Clinical Update Research Articles

Responding to a Behavioral Health Crisis: Applying a New Care Model in the Emergency Department.

Emergency department (ED) visits for behavioral health (BH) emergencies continue to rise, and institutions across the country encounter barriers and struggle to put BH processes in place to address their needs. After learning of an unanticipated closure of a local psychiatric crisis response center (CRC), our ED implemented quality improvement interventions to respond to an acute surge of BH patients. Interventions included an enhanced BH database, the role of social workers as extenders, shared electronic health record documentation, increased staffing, clinical pathway updates, and processes to improve communication. We aimed to develop a care model to maintain safe care with timely evaluation and patient disposition despite an anticipated surge of ED patients. After the CRC closure, 7383 patients met our cohort definition over 18 months, whereas 4326 patients met the cohort definition in the 18 months prior the CRC closure. Of the total patients seen in the study period, 42% were evaluated by the ED team with psychiatry and social work, and the median length of stay for discharged patients evaluated by this team decreased from 4.2 hours to 3.5 hours after CRC closure. A multifaceted approach allowed our ED to successfully respond to an unexpected surge of BH patients. Other institutions may be able to apply a population health and quality improvement approach when addressing the rising prevalence of ED BH visits. Future studies and practices should explore the optimal role of the acute care setting in the continuum of care of these patients.

Giant Congenital Melanocytic Nevi of the Head and Neck: Clinical Update and Advances in Treatment

Introduction: Giant congenital melanocytic nevi are rare lesions of various size, shape, color, and location with potential complications including malignant and neurocutaneous melanoma. Here we discuss the etiology and epidemiology of giant congenital melanocytic nevi, the indications and options for treatment, and current data regarding outcomes, as well as our preferred approach to patient management. Methods: Full text case reports, retrospective studies, prospective studies, clinical trials, and review articles regarding giant congenital melanocytic nevi in English were included in this analysis utilizing PubMed, MEDLINE, EMBASE, and Google scholar databases. Results: Giant congenital melanocytic nevi pose a difficult diagnostic and reconstructive challenge for the plastic surgeon. Indications for treatment depend on the size of the nevus, pigmentation, established melanoma, persistent symptoms, maintenance of function, and psychological burden. A multidisciplinary approach should be applied to establish an individualized treatment plan for patients with giant congenital melanocytic nevi. Numerous surgical and nonexcisional options have been illustrated for the management of these lesions. Chemical peels and laser ablation are among the most common non-surgical approaches. When considering surgical treatment for lesions with malignant potential, a multimodal approach is generally employed, including serial excision, excision with skin grafting and/or skin substitutes, and tissue expansion. Conclusion: A proper understanding of the disease’s histology, natural history, complications, and treatment options are essential in the management of these complex lesions.

Canine Distemper, Clinical Update, Based on our Medical Experience and Scientific Evidence

Canine Distemper, Clinical Update, Based on our Medical Experience and Scientific Evidence

Moral injury and psychiatrists in public community mental health services.

This study aims to provide a clinical update on moral injury from the perspective of a public sector community psychiatrist, and to outline approaches to addressing the issues raised. Although not considered a mental illness, moral injury is an important condition for psychiatrists to have an awareness of, as it is associated with psychological distress and/or impairments in emotional, social or behavioural functioning. Potentially morally injurious events (PMIEs) for community psychiatrists may include staff shortages and deficient resources rendering it difficult to provide an acceptable standard of professional care; time constraints negatively impacting teaching, supervising and mentoring medical students; cost-prohibition regarding preferred medication choices; lack of gender and cultural diversity of available psychiatrists; and work environments not conducive to psychiatrists speaking out about their concerns. The COVID-19 pandemic has exposed and exacerbated PMIEs for some community psychiatrists. Whether or not a PMIE transitions to a moral injury may be influenced by the individual's resilience and the quality of emotional, psychological and administrative support they receive before, during and after the potentially precipitating event. Preventative strategies to mitigate susceptibility to a moral injury may be implemented at both a systems level and individual level, and include collective healthcare advocacy action.

Clinical Updates in Mucositis-Related Symptom Management.

