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Examining Shift Length and Fatigue: A National Study of Neonatal Advanced Practice Providers
No full textBACKGROUND: Neonatal advanced practice providers (APPs) often work prolonged hours in high-acuity neonatal intensive care units (NICUs). It is imperative to understand how fatigue affects the APP\u27s ability to react quickly following long shifts. There is a lack of data on the effects of shift length and fatigue on neonatal APP job performance and clinical decision-making.
PURPOSE: The purpose of this study was to describe the variation in shift length, knowledge-based competency, personal well-being, and behavioral alertness for neonatal APPs.
METHODS: This study evaluated neonatal APPs before and after a clinical shift. Provider well-being was assessed during the pre-survey. Pretest-posttest surveys evaluated neonatal APP\u27s psychomotor vigilance skills and knowledge. Participants completed an online, anonymous questionnaire to answer a series of knowledge-based questions before and after their shift, along with a psychomotor vigilance test (PVT). A paired t test analysis evaluated the pre- and post-shift PVT values and knowledge-based test scores.
RESULTS: Overall, 61 pre-surveys and 42 post-surveys were completed; 36 were matched by participants pre- to post-survey. The mean between pre- and post-knowledge-based questions was statistically significant, with higher posttest scores. There was no statistical difference noted in the paired t test analysis of the PVT values.
IMPLICATIONS FOR PRACTICE AND RESEARCH: The small sample size may limit the generalizability of findings, but these results may indicate that shift length does not affect psychomotor vigilance or knowledge-based competency. It is vital that future work assess the associations between APP shift length, fatigue, and critical decision-making
Surgical outcomes of Adenoid cystic carcinoma treated with Mohs Micrographic Surgery and excision: a systematic review
No full textAdenoid cystic carcinoma (ACC) is a rare cancer that most commonly occurs in the salivary glands, making up approximately 2-4% of all head and neck malignancies. Treatment for ACC varies, with combinations of surgical excision, adjuvant radiotherapy, and chemotherapy reported in the literature. In this study, we aim to assess ACC recurrence rates with Mohs Micrographic Surgery (MMS) treatment compared to traditional wide local excision (WLE). In June of 2024, a comprehensive review of the literature was performed using the following keywords: Adenoid Cystic Carcinoma and/or Mohs Micrographic Surgery and/or MMS and/or excision. Between the two databases, 25 articles were identified which included a total of 30 patients. Among all the articles, 30 procedures were documented - 8 MMS and 22 WLE. Patients with ACC treated with WLE had a higher rate of recurrence (40.9%) compared to those treated with MMS (12.5%). Limitations include a small number of tumors treated and reporting bias. MMS for the treatment of ACC demonstrated a decreased recurrence rate compared to WLE. Further studies with larger sample sizes are needed to confirm the benefit of MMS over WLE
Totally implantable venous access port metastasis in a patient with multiple myeloma
No full textMultiple myeloma is a hematologic malignancy characterized by the proliferation of monoclonal plasma cells within the bone marrow. Extramedullary plasmacytomas, a rare manifestation of multiple myeloma, occur in a small percentage of patients. These plasmacytomas can develop in the skin, often near venous catheter access sites, posing diagnostic challenges due to their rarity. We report a case of a 63-year-old man with multiple myeloma who presented with a mildly painful, swollen left chest port site. A whole-body FDG PET/CT scan revealed a hypermetabolic soft tissue mass surrounding the port site, suggestive of malignancy. Subsequent surgical excision and histopathological analysis confirmed the presence of a metastatic subcutaneous plasmacytoma, consistent with the patient\u27s known multiple myeloma. Cutaneous extramedullary plasmacytomas at central venous catheter sites are rarely reported. Potential mechanisms for tumor development at trauma sites include local expression of chemokines that attract myeloma cells. This case underscores the importance of recognizing cutaneous plasmacytomas in patients with multiple myeloma and venous access ports to avoid misdiagnosis and unnecessary interventions. It contributes to the broader understanding of extramedullary disease manifestations in multiple myeloma and emphasizes the need for thorough investigation and appropriate management in such cases
Palliative Care Initiated in the Emergency Department: A Cluster Randomized Clinical Trial
No full textIMPORTANCE: The emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness.
OBJECTIVE: To assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness.
DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded.
INTERVENTION: A multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff.
MAIN OUTCOME AND MEASURES: The primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months.
RESULTS: There were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, -3.1% [95% CI, -3.7% to -2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]).
CONCLUSIONS AND RELEVANCE: This multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03424109
A Canvas of Contemporary Insights into Clinical Vitiligo
No full textVitiligo is a chronic skin condition characterized by the loss of melanocytes, resulting in white patches on the skin. While its exact cause is unknown, it\u27s believed to be an autoimmune disorder involving genetic, environmental, and immunologic factors. Various treatments, including topical drugs, phototherapy, and surgery, exist, but further research is needed for more targeted therapies. Standardization of treatment goals and outcome measures is crucial. Future directions involve personalized treatments based on genetic and immunologic profiles, along with advancements in melanocyte biology for more effective therapies. Collaborative research is the key to improving outcomes and quality of life for vitiligo patients
Predictive Factors of Post-ERCP Hepatic Decompensation in Patients with Cirrhosis: A Retrospective Case-Control Study
No full textBACKGROUND AND AIM: Endoscopic retrograde cholangiopancreatography (ERCP) is a crucial diagnostic and therapeutic procedure in patients with cirrhosis; however, it carries the risk of post-procedural hepatic decompensation. This study aims to identify predictive factors associated with post-ERCP hepatic decompensation in patients with cirrhosis to better inform clinical decision-making and minimize adverse outcomes.
METHODS: A retrospective analysis was conducted on patients with cirrhosis undergoing ERCP. Clinical, biochemical, and procedural variables were evaluated to determine their association with hepatic decompensation. Multivariate analysis was performed to identify independent predictors.
RESULTS: A total of 277 patients with cirrhosis who underwent an ERCP were included. The cohort had a mean age of 63.4 years, with a male predominance (65.3%) and various etiologies of cirrhosis, including alcohol-related (39.3%) and hepatitis C (11.4%). Post-ERCP complications occurred in 26.7% of patients. The most common complications were hepatic decompensation events (18.4%), sepsis (10.8%), and cholangitis (6.1%). Patients with complications had significantly higher baseline MELD scores, INR, chronic kidney disease (CKD) and history of ascites, hepatic encephalopathy, and hepatorenal syndrome (HRS). A Multivariate analysis revealed that factors such as higher MELD score, ascites, hepatic encephalopathy, and stent placement were associated with post-ERCP complications. Subgroup analyses indicated that patients who developed hepatic decompensation events (ascites, SBP, or HRS) had a more severe liver dysfunction at baseline, as reflected by a higher MELD score and INR, and prior episodes of ascites and hepatic encephalopathy.
CONCLUSION: Pre-procedural liver function parameters and procedural factors are crucial predictors of post-ERCP hepatic decompensation in patients with cirrhosis. Key risk factors include higher MELD score, CKD, history of ascites, and hepatic encephalopathy. Careful pre-procedural evaluation and management are essential to reduce these risks
Benign Tracheal Stenosis and Subglottic Stenosis
No full textLaryngotracheal stenosis is a narrowing of the proximal airways that can result in significant respiratory ailments. It can occur due to various causes, including iatrogenic causes such as intubation and tracheostomy, inflammatory conditions, and infections. This article aims to provide an overview of benign tracheal and subglottic stenosis, including its diagnosis, etiology, and available management strategies
Perception of Lemborexant Effectiveness as Assessed by the Patient Global Impression-Insomnia Questionnaire
No full textOBJECTIVE: Using data from a clinical study of lemborexant, evaluate responses to the Patient Global Impression-Insomnia (PGI-I) questionnaire, a simple 4-item questionnaire that assesses patients\u27 perceptions of the effects of medication on sleep, which may help evaluate clinically meaningful changes from the patient\u27s perspective.
METHODS: Study E2006-G001-303, a 12-month, placebo (PBO)-controlled (first 6 months) Phase 3 study in adults with insomnia disorder, randomized subjects (1:1:1) to lemborexant 5 mg (LEM5; n=316), 10 mg (LEM10; n=315), or PBO (n=318). The second 6 months are not presented here. PGI-I results were analyzed post hoc in relation to patient-reported (subjective) sleep-onset latency (sSOL) and total-sleep-time (sTST).
RESULTS: At 6 months: 67.3% (LEM5) and 68.8% (LEM10) of subjects reported positive effects of medication helping them sleep versus 45.0% (both p\u3c 0.0001) with PBO. Positive effects on time to fall asleep were reported by 72.8% (LEM5) and 73.1% (LEM10) versus 46.1% with PBO (p\u3c 0.0001), and 58.0% (LEM5) and 62.0% (LEM10) reported positive effects on sleep duration versus 39.9% with PBO (p\u3c 0.0001). Subjects reporting positive effects on time to fall asleep had greater change from baseline (CFB; improvement) at 6 months in median sSOL (in minutes; LEM5= -26.8; LEM10= -32.1; PBO= -17.5; p\u3c 0.01) versus those reporting negative effects (LEM5= -9.1; LEM10= -10.4; PBO= -8.6; LEM5 vs PBO, p=0.52; LEM10 vs PBO, p=0.69). For sTST (in minutes) at 6 months, mean CFB tended to be greater for subjects reporting positive (LEM5=81.2, LEM10=93.2, PBO=74.8; LEM5 vs PBO, p=0.28; LEM10 vs PBO, p=0.18) versus negative (LEM5=46.4, LEM10=35.0, PBO=38.6; LEM5 vs PBO, p=0.44; LEM10 vs PBO, p=0.52) effects, although this was not statistically significant.
CONCLUSION: Patient impressions of the effects of lemborexant were positive based on the PGI-I and reflected improvements in subjective sleep outcome measures, indicating that the brief PGI-I tool may be useful in clinical practice. People with chronic insomnia, a common sleep disorder, have trouble falling asleep and/or staying asleep 3 or more times per week for at least 3 months. Insomnia treatments should improve sleep when measured objectively but should also improve sleep from the patient’s perspective. The Patient Global Impression–Insomnia (PGI-I) is a simple 4-item questionnaire that assesses a patient’s perceived efficacy of their sleep medication. Lemborexant is a medicine used to treat insomnia. This study evaluated the patient’s view of the success of lemborexant treatment over time. There were 316, 315, and 318 people with chronic insomnia in the lemborexant 5 mg, lemborexant 10 mg, and no active treatment (placebo) groups, respectively, in this study. People treated with lemborexant reported more positive views of their medication on the PGI-I compared with those treated with placebo. These positive impressions of lemborexant on the PGI-I were associated with improvements in related subjective measurements of sleep. These results indicate that the PGI-I is a tool that may help assess whether an insomnia treatment is working from the patient’s viewpoint
Combined neoadjuvant and adjuvant therapy versus adjuvant therapy in high-risk upper tract urothelial carcinoma: a propensity matched multicenter analysis (ROBUUST 2.0 International Collaborative Group)
No full textINTRODUCTION: The efficacy of combined neoadjuvant and adjuvant therapy (CNAT) in upper tract urothelial carcinoma (UTUC) remains unclear despite its demonstrated potential in bladder urothelial carcinoma. High-risk features- clinical stage ≥ T3, node-positive disease, multifocality, high-grade pathology, hydronephrosis, and large tumor size - are associated with poor prognosis in UTUC. We investigated the oncological outcomes of CNAT versus adjuvant therapy (AT) alone in high-risk UTUC patients.
MATERIALS AND METHODS: We analyzed perioperative data from 2433 patients with UTUC (2015-2023) across 17 centers in the US, Europe, and Asia. Propensity score matching was performed using preoperative clinical T and N stages. Kaplan-Meier curves and Cox proportional hazards models were used to evaluate overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), and metastasis-free survival (MFS).
RESULTS: Among 285 high-risk UTUC patients, 76 matched patients (38 CNAT, 38 AT) were analyzed after matching, with a median follow-up of 15 months. CNAT and AT groups had comparable oncological outcomes: 2-year OS (72.9% vs. 71.8%; p = 0.89), CSS (76.7% vs. 75.3%; p = 0.92), RFS (30.1% vs. 39%; p = 0.97), or MFS (45.5% vs. 44.7%; p = 0.91), respectively. Cox regression showed no significant survival benefit of CNAT over AT after adjusting for clinical and pathological factors (HR for OS: 1.06; p = 0.9).
CONCLUSION: In this large multicenter international cohort, our findings suggest that CNAT does not provide a clear advantage over AT alone in patients with high-risk UTUC. Prospective randomized trials are needed to clarify the role of multimodal therapy in UTUC management
Association between intravenous 5 % albumin administration and acute kidney injury after partial nephrectomy. A retrospective study
No full textBACKGROUND: Acute kidney injury (AKI) after partial nephrectomy is a frequent postoperative complication that can affect nearly half of patients, according to various studies. In the current study, we investigated the association of intraoperative administration of 5 % albumin, compared with crystalloids alone, with AKI after partial nephrectomy.
METHODS: This single-center retrospective study included adult patients undergoing partial nephrectomy. The primary endpoint was AKI within 72 h after surgery using the KIDGO definition. Secondary endpoints were time-to-AKI, reoperations, AKI severity and length of hospital stay. We used propensity score-based nearest-neighbor methods balance the patient baseline characteristics.
RESULTS: A total of 1688 patients were included in the analysis, with 809 receiving 5 % albumin and 879 in the control group. After matching, 729 patients received 5 % albumin, while 674 were controls. The incidence of acute kidney injury (AKI) was significantly higher in the 5 % albumin group (32.78 %) compared to the control group (25.51 %). Multivariate analysis revealed that receiving 5 % albumin was associated with a 32 % increased risk of developing AKI. Furthermore, the analysis indicated that this association was dose-dependent.
CONCLUSION: Our study suggests that intraoperative administration of 5 % albumin may not be a risk factor for AKI after partial nephrectomy. Given the discrepancy between these results and previous studies, a future prospective randomized controlled trial is needed to confirm our findings