Lyme Disease Patient Outcomes and Experiences; A Retrospective Cohort Study

Lyme disease is a vector-borne illness caused by Borrelia spp. bacterium spread by ticks to humans and other mammals. Despite being prevalent in many regions of the world, there remains considerable uncertainty surrounding many aspects of the disease, and consensus on the most appropriate and effective means of treating the illness remains to be achieved. Recommendations published by the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS), the primary guidelines followed by health care professionals treating Lyme disease, diverge in many of their key recommendations, including treatment duration. Given this lack of consensus, surprisingly little research has been conducted on patient outcomes following different treatment approaches. In this study, patient outcomes were evaluated from a cohort of 210 Canadian Lyme disease patients seeking treatment at one US Lyme disease clinic following a treatment regimen conforming to the ILADS treatment guidelines. It was found that the majority of Lyme disease patients at the clinic responded positively to treatment and a significant (p < 0.05) decrease in symptoms was observed over time. This study, along with related studies, may help to guide physicians to provide their patients with the most effective care.

Preliminary Radiology Report Discordances and Patient Outcomes

RATIONALE AND OBJECTIVES

At our institution, resident and fellow radiologists issue preliminary reports for off-hours imaging studies, which are overread by attending radiologists the next day using structured discrepancy templates. In this study, we examined the impact on patient management and outcome of studies with major discordance.

MATERIALS AND METHODS

For our retrospective observational study, preliminary reports between March and June 2017 that received major discordance were identified through report text search. Electronic medical records were reviewed for patient management change and patient outcome.

RESULTS

Of the 199 cases, 52 cases (26%) had management change and 119 cases (60%) did not have management change. In 25 cases (13%), the preliminary report was proven correct on subsequent management. Three cases (2%) were lost to follow-up. In only one case was adverse outcome directly related to the discordant finding. In cases with patient management change, there was higher proportion of perceptual error compared with those without management change (73% versus 59%). In 47 cases (24%), the discordant finding or diagnosis was known to the clinical team, and better history could have avoided the major change.

CONCLUSION

Adverse outcome from the discordant imaging finding was low (0.5%). Major change in preliminary report could be reduced with better clinical history. Patient management change was more frequently seen with perceptual errors, placing greater emphasis on strategies to reduce them.

The impact of biomarkers of acute kidney injury on individual patient care

Acute kidney injury (AKI) remains a common clinical syndrome associated with increased morbidity and mortality. In the last several years there have been several advances in the identification of patients at increased risk for AKI through the use of traditional and newer functional and damage biomarkers of AKI. This article will specifically focus on the impact of biomarkers of AKI on individual patient care, focusing predominantly on the markers with the most expansive breadth of study in patients and reported literature evidence. Several studies have demonstrated that close monitoring of widely available biomarkers such as serum creatinine and urine output is strongly associated with improved patient outcomes. An integrated approach to these biomarkers used in context with patient risk factors (identifiable using electronic health record monitoring) and with tests of renal reserve may guide implementation and targeting of care bundles to optimize patient care. Besides traditional functional markers, biochemical injury biomarkers have been increasingly utilized in clinical trials both as a measure of kidney injury as well as a trigger to initiate other treatment options (e.g. care bundles and novel therapies). As the novel measures are becoming globally available, the clinical implementation of hospital-based real-time biomarker measurements involves a multidisciplinary approach. This literature review discusses the data evidence supporting both the strengths and limitations in the clinical implementation of biomarkers based on the authors' collective clinical experiences and opinions.

Reversal Treatment in Oral Anticoagulant-Related Intracerebral Hemorrhage-An Observational Study Based on the Swedish Stroke Register

Introduction: Intracerebral hemorrhage (ICH) is the most serious adverse effect of oral anticoagulant (OAC) treatment. The effect of OAC reversal therapy on outcome is uncertain. We compared 90-day survival and functional outcome in patients with OAC-ICH who received OAC reversal therapy with those who did not. Methods: Data from The Swedish Stroke Register (Riksstroke) for all registered cases of OAC-ICH during 2017 (572 patients) were used to obtain information on reversal (n = 369) and non-reversal (n = 203) treatment receiving patients. Univariate and multivariate Cox regression analysis stratified for level of consciousness (LOC) on admission, and adjustment for relevant baseline variables, was used to compare 90-day Hazard Ratios (HR) for mortality. Results: Sixty-five percent of patients received reversal treatment. These patients were younger, more often pre-stroke independent and alert at presentation. Withholding reversal treatment was associated with an increased death rate (HR = 1.47; 95% CI: 1.08-2.01) in a Cox regression model stratified for LOC and adjusted for baseline imbalances. Additional factors associated with an increased 90-day death rate were male sex (HR = 1.42; 95% CI: 1.06-1.92), age (HR = 1.05; 95% CI: 1.02-1.07), and intraventricular hemorrhage (HR = 2.41; CI: 1.77-3.29). Conclusion: In this large observational study 35% of patients with OAC-ICH did not receive reversal treatment. Patients receiving OAC-reversal treatment had an improved 90-day mortality outcome compared to those not receiving treatment. Mortality was strongly related to LOC. Further, and larger, studies are required to determine which patient groups may benefit from reversal therapy and in whom non-reversal is adequate.

Impact of South Korea's Comprehensive Nursing Service Policy on Nurse and Patient Outcomes

In some Asian and African countries, caregivers of patients are permitted to reside in hospital rooms and support the daily tasks of patient care. To solve the various problems that this system could cause, the Korean government has established a comprehensive nursing service, whereby caregivers are no longer permitted in the hospital and, instead, nurses provide all the patient care. This study aimed to identify and evaluate the effectiveness of the comprehensive nursing service, by surveying 1348 nurses to evaluate nursing outcomes-specifically, the Nurses' Assessment of Quality Scale, job satisfaction, and turnover intention. A total of 396 patients were also surveyed to determine patient outcome, in particular patient satisfaction. In the comprehensive nursing service ward, the total score on the Nurses' Assessment of Quality Scale, job satisfaction, and patient satisfaction scores were higher than in the non-comprehensive nursing service ward. Moreover, turnover intention was lower. All differences were statistically significant. The results of this study demonstrate that the decision to implement policy-based comprehensive nursing services has thus far been beneficial. In the future, the government should revise and supplement its policies through various socioeconomic assessments.

Considerations for Postacute Rehabilitation for Survivors of COVID-19

Coronavirus disease (COVID-19), the infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported on December 31, 2019. Because it has only been studied for just over three months, our understanding of this disease is still incomplete, particularly regarding its sequelae and long-term outcomes. Moreover, very little has been written about the rehabilitation needs of patients with COVID-19 after discharge from acute care. The objective of this report is to answer the question "What rehabilitation services do survivors of COVID-19 require?" The question was asked within the context of a subacute hospital delivering geriatric inpatient and outpatient rehabilitation services. Three areas relevant to rehabilitation after COVID-19 were identified. First, details of how patients may present have been summarized, including comorbidities, complications from an intensive care unit stay with or without intubation, and the effects of the virus on multiple body systems, including those pertaining to cardiac, neurological, cognitive, and mental health. Second, I have suggested procedures regarding the design of inpatient rehabilitation units for COVID-19 survivors, staffing issues, and considerations for outpatient rehabilitation. Third, guidelines for rehabilitation (physiotherapy, occupational therapy, speech-language pathology) following COVID-19 have been proposed with respect to recovery of the respiratory system as well as recovery of mobility and function. A thorough assessment and an individualized, progressive treatment plan which focuses on function, disability, and return to participation in society will help each patient to maximize their function and quality of life. Careful consideration of the rehabilitation environment will ensure that all patients recover as completely as possible.

Difference in Profiles of the Gut-Derived Tryptophan Metabolite Indole Acetic Acid between Transplanted and Non-Transplanted Patients with Chronic Kidney Disease

BACKGROUND

Uremic toxins have emerged as potential mediators of morbidity and mortality in patients with chronic kidney disease (CKD). Indole-3-acetic acid (IAA, a tryptophan-derived uremic toxin) might be a useful biomarker in patients with CKD. The objectives of the present study were to (i) describe IAA concentrations in a cohort of non-transplanted patients with CKD and a cohort of transplanted patients with CKD, and (ii) investigate the possible relationship between IAA levels and adverse outcomes in the two cohorts.

METHODS

Levels of free and total IAA were assayed in the two prospective CKD cohorts (140 non-transplanted patients and 311 transplanted patients). Cox multivariate analyses were used to evaluate the association between IAA levels and outcomes (mortality, cardiovascular events, and graft loss).

RESULTS

In the non-transplanted CKD cohort, free and total IAA increased progressively with the CKD stage. In the transplanted CKD cohort, free and total IAA levels were elevated at the time of transplantation but had fallen substantially at one-month post-transplantation. Indole acetic acid concentrations were lower in transplanted patients than non-dialysis non-transplanted patients matched for estimated glomerular filtration rate (eGFR), age, and sex. After adjustment for multiple confounders, the free IAA level predicted overall mortality and cardiovascular events in the non-transplanted CKD cohort (hazard ratio [95% confidence interval]: 2.5 [1.2-5.1] and 2.5 [1.3-4.8], respectively). In the transplanted CKD cohort, however, no associations were found between free or total IAA on one hand, and mortality, CV event, or graft survival on the other.

CONCLUSION

We demonstrated that levels of IAA increase with the CKD stage, and fall substantially, even normalizing, after kidney transplantation. Free IAA appears to be a valuable outcome-associated biomarker in non-transplanted patients, but-at least in our study setting-not in transplanted patients.

Comparison of the Outcome of Patient Management with Physician Extenders Only and with both Residents and Extenders

This was a retrospective study that aimed to determine the treatment outcome of patients seen in the trauma unit of the Johnson City Medical Center (JCMC). The study included 2844 patients in the trauma registry and evaluated age, sex, injury severity score (ISS), length of stay (LOS) in the intensive care unit (ICU), overall hospital lengths of stay (LOS), ventilator days, discharge disposition, and complications between one group managed by extenders only and the second managed by both residents and extenders. The sample size of the two groups was similar (group one = 1446 and group two = 1398) and the proportions of males and females in the two groups were identical (males = 65%, females = 35%). Both groups had similar mechanisms of injury, although group one had a higher percentage of falls (32.9% vs. 22.03%) and group two had a higher proportion of motor vehicle crash (MVC) traumas (40.41% vs 30%). There was no significant difference in those discharged home and deaths between the two groups. (χ²(1, N = 2258) = 0.04, p = 0.82). Complications showed statistical significance when looking at extenders vs. residents plus extenders for all complications (χ²(7, N = 196) = 38.73, p ≤ 0.0001). It is possible that having extenders only versus both extenders and residents had no significant difference among the patient outcomes based on the variables age, sex, ISS, ICU days, overall hospital LOS, and ventilator days; however, when observing complications between the two groups, it is possible that patients are more likely to have complications due to overall hospital LOS in the residents plus extenders group.

Classifications and Clinical Assessment of Haemorrhoids: The Proctologist's Corner

BACKGROUND

Haemorrhoidal disease (HD) is a benign condition affecting a considerable part of adult population. HD can be considered a social and economic burden with high impact on patients' lifestyle. Several new techniques and devices have been proposed for HD treatment; however, preoperative assessment is essential and the use of classification system is recommended.

METHODS

In the last two decades many studies described the preoperative assessment and several attempts of classification for HD. This review focuses on the most relevant studies found in literature where classification systems and clinical evaluation with differential diagnosis have been evaluated.

RESULTS

The knowledge of classification systems and differential diagnosis for HD has been shown to play a central role in the clinical assessment and the best treatment choice. Although there are new challenging techniques and devices for HD treatment, a preoperative assessment is always mandatory.

CONCLUSION

Preoperative clinical evaluation is essential for HD patient treatment and outcome. Classification systems are useful for the therapeutic choice and researches on new medical or surgical treatments. In fact, the international guidelines advise several therapeutic options depending on the severity of the HD.

MRI phenotypes of the brain are related to future stroke and mortality in patients with manifest arterial disease: The SMART-MR study

Neurodegenerative and neurovascular diseases lead to heterogeneous brain abnormalities. A combined analysis of these abnormalities by phenotypes of the brain might give a more accurate representation of the underlying aetiology. We aimed to identify different MRI phenotypes of the brain and assessed the risk of future stroke and mortality within these subgroups. In 1003 patients (59 ± 10 years) from the Second Manifestations of ARTerial disease-Magnetic Resonance (SMART-MR) study, different quantitative 1.5T brain MRI markers were used in a hierarchical clustering analysis to identify 11 distinct subgroups with a different distribution in brain MRI markers and cardiovascular risk factors, and a different risk of stroke (Cox regression: from no increased risk compared to the reference group with relatively few brain abnormalities to HR = 10.34; 95% CI 3.80↔28.12 for the multi-burden subgroup) and mortality (from no increased risk compared to the reference group to HR = 4.00; 95% CI 2.50↔6.40 for the multi-burden subgroup). In conclusion, within a group of patients with manifest arterial disease, we showed that different MRI phenotypes of the brain can be identified and that these were associated with different risks of future stroke and mortality. These MRI phenotypes can possibly classify individual patients and assess their risk of future stroke and mortality.

Associations between work satisfaction, engagement and 7-day patient mortality: a cross-sectional survey

OBJECTIVE

This study examines the association between profession-specific work environments and the 7-day mortality of patients admitted to these units with acute myocardial infarction (AMI), stroke and hip fracture.

DESIGN

A cross-sectional study combining patient mortality data extracted from the South-Eastern Norway Health Region, and the work environment scores at the hospital ward levels. A case-mix adjustment model was developed for the comparison between hospital wards.

SETTING

Fifty-six patient wards in 20 hospitals administered by the South-Eastern Norway Regional Health Authority.

PARTICIPANTS

In total, 46 026 patients admitted to hospitals with AMI, stroke and hip fracture, and supported by 8800 survey responses from physicians, nurses and managers over a 3-year period (2010-2012).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measures were the associations between the relative mortality rate for patients admitted with AMI, stroke and hip fractures and the profession-specific (ie, nurses, physicians, middle managers) mean scores on the 19 organisational factors in a validated cross sectional, staff survey conducted annually in Norway. The secondary outcome measures were the mean scores with SD on the organisational factors in the staff survey reported by each profession.

RESULTS

The Nurse workload (beta 0.019 (95% CI0.009-0.028)) and middle manager engagement (beta 0.024 (95% CI0.010-0.037)) levels were associated with a case-mix adjusted 7-day patient mortality rates. There was no significant association between physician work environment scores and patient mortality rates.

CONCLUSION

7-day mortality rates in hospital wards were negatively correlated with the nurse workload and manager engagement levels. A deeper understanding of the relationships between patient outcomes, organisational structure and their underlying cultural barriers is needed because they may provide a better understanding of the harm and death risks for patients due to organisational characteristics.

Native Nephrectomy before and after Renal Transplantation in Patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD)

The aim of this study was 1) to evaluate and compare pre-, peri-, and post-operative data of Autosomal Dominant Polycystic Kidney Disease (ADPKD) patients undergoing native nephrectomy (NN) either before or after renal transplantation and 2) to identify advantages of optimal surgical timing, postoperative outcomes, and economical aspects in a tertiary transplant centre. This retrospective analysis included 121 patients divided into two groups-group 1: patients who underwent NN prior to receiving a kidney transplant (n = 89) and group 2: patients who underwent NN post-transplant (n = 32). Data analysis was performed according to demographic patient details, surgical indication, laboratory parameters, perioperative complications, underlying pathology, and associated mortality. There was no significant difference in patient demographics between the groups, however right-sided nephrectomy was performed predominantly within group 1. The main indication in both groups undergoing a nephrectomy was pain. Patients among group 2 had no postoperative kidney failure and a significantly shorter hospital stay. Higher rates of more severe complications were observed in group 1, even though this was not statistically significant. Even though the differences between both groups were substantial, the time of NN prior or post-transplant does not seem to affect short-term and long-term transplantation outcomes. Retroperitoneal NN remains a low risk treatment option in patients with symptomatic ADPKD and can be performed either pre- or post-kidney transplantation depending on patients' symptom severity.

Alberta Stroke Program Early CT Score Versus Computed Tomographic Perfusion to Predict Functional Outcome After Successful Reperfusion in Acute Ischemic Stroke

Background and Purpose- We aimed to compare the ability of conventional Alberta Stroke Program Early CT Score (ASPECTS), automated ASPECTS, and ischemic core volume on computed tomographic perfusion to predict clinical outcome in ischemic stroke because of large vessel occlusion ≤18 hours after symptom onset. Methods- We selected patients with acute ischemic stroke from the CRISP study (Computed Tomographic Perfusion to Predict Response to Recanalization in Ischemic Stroke Project) with successful reperfusion (modified treatment in cerebral ischemia score 2b or 3). We used e-ASPECTS software to calculate automated ASPECTS and RAPID software to estimate ischemic core volumes. We studied associations between these imaging characteristics and good outcome (modified Rankin Scale score, 0-2) or poor outcome (modified Rankin Scale score, 4-6) in univariable and multivariable analysis, after adjustment for relevant clinical confounders. Results- We included 156 patients. Conventional and automated ASPECTS was not associated with good or poor outcome in univariable analysis ( P=nonsignificant for all). Automated ASPECTS was associated with good outcome in multivariable analysis ( P=0.02) but not with poor outcome. Ischemic core volume was associated with good ( P<0.01) and poor outcome ( P=0.04) in univariable and multivariable analysis ( P=0.03 and P=0.02, respectively). Computed tomographic perfusion predicted good outcome with an area under the curve of 0.62 (95% CI, 0.53-0.71) and optimal cutoff core volume of 15 mL. Conclusions- Ischemic core volume assessed on computed tomographic perfusion is a predictor of clinical outcome among patients in whom endovascular reperfusion is achieved ≤18 hours after symptom onset. In this population, conventional or automated ASPECTS did not predict outcome.

Nursing care and outcome in surgical patients - why do we have to care?

Nurses have an important role in patient care. They continuously work in very close contact with patients and foster the realization of activities of daily living as well as ensure quality medical treatment. For both, a high educational level is needed. A large proportion of patients with complex health situations involving chronic illnesses and multimorbidities are treated in hospitals with shortened hospital lengths of stay, changing the caring needs and the demands on nursing. Nurses must handle complex nursing tasks for which a higher educational level is indispensable, including the ability to implement evidence-based practice. In addition, studies show a correlation between the educational level of nursing staff and the health outcomes of patients. If there are too few highly educated nurses, there is an increase in patient mortality as well as the risk of patient complications, such as falls. Also, a low number of nursing staff and a high proportion of admissions decrease the quality of nursing and result in unfavorable patient outcomes. Both developments call for the necessity of a changing nursing practice and the possibilities to transform interprofessional work.

Associations of pathogen-specific and host-specific characteristics with disease outcome in patients with Staphylococcus aureus bacteremic pneumonia

Objective

To understand the relationships of Staphylococcus aureus (SA) bacteremic pneumonia (SABP) outcome with patient‐specific and SA‐specific variables.

Methods

We analysed SA bloodstream isolates and matching sera in SABP patients by sequencing SA isolates (n = 50) and measuring in vitro AT production, haemolytic activity and expression of ClfA and ClfB. Controls were sera from gram‐negative bacteremia patients with or without pneumonia and uninfected subjects. Levels of IgGs, IgMs and neutralizing antibodies (NAbs) against SA antigens were quantified and analysed by one‐way ANOVA. Associations of patient outcomes with patient variables, antibody levels and isolate characteristics were evaluated by univariate and multivariate logistic regression analyses.

Results

SABP patients had higher levels of IgGs against eight virulence factors and anti‐alpha toxin (AT) NAbs than uninfected controls. Levels of IgG against AT and IgMs against ClfA, FnbpA and SdrC were higher in clinically cured SABP patients than in clinical failures. Anti‐LukAB NAb levels were elevated in all cohorts. Increased odds of cure correlated with higher haemolytic activity of SA strains, longer time between surgery and bacteremia (> 30 days), longer duration of antibiotic therapy, lower acute physiology and total APACHE II scores, lack of persistent fever for > 72 h and higher levels of antibodies against AT (IgG), ClfA (IgM), FnbpA (IgM) and SdrC (IgM).

Discussion

Limitations included the cross‐sectional observational nature of the study, small sample size and inability to measure antibody levels against all SA virulence factors.

Conclusion

Our results suggest that SABP patients may benefit from immunotherapy targeting multiple SA antigens.

Long-term prognosis after cancer surgery with inhalational anesthesia and total intravenous anesthesia: a systematic review and meta-analysis

BACKGROUND

A number of teams have investigated the association between the mode of anesthesia and the long-term outcomes after cancer surgeries, with inconsistent conclusions. We conducted this systematic review and meta-analysis to summarize the currently available findings of clinical studies on the long-term outcomes after cancer surgery under inhalational anesthesia with volatile anesthetics (VA) and total intravenous anesthesia (TIVA) with propofol.

METHODS

We systematically searched PubMed, Central, EMBASE, CINAHL, Google Scholar, Web of Science citation index, US clinical trials register, UK clinical trials register, Australia and New Zealand Clinical trials register for clinical studies comparing postoperative outcomes of VA and TIVA. The included outcomes were all-cause mortality, recurrence and recurrence free survival. Meta-analysis was done using the generic inverse variance method.

RESULTS

The overall pooled hazard ratio for all-cause mortality was in favor of TIVA [Harzard ratio (HR) 0.73, 95% confidence interval (CI) 0.60 to 0.89], so was the recurrence free survival (HR 1.22, 95% CI 1.07 to 1.41). The subgroup analysis of mortality in different cancer types did not show any remarkable difference between the intravenous or volatile anesthesia. There was also no significant difference in recurrence.

CONCLUSION

Our meta-analysis suggests that TIVA is associated with lower all-cause mortality after cancer surgeries. As cancers of different origins can respond very differently to pharmacological intervention, more clinical trials are needed in each cancer types in order to substantiate the role of anesthesia in cancer surgery prognosis.

Serologic and Histologic Predictors of Long-Term Renal Outcome in Biopsy-Confirmed IgA Nephropathy (Haas Classification): An Observational Study

Background and objective: The Haas classification of IgA nephropathy should be validated for Asian populations. More detailed and newer predictions regarding renal outcome of IgA nephropathy remains mandatory. Materials: We conducted a retrospective cohort study between January 2003 and December 2013. Clinical, Pathological, and laboratory data were all collected via available medical records. A Mann–Whitney U test was used for continuous variables and the Chi-square test was implemented for categorical variables. A Kaplan–Meier curve was put in place in order to determine patient survival and renal survival. The Youden index and Cox proportional hazard regression were used to investigate the possible factors for renal survival and predictive power. Results: All 272 renal biopsy-confirmed IgAN patients were enrolled for further studies. The univariate analysis showed that risk factors for poor renal outcome included stage 4–5 of Haas classification (HR = 3.67, p < 0.001), a poor baseline renal function (HR = 1.02 and p < 0.001 for higher BUN; HR = 1.14 and p < 0.001 for higher serum creatinine; HR = 0.95, p < 0.001 for higher eGFR), IgG ≤ 907 (HR = 2.29, p = 0.003), C3 ≤ 79.7 (HR = 2.76, p = 0.002), a higher C4 (HR = 1.02, p = 0.026), neutrophil-to-lymphocyte ratio > 2.75 (HR = 2.92, p < 0.001), and a platelet-to-lymphocyte ratio ≥ 16.06 (HR = 2.02, p = 0.012). A routine-checked markers, such as neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio, in order to predict the renal outcome, is recommended. Conclusions: This is the first study to demonstrate that Haas classification is also useful for establishing predictive values in Asian groups. A lower serum IgG (≤907 mg/dL) and serum C3 (≤79.7 mg/dL) were both risk factors for poor renal outcome. Additionally, this is the first study to reveal that serum C4 levels, an NLR > 2.75 and a PLR > 16.06, S could suggest poor renal outcome.

Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review

The goal of this systematic review was to examine the existing literature base regarding the factors impacting patient outcomes associated with use of emergency medical services (EMS) operating in urban versus rural areas. A specific subfocus on low and lower-middle-income countries was planned but acknowledged in advance as being potentially limited by a lack of available data. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed during the preparation of this systematic review. A comprehensive literature search of PubMed, EBSCO (Elton B. Stephens Company) host, Web of Science, ProQuest, Embase, and Scopus was conducted through May 2018. To appraise the quality of the included papers, the Critical Appraisal Skills Programme Checklists (CASP) were used. Thirty-one relevant and appropriate studies were identified; however, only one study from a low or lower-middle-income country was located. The research indicated that EMS in urban areas are more likely to have shorter prehospital times, response times, on-scene times, and transport times when compared to EMS operating in rural areas. Additionally, urban patients with out-of-hospital cardiac arrest or trauma were found to have higher survival rates than rural patients. EMS in urban areas were generally associated with improved performance measures in key areas and associated higher survival rates than those in rural areas. These findings indicate that reducing key differences between rural and urban settings is a key factor in improving trauma patient survival rates. More research in rural areas is required to better understand the factors which can predict these differences and underpin improvements. The lack of research in this area is particularly evident in low- and lower-middle-income countries.

Effects of an in situ instructional design based postpartum hemorrhage simulation training on patient outcomes: an uncontrolled before-and-after study

Objective: To compare postpartum hemorrhage (PPH) patient outcomes before and after an in situ instructional design based PPH simulation attended by obstetrics and gynecology (OBGYN) residents.Methods: This uncontrolled before-and-after study was conducted in Recife, Brazil including all 1388 women delivering from June to August 2012 and all 1357 delivering from June to August 2013. The 36 OBGYN residents were divided into13 teams of two or three participants and were trained through ID based PPH simulation training with the following eight steps: (1) prior knowledge activation, (2) video demonstration, (3) dual-coding PPH protocol discussion-an image association during the training, (4) training scenario # 1, (5) debriefing, (6) training scenario # 2 with immediate feedback, (7) training scenario # 3, and (8) debriefing with self-assessment. The training scenarios had an increasing level of complexity. The main goal of the training was the adequate management of PPH and situational awareness improvement-the ability to anticipate, recognize, and intercept unfolding error chains. The primary patient outcomes rates used for the before and after comparison were therapeutic uterotonics use within 24 h of birth and blood transfusion. Secondary outcomes were therapeutic oxytocin mean dosage IU within 24 h of birth, postpartum Hb < 6 g/dL, among others. Chi-square test was used for categorical variables comparison and independent t-test for continuous variables.Results: PPH rates were 100 (7.2% of 2012 deliveries) and 80 cases (5.9% of 2013 deliveries), respectively. Comparison of primary post- and pre-simulation outcomes revealed no significant differences. However, in the comparison for therapeutic oxytocin mean dosage IU within 24 h of birth, there was an increase found after the simulation (15.98 ± 7.4 versus 25.1 ± 12.3; p < .001). For all other outcome measures, there were no statistical differences.Conclusions: In situ ID based PPH simulation leads to an increase in the mean dosage of oxytocin after training, in selected cases. This may indicate better situational awareness when managing women with PPH.

A New Surgical Site Infection Risk Score: Infection Risk Index in Cardiac Surgery

Various scoring systems attempt to predict the risk of surgical site infection (SSI) after cardiac surgery, but their discrimination is limited. Our aim was to analyze all SSI risk factors in both coronary artery bypass graft (CABG) and valve replacement patients in order to create a new SSI risk score for such individuals. A priori prospective collected data on patients that underwent cardiac surgery (n = 2020) were analyzed following recommendations from the Reporting of studies Conducted using Observational Routinely collected health Data (RECORD) group. Study participants were divided into two periods: the training sample for defining the new tool (2010–2014, n = 1298), and the test sample for its validation (2015–2017, n = 722). In logistic regression, two preoperative variables were significantly associated with SSI (odds ratio (OR) and 95% confidence interval (CI)): diabetes, 3.3/2–5.7; and obesity, 4.5/2.2–9.3. The new score was constructed using a summation system for punctuation using integer numbers, that is, by assigning one point to the presence of either diabetes or obesity. The tool performed better in terms of assessing SSI risk in the test sample (area under the Receiver-Operating Characteristic curve (aROC) and 95% CI, 0.67/055–0.76) compared to the National Nosocomial Infections Surveillance (NNIS) risk index (0.61/0.50–0.71) and the Australian Clinical Risk Index (ACRI) (0.61/0.50–0.72). A new two-variable score to preoperative SSI risk stratification of cardiac surgery patients, named Infection Risk Index in Cardiac surgery (IRIC), which outperforms other classical scores, is now available to surgeons. Personalization of treatment for cardiac surgery patients is needed.

Harmonized outcome measures for use in asthma patient registries and clinical practice

BACKGROUND

Asthma, a common chronic airway disorder, affects an estimated 25 million persons in the United States and 330 million persons worldwide. Although many asthma patient registries exist, the ability to link and compare data across registries is hindered by a lack of harmonization in the outcome measures collected by each registry.

OBJECTIVES

The purpose of this project was to develop a minimum set of patient- and provider-relevant standardized outcome measures that could be collected in asthma patient registries and clinical practice.

METHODS

Asthma registries were identified through multiple sources and invited to join the workgroup and submit outcome measures. Additional measures were identified through literature searches and reviews of quality measures and consensus statements. Outcome measures were categorized by using the Agency for Healthcare Research and Quality's supported Outcome Measures Framework. A minimum set of broadly relevant measures was identified. Measure definitions were harmonized through in-person and virtual meetings.

RESULTS

Forty-six outcome measures, including those identified from 13 registries, were curated and harmonized into a minimum set of 21 measures in the Outcome Measures Framework categories of survival, clinical response, events of interest, patient-reported outcomes, resource utilization, and experience of care. The harmonized definitions build on existing consensus statements and are appropriate for adult and pediatric patients.

CONCLUSIONS

The harmonized measures represent a minimum set of outcomes that are relevant in asthma research and clinical practice. Routine and consistent collection of these measures in registries and other systems would support creation of a national research infrastructure to efficiently address new questions and improve patient management and outcomes.

Nucleostemin expression in breast cancer is a marker of more aggressive phenotype and unfavorable patients' outcome: A STROBE-compliant article

Cancer stem cells (CSCs) are postulated to play significant role in the pathogenesis, progression as well as drug resistance of breast cancer. Nucleostemin (NS) is thought to be a key molecule for stemness, and the clinical impact of NS immunoreactivity in breast cancer can indicate its actual role and future therapeutic potentials.The current study is an observational study with an attempt to evaluate the correlation between NS expression (protein and gene expression levels) and different clinicopathological attributes of invasive breast cancer. For that reason, we investigated NS immunohistochemistry expression on commercial tissue microarray (TMA) of 102 patients and 51 archival specimens from patients admitted to Saqr Hospital, Ras Al Khaimah and diagnosed in Al Baraha Hospital, Dubai, UAE. In addition, the association between NS (GNL3) gene expression and different prognostic parameters as well as patient outcome was also evaluated using 2 large publicly available databases.Interestingly, we found NS expression to be associated with less differentiated and more advance stage. In addition, NS expression was significantly higher in larger size (P = .001) and LN-positive tumors (P = .007). Notably, NS expression was significantly correlated to P53 positive (P = .037) status. Furthermore, NS was found to be more expressed in the highly aggressive breast cancer subtypes including human epidermal growth factor receptor 2 (HER-2) and triple negative breast cancer (TNBC) subtypes. Moreover, our results also showed that high GNL3 gene expression to be associated with poor patient outcome and higher chances of tumor recurrence.Our results highlight NS expression as a marker of aggressive phenotype and poor outcome and indicate its possible use as a potential target for CSC-associated breast cancer management.

Genetic variations in human papillomavirus and cervical cancer outcomes

Cervical cancer is driven by persistent infection of human papillomavirus (HPV), which is influenced by HPV type and intratypic variants, yet the impact of HPV type and intratypic variants on patient outcomes is far less understood. Here, we examined the association of cervical cancer stage and survival with HPV type, clade, lineage, and intratypic variants within the HPV E6 locus. Of 1,028 HPV-positive cases recruited through the CerGE study, 301 were in-situ and 727 were invasive cervical cancer (ICC), with an average post-diagnosis follow-up of 4.8 years. HPV sequencing was performed using tumor-isolated DNA to assign HPV type, HPV 16 lineage, clade, and intratypic variants within the HPV 16 E6 locus, of which nonsynonomous variants were functionally annotated by molecular modeling. HPV 18-related types were more prevalent in ICC compared to in-situ disease and associated with significantly worse recurrence-free survival (RFS) compared to HPV 16-related types. The HPV 16 Asian American lineage D3 and Asian lineage A4 associated more frequently with ICC than with in situ disease and women with an intratypic HPV 16 lineage B exhibited a trend toward worse RFS than those with A, C, or D lineages. Participants with intratypic E6 variants predicted to stabilize the E6-E6AP-p53 complex had worse RFS. Variants within the highly immunogenic HPV 16 E6 region (E14-I34) were enriched in ICC compared to in-situ lesions but were not associated with survival. Collectively, our results suggest that cervical cancer outcome is associated with HPV variants that affect virus-host interactions.

Effect of anaesthesia type on postoperative mortality and morbidities: a matched analysis of the NSQIP database

BACKGROUND

The anaesthetic technique may influence clinical outcomes, but inherent confounding and small effect sizes makes this challenging to study. We hypothesized that regional anaesthesia (RA) is associated with higher survival and fewer postoperative organ dysfunctions when compared with general anaesthesia (GA).

METHODS

We matched surgical procedures and type of anaesthesia using the US National Surgical Quality Improvement database, in which 264,421 received GA and 64,119 received RA. Procedures were matched according to Current Procedural Terminology (CPT) and ASA physical status classification. Our primary outcome was 30-day postoperative mortality and secondary outcomes were hospital length of stay, and postoperative organ system dysfunction. After matching, multiple regression analysis was used to examine associations between anaesthetic type and outcomes, adjusting for covariates.

RESULTS

After matching and adjusting for covariates, type of anaesthesia did not significantly impact 30-day mortality. RA was significantly associated with increased likelihood of early discharge (HR 1.09; P< 0.001), 47% lower odds of intraoperative complications, and 24% lower odds of respiratory complications. RA was also associated with 16% lower odds of developing deep vein thrombosis and 15% lower odds of developing any one postoperative complication (OR 0.85; P < 0.001). There was no evidence of an effect of anaesthesia technique on postoperative MI, stroke, renal complications, pulmonary embolism or peripheral nerve injury.

CONCLUSIONS

After adjusting for clinical and patient characteristic confounders, RA was associated with significantly lower odds of several postoperative complications, decreased hospital length of stay, but not mortality when compared with GA.