bluuebunny/crossref_metadata_2025_split huggingface dataset:
Impact of a Blood Pressure Practice Initiative on Attitude, Practice Behavior, and Knowledge Among Outpatient Rehabilitation Providers: An Observational Study
Authors: Arena Sara K. , Peterson Edward 
Published: September 2019

Purpose:
The purpose of this study is to describe the impact of a blood pressure (BP) educational initiative on the attitude, practice behaviors, and knowledge of outpatient (OP) physical therapists.

Methods:
An observational pre-test and post-test study design was initiated using a sample of convenience at 12 OP rehabilitation clinics. A 4-phase protocol included (1) evaluation of BP equipment, (2) pre-test questionnaire, (3) attendance at a 1-hour lecture on BP practice recommendations, and (4) performing BP measures on patient evaluations for 1 week followed by the post-test questionnaire. Descriptive statistics reported demographics, whereas a paired t test compared means of the presurvey and postsurvey responses with statistical significance set at P < .05.

Results:
Of the 55 therapists included, 70.9% were female and 29.1% male, whereas 41.8% and 58.2% reported having ≤15 and >15 years of experience, respectively. A significant improvement in BP attitudes (P = .02), practice behaviors (P = .001), and knowledge (P = .002) was identified.

Conclusions:
An educational initiative that provided BP assessment tools, a 1-hour evidence-based BP lecture, a decision-making reference, and a directive to perform valid and reliable BP techniques and interventions resulted in positive changes to an OP therapists attitude, immediate practice behavior, and knowledge of BP.
Exploration of a Simulation-Based Learning Experience in Critical Care: The Use of Standardized Patients for Early Mobility Training
Authors: Cunningham Shala , Cunningham Cynthia 
Published: September 2019

Purpose:
The purpose of this study was to examine the influence of a simulation experience, using standardized patients (SPs), on physical therapy students' perceptions of comfort with early mobilization of patients in a critical care environment.

Methods:
To explore the influence of the simulation experience on students' confidence in the assessment and treatment of critically ill patients, a survey investigating the skills associated with cardiovascular and pulmonary physical therapy was developed and administered before and after the experience. In addition, focus group interviews explored the students' perceptions of the simulation scenarios.

Results:
Similar to studies using high-fidelity human simulators, students reported increased comfort with the skills required for early rehabilitation of patients in critical care settings. In addition, students discussed the realism of scenarios, the practical application of previously acquired knowledge, and the need to adapt to the patient response during the scenarios.

Conclusions:
With the advancement of the simulation technology, SPs can be used to accurately portray patients in critical care units. The use of SPs allows for the unrestricted ability to mobilize the patient and, therefore, the ability to practice the skills associated with early rehabilitation in the intensive care setting.
Area Deprivation as a Risk Factor for Methicillin-resistant Staphylococcus aureus Infection in Pediatric Cystic Fibrosis
Authors: Oates Gabriela R. , Harris William T. , Rowe Steven M. , Solomon George M. , Dey Suranjana , Zhu Aowen , Hoover Wynton C. , Gutierrez Hector H. 
Published: September 2019

Background:
In US cystic fibrosis (CF) patients, methicillin-resistant Staphylococcus aureus (MRSA) rates have tripled in the past 2 decades. Known clinical risk factors include exposure to a healthcare setting, Pseudomonas aeruginosa and CF-related diabetes. Area-level socio-environmental exposures have not been evaluated. We explored the association of area-level deprivation with MRSA prevalence in a pediatric CF Center in the Southeastern United States.

Methods:
Patients’ residential addresses were geocoded and linked to a composite Area Deprivation Index and Rural-Urban Commuting Area scores. The association of MRSA with Area Deprivation Index and Rural-Urban Commuting Area scores was evaluated using logistic regression with robust standard errors adjusted for sociodemographic covariates (age, sex, race, mother’s and father’s education and household income), clinical risk factors (P. aeruginosa, CF-related diabetes, hospitalizations and number of clinic visits) and clustering.

Results:
The study included all pediatric patients (N = 231; mean age 12) at a single CF Center. MRSA was present in 44% of subjects. Higher area-level deprivation was correlated with rural residence, lack of parental college education and lower household income (P < 0.001 for each). In a multiple regression model fully adjusted for patient-level sociodemographic covariates, clinical risk factors and clustering, neighborhood deprivation was associated with more than 2-fold increase in the odds of having MRSA [OR 2.26 (1.14–4.45), P < 0.05].

Conclusions:
Neighborhood deprivation is a risk factor for MRSA in pediatric CF, doubling the odds of infection. Community-level socioeconomic risk factors should be considered when developing prevention strategies and treatment plans for MRSA infection in pediatric patients with CF.
A Nonopioid, Nonbenzodiazepine Treatment Approach for Intractable Nausea and Vomiting in the Emergency Department
Authors: Valdovinos Erica M. , Frazee Bradley W. , Hailozian Christian , Haro Daniel A. , Herring Andrew A. 
Published: September 2019

Goal:
We sought to assess the feasibility and efficacy of a treatment protocol for nausea and vomiting using the combination of chlorpromazine, a dopamine antagonist antiemetic, and ketamine, a nonopioid analgesic.

Background:
Increasing numbers of patients with cannabis use disorder are presenting to emergency departments with a poorly understood syndrome characterized by intractable nausea and vomiting.

Methods:
This is a prospective, observational study involving a convenience sample of patients with unexplained nausea and vomiting. Subjects were given ketamine 15 mg slow intravenous push and chlorpromazine 12.5 mg intravenous over 15 minutes. Outcomes were number of episodes of emesis after study drug administration; change in nausea severity; change in pain severity; adverse events; and patient satisfaction.

Results:
We enrolled 28 subjects on 30 emergency department visits. Twenty-three subjects (82%) reported at least weekly cannabis use with 19 reporting daily use. Initial symptoms were severe, with median pain and nausea scores both 10. After receiving study medication, the mean decrease in pain score over 120 minutes was 4.1 (95% confidence interval: 3.2, 5.0) and the mean decrease in nausea score was 4.9 (95% confidence interval: 4.0, 5.8). There were no adverse events. All 28 subjects who were asked reported they would want to receive these medications again.

Conclusion:
In this single-center study, the majority of patients presenting with intractable nausea and vomiting reported heavy cannabis use, and symptoms were severe. The combination of chlorpromazine plus ketamine resulted in rapid, definitive cessation of symptoms in most of these patients without the need for opioids or benzodiazepines.
Diagnosis and Management of Adrenal Insufficiency in Hospitalized Patients
Authors: Reddy Pramod 
Published: September 2019

Background:
Plasma cortisol is commonly obtained in hospitalized hypotensive patients, and adrenocorticotropic hormone (ACTH) challenge is typically conducted to further workup hypocortisolemia. It is important to recognize that relative adrenal insufficiency (AI) is the most common cause of low cortisol levels and failed ACTH challenge in ill patients. Both cortisol and synthetic ACTH challenge assays are unreliable in critically ill patients. In clinical practice, corticosteroid therapy in septic shock patients results in immediate hemodynamic benefits with less vasopressor and ventilator dependence.

Areas of Uncertainty:
There is no consensus about the diagnostic criteria of relative AI, appropriate cortisol level, and the dose used for synthetic ACTH challenge in patients with septic shock. There is controversy about the mortality benefits of supplemental steroid therapy and about the use of adjunctive fludrocortisone.

Data Sources:
PubMed search of randomized control trials and meta-analyses.

Therapeutic Opinion:
Despite all the controversies, hospital physicians frequently use steroids in patients with septic shock with hypocortisolemia. Hydrocortisone should be the choice of steroid for most relative AI patients, and fludrocortisone can be added on a case-by-case basis in refractory shock. Most of the adverse effects induced by a short course of steroids are easily managed in the inpatient setting.
Is Insulin Therapy Safe?
Authors: Home Philip , Itzhak Baruch 
Published: September 2019

Background:
After 98 years of insulin therapy, issues of safety remain of concern.

Areas of Uncertainty:
Uncertainty has been expressed variously in regard of arterial cell wall proliferation, promotion of proliferative retinopathy, promotion of tumor growth, and for pregnancy. Immunological issues have been little studied since the advent of highly purified insulins in the 1970s. A specific topic is whether hypoglycemia, severe or otherwise, might promote cardiac thrombotic or dysrhythmic events.

Data Sources:
A literature review in these areas is difficult because nearly all clinical trials with insulin refer to adverse events. However, the specific topics aforementioned allow for some informed literature searching supplemented by finger-searching of published articles, notably in connection with the insulin analogues.

Therapeutic Understandings:
Safety data for pregnancy are weak because of power problems, but there are no signals for added maternal or fetal risk. Clinical-outcome trials that assess insulin against other glucose-lowering therapies or with significantly different insulin preparations in different arms are few and are sometimes conducted at modest dosage but fail to suggest promotion of arterial disease. Concern over growth-promoting activity of insulin glargine turned out to be ill-founded when the circulating moiety after injection was noted to have a lower IGF-1:insulin activity than human insulin, and a direct study of retinopathy progression or meta-analysis of malignancy incidence failed to show signals of concern. It does seem that severe hypoglycemia can cause death in some people with type 1 diabetes, although the tissue mechanism is unknown, but reducing severe hypoglycemia in type 2 diabetes does not protect against arterial events. Both symptomatic and severe hypoglycemia can however be reduced by use of more recently marketed insulin analogues, and this improves tolerability if not safety.

Conclusions:
In conclusion, although insulin therapy clearly gives health benefits, the evidence for long-term harm is absent or weak.
The controversial role of red cell transfusions for sickle cell pain
Authors: Karafin Matthew S. , Field Joshua J. 
Published: September 2019

Purpose of review
Red cell transfusions are one of the most common and important therapies used for patients with sickle cell disease (SCD). For prevention of strokes, there is abundant evidence that transfusions are efficacious, whereas for other indications, such as prevention of pain, there are less data. Nonetheless, with few therapeutic options, the use of transfusion for prevention of acute pain has increased in children and adults with SCD without a clear understanding of its benefits.

Recent findings
Although it makes conceptual sense that red cell transfusions would prevent pain that arises from vaso-occlusion, we now know that the mechanism of pain is more complex than vaso-occlusion alone. Recent taxonomies recognize a chronic pain syndrome that is both common in adults with SCD and affects the presentation of acute pain. It is not known if acute pain on the background of chronic pain responds differently to sickle cell therapies, such as hydroxyurea and blood transfusion.

Summary
In this review, we will examine the studies that have investigated whether red cell transfusions are efficacious for preventing pain. In the absence of high-quality data that specifically addresses this question, we will outline our approach, which might soon change with new drugs and curative therapies on the horizon.
Single-Room Ward Design and Its Impact on Service and Patient Outcomes
Authors: Davis Melissa , Elliott Rosalind , Hills Rosemary , Fry Margaret 
Published: September 2019

BACKGROUND:
Evidence suggests that single-room inpatient wards are associated with better patient outcomes than open-room wards but little is known about the impact on adverse events, patient satisfaction, and clinician experiences.

METHODS/PURPOSE:
We evaluated the impact of a new inpatient single-room orthopaedic ward on patient and clinician outcomes using a medical record audit; patient, nurse, and medical doctor surveys; and nonparticipant observations in a tertiary hospital in Sydney, Australia.

RESULTS:
The audit (1,569 patients; 819 open-room ward and 750 new single-room ward) revealed unchanged adverse event rates and fewer emergency calls after the move to a single-room ward. Survey responses from nurses, medical doctors, and patients were positive. Observations suggested that clinicians devised solutions to potential threats to patient safety.

CONCLUSION:
The single-room ward design did not negatively impact on patient and clinician outcomes and was preferred by them. Clinicians organized their work to ensure patient safety.
Assessment of the Independent and Synergistic Effects of Fluid Overload and Acute Kidney Injury on Outcomes of Critically Ill Children*
Authors: Gist Katja M. , Selewski David T. , Brinton John , Menon Shina , Goldstein Stuart L. , Basu Rajit K. 
Published: September 2019

Objectives:
Evaluate the independent and synergistic associations of fluid overload and acute kidney injury with outcome in critically ill pediatric patients.

Design:
Secondary analysis of the Acute Kidney Injury in Children Expected by Renal Angina and Urinary Biomarkers (NCT01735162) prospective observational study.

Setting:
Single-center quaternary level PICU.

Patients:
One-hundred forty-nine children 3 months to 25 years old with predicted PICU length of stay greater than 48 hours, and an indwelling urinary catheter enrolled (September 2012 to March 2014). Acute kidney injury (defined by creatinine or urine output on day 3) and fluid overload (≥ 20% on day 3) were used as outcome variables and risk factors for ICU endpoints assessed at 28 days.

Interventions:
None.

Measurements and Main Results:
Acute kidney injury and fluid overload occurred in 19.4% and 24.2% respectively. Both acute kidney injury and fluid overload were associated with longer ICU length of stay but neither maintained significance after multivariate regression. Delineation into unique fluid overload/acute kidney injury classifications demonstrated that fluid overload+ patients experienced a longer ICU and hospital length of stay and higher rate of mortality compared with fluid overload– patients, regardless of acute kidney injury status. Fluid overload+/acute kidney injury– patients had increased odds of death (p = 0.013). After correction for severity of illness, ICU length of stay remained significantly longer in fluid overload+/acute kidney injury+ patients compared with patients without both classifications (17.4; 95% CI, 11.0–23.7 vs 8.8; 95% CI, 7.3–10.9; p = 0.05). Correction of acute kidney injury classification for net fluid balance led to acute kidney injury class switching in 29 patients and strengthened the association with increased mechanical ventilation and ICU length of stay on bivariate analysis, but reduced the increased risk conferred by fluid overload for mortality.

Conclusions:
The current study suggests the effects of significant fluid accumulation may be delineable from the effects of acute kidney injury. Concurrent fluid overload and acute kidney injury significantly worsen outcome. Correction of acute kidney injury assessment for net fluid balance may refine diagnosis and unmask acute kidney injury associated with deleterious downstream sequelae. The unique effects of fluid overload and acute kidney injury on outcome in critically ill patients warrant further study.
Fluid Overload in Pediatric Severe Traumatic Brain Injury*
Authors: Stulce Casey , Reisner Andrew , Kane Jason M. , Shin H. Stella , McCracken Courtney , Williamson Julie , Walson Karen , Paden Matthew 
Published: September 2019

Objective:
Pediatric traumatic brain injury is a major public health problem in the United States. Hypertonic saline therapy is a well-established treatment in patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) who have intracranial hypertension. In children, fluid overload is associated with increased mortality, ventilator duration, and length of PICU stay, even when controlling for severity of illness. This study reports prevalence of fluid overload in pediatric patients with severe traumatic brain injury treated with 3% hypertonic saline and effect on clinical outcomes.

Design:
Single-center retrospective chart review.

Setting:
PICUs at two tertiary children’s hospitals.

Patients:
One hundred thirty-eight patients with traumatic brain injury with postresuscitation Glasgow Coma Scale less than or equal to 8 who received hypertonic saline from September 1, 2010, to February 28, 2016, and intracranial pressure monitoring and survived at least 24 hours from admission.

Interventions:
None.

Measurements and Main Results:
We used fluid balance percentage greater than or equal to 10% as our definition of fluid overload. Ninety-one percent of patients less than 1 year old had fluid overload on day 10 of admission compared with 47% of patients greater than 1 year. Fluid overloaded patients did not have increased mortality, acute kidney injury, PICU length of stay, or ventilator days. Hypertonic saline was not the cause of fluid overload in these patients.