To provide an overview with the most up-to-date evidence on the management of cancer-treatment related mucositis. Peer-reviewed articles, textbooks, and the internet. A multitude of new and innovative treatments for the management of mucositis exist. Mucositis guidelines have changed to reflect the current evidence, but more research is needed on emerging modalities. Oncology nurses have a primary role in the assessment and early identification of mucositis. Educating patients and recommending evidence-based guidelines is paramount in preventing and ameliorating this challenging side effect of treatment.

Clinical Updates in Nausea and Vomiting.

To review recent updated antiemetic guidelines from national cancer organizations and its impact on chemotherapy-induced nausea and vomiting (CINV) in the prevention and delayed phase of therapy. This article will also describe assessment and nursing strategies for individualized care and timely side effect management. Data sources include peer-reviewed articles sourced in electronic databases. CINV is a persistent problem for a large percentage of patients undergoing chemotherapy treatment despite advances in antiemetic therapy and increased use of targeted therapies. CINV management should be based on patient-focused assessment and adherence to national antiemetic guidelines. Ongoing assessment and follow-up are critical to ensure optimum management of side effects to optimized quality of life. Awareness of national antiemetic guidelines is important in caring for patients undergoing chemotherapy. CINV can have a significant impact on patients, causing physical effects, treatment delays, and diminished quality of life. Oncology nurses play a key role in assessment of patient-related risk factors, education of patients and caregivers regarding pain medications, side effects, and oral adherence and continued follow-up for early recognition and intervention for uncontrolled CINV.

Clinical Practice Guideline: Tympanostomy Tubes in Children (Update).

Clinical Practice Guideline: Tympanostomy Tubes in Children (Update).

Sonographic diagnostics in the head and neck area, part 2 - transcervical sonography

Transcervical sonography has become an integral part of the diagnostic spectrum of otorhinolaryngology, as evidenced by its firm inclusion in continuing education catalogs and guidelines. For these reasons, the user should be aware of a basic understanding of ultrasound physics and of technical innovations. A standardized examination scheme with structured reporting and documentation is an elementary prerequisite to meet the daily clinical challenges and to be able to answer specific questions. In this educational article, we span from an introduction to structured examination techniques to a clinical update on sonography of the cephalic glands and cervical lymph nodes.

Clinical Update on Patient-Controlled Analgesia for Acute Postoperative Pain.

Patient-controlled analgesia (PCA) is an effective method for controlling acute pain, including postoperative pain in adults and in children from five years of age, pain resulting from labor, trauma, or other medical situations, or chronic and malignant pain. The treatment consists of a mini-computer-controlled infusion pump permitting the administration of on-demand, continuous, or combined doses of analgesic (mainly opioid) variations in response to therapy, which allows pain to be significantly controlled. Intravenous (IV)-PCA minimizes individual pharmacodynamics and pharmacokinetic differences and is widely accepted as a reference method for mild or severe postoperative pain. IV-PCA is the most studied route of PCA; other delivery methods have been extensively reported in the literature. In addition, IV-PCA usually voids the gap between pain sensation and analgesic administration, permitting better recovery and fewer side effects. The most commonly observed complications are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention. However, human factors such as pharmacy preparation and device programming can also be involved in the occurrence of these complications, while device failure is much less of an issue.

BCMA targeting CAR T cells using a novel D-domain binder for multiple myeloma: clinical development update

Relapsed and refractory multiple myeloma patients have poor prognoses and limited treatment options even with the recent FDA approval of idecabtagene vicleucel. Idecabtagene vicleucel joins four other US FDA approved chimeric antigen receptor T cell therapies each with promising efficacy and response rates across various hematological malignancies. Notwithstanding the early success of chimeric antigen receptor T therapies, there remain many challenges that warrant further development of chimeric antigen receptor T structure and function as they relate to durability of response, T cell exhaustion due to tonic signaling, immunogenicity, manufacturing-related limitations, and incidence of serious adverse events including cytokine release syndrome and immune effector cell associated neurotoxicity syndrome. D-domain based chimeric antigen receptor T cells are a new class of structurally and functionally distinct cell therapies that represