generated by different cross-linking technologies display differential diffusion patterns in skin tissues.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, II.
Role of Fresh Frozen Cartilage in Revision Rhinoplasty
Authors: Mohan Raja , Shanmuga Krishnan R. Raja , Rohrich Rod J. 
Published: June 2019

Background:
Correction of secondary nasal deformities frequently requires cartilage to build the framework of the nose. Traditionally, autologous costal cartilage has been used because of the paucity of the septal cartilage. Because of associated donor-site complications and increased operating time, irradiated allografts have been used. These grafts have a higher rate of resorption and infection. Thus, the authors have used fresh frozen, nonirradiated, cadaveric rib cartilage as donor cartilage to avoid these shortcomings, and they present their early experience.

Methods:
The operative data of 50 patients who underwent secondary rhinoplasty performed by the senior author between 2014 and 2017 were analyzed. The outcomes of the rhinoplasty were evaluated by preoperative and postoperative photographs by four blinded plastic surgeons, and the results were tabulated using the Independent Rhinoplasty Outcome Score.

Results:
Fifty patients were followed up over an average period of 3.35 months (range, 1 to 18 months). There was only one complication (infection, 2 percent), which did not need revision surgery. There was no warping or extrusion in this cohort.

Conclusions:
The authors believe that fresh frozen, nonirradiated cartilage allografts are an evolving source of donor cartilage grafts for revision rhinoplasty because they are associated with lower complication rates. However, further long-term studies with an increased sample size are necessary to prove that fresh frozen cartilage grafts are better than other sources.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Assessment of Hepatic Perfusion Using GRASP MRI
Authors: Weiss Jakob , Ruff Christer , Grosse Ulrich , Grözinger Gerd , Horger Marius , Nikolaou Konstantin , Gatidis Sergios 
Published: June 2019

Purpose
The aim of this study was to demonstrate the feasibility of hepatic perfusion imaging using dynamic contrast-enhanced (DCE) golden-angle radial sparse parallel (GRASP) magnetic resonance imaging (MRI) for characterizing liver parenchyma and hepatocellular carcinoma (HCC) before and after transarterial chemoembolization (TACE) as a potential alternative to volume perfusion computed tomography (VPCT).

Methods and Materials
Between November 2017 and September 2018, 10 patients (male = 8; mean age, 66.5 ± 8.6 years) with HCC were included in this prospective, institutional review board–approved study. All patients underwent DCE GRASP MRI with high spatiotemporal resolution after injection of liver-specific MR contrast agent before and after TACE. In addition, VPCT was acquired before TACE serving as standard of reference. From the dynamic imaging data of DCE MRI and VPCT, perfusion maps (arterial liver perfusion [mL/100 mL/min], portal liver perfusion [mL/100 mL/min], hepatic perfusion index [%]) were calculated using a dual-input maximum slope model and compared with assess perfusion measures, lesion characteristics, and treatment response using Wilcoxon signed-rank test. To evaluate interreader agreement for measurement repeatability, the interclass correlation coefficient (ICC) was calculated.

Results
Perfusion maps could be successfully generated from all DCE MRI and VPCT data. The ICC was excellent for all perfusion maps (ICC ≥ 0.88; P ≤ 0.001). Image analyses revealed perfusion parameters for DCE MRI and VPCT within the same absolute range for tumor and liver tissue. Dynamic contrast-enhanced MRI further enabled quantitative assessment of treatment response showing a significant decrease (P ≤ 0.01) of arterial liver perfusion and hepatic perfusion index in the target lesion after TACE.

Conclusions
Dynamic contrast-enhanced GRASP MRI allows for a reliable and robust assessment of hepatic perfusion parameters providing quantitative results comparable to VPCT and enables characterization of HCC before and after TACE, thus posing the potential to serve as an alternative to VPCT.