Conclusions:
Patients with severe traumatic brain injury do have high rates of fluid overload. However, fluid overload did not contribute to mortality, longer days on the ventilator, increased risk of acute kidney injury, or increased PICU length of stay.
Urine Injury Biomarkers Are Not Associated With Kidney Transplant Failure
Authors: Koyawala Neel , Reese Peter P. , Hall Isaac E. , Jia Yaqi , Thiessen-Philbrook Heather R. , Mansour Sherry G. , Doshi Mona D. , Akalin Enver , Bromberg Jonathan S. , Harhay Meera N. , Mohan Sumit , Muthukumar Thangamani , Schröppel Bernd , Singh Pooja , Weng Francis L. , Parikh Chirag R. 
Published: September 2019

Background.
Kidneys transplanted from deceased donors with serum creatinine-defined acute kidney injury (AKI) have similar allograft survival as non-AKI kidneys but are discarded at a higher rate. Urine injury biomarkers are sensitive markers of structural kidney damage and may more accurately predict graft outcomes.

Methods.
In the 2010–2013 multicenter Deceased Donor Study of 2430 kidney transplant recipients from 1298 donors, we assessed the association of donor urine injury biomarkers microalbumin, neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, IL-18, and liver-type fatty acid binding protein with graft failure (GF) and death-censored GF (dcGF) using Cox proportional hazard models (median follow-up 4 y). We examined if serum creatinine-defined donor AKI modified this association to assess the relationship between subclinical donor AKI (elevated biomarkers without creatinine-defined AKI) and GF. Through chart review of a subcohort (1137 recipients), we determined associations between donor injury biomarkers and a 3-year composite outcome of GF, mortality, or estimated glomerular filtration rate ≤ 20mL/min/1.73m2.

Results.
Risk of GF, dcGF, and 3-year composite outcome did not vary with donor injury biomarker concentrations after adjusting for donor, transplant, and recipient characteristics (adjusted hazard ratio ranged from 0.96 to 1.01 per log-2 increase in biomarker). Subclinical injury in transplanted kidneys without AKI was not associated with GF.

Conclusions.
AKI measured using injury biomarkers was not associated with posttransplant graft outcomes (at median 4 y posttransplant). When assessing posttransplant graft viability, clinicians can prioritize other donor and recipient factors over donor kidney injury, measured by either serum creatinine or urine injury biomarkers.
A Multicenter Japanese Survey Assessing the Long-term Outcomes of Liver Retransplantation Using Living Donor Grafts
Authors: Kuramitsu Kaori , Fukumoto Takumi , Egawa Hiroto , Ohdan Hideki , Umeshita Koji , Uemoto Shinji , Hibi Taizo , Kasahara Mureo , Yoshizumi Tomoharu , Mizuta Koichi , Shimamura Tsuyoshi , Furukawa Hiroyuki 
Published: September 2019

Background.
Liver transplantation is the most suitable treatment option available for end-stage liver disease. However, some patients require retransplantation, despite medical advances that have led to improved survival. We aimed to compile a definitive, nationwide resource of liver retransplantation data in Japan, seeking to identify the predictors of patient survival posttransplantation.

Methods.
Questionnaires were sent to 32 institutions that had conducted 281 retransplantations before 2015.

Results.
Among the 265 patients included in this study (142 pediatric cases), the average age at primary transplantation was 23 years, and retransplantation was performed after an average of 1468 days. The main indication for retransplantation was graft rejection (95 patients). Living-donor liver transplantation accounted for 94.7% of primary transplantations and 73.2% of retransplantations. Patient survival at 1, 3, or 5 years did not differ by type of transplantation but was better for pediatric (70.8%, 68.3%, and 60.1%, respectively) than for adult (57.2%, 50.4%, and 45.2%, respectively) recipients (P = 0.0003). Small-for-size syndrome, retransplantation within 365 days, and inpatient status at retransplantation were significant predictors of poor survival in pediatric cases. Retransplantation within 365 days and conditions warranting retransplantation were significant predictors of poor survival in adult patients.

Conclusions.
In Japan, where >70% of retransplantations are performed using living donors, the indications and timing are different from those in previous reports from other countries, while maintaining comparable survival rates. Considering technical challenges, graft failure within 365 days should be thoroughly restricted to justify the use of living donor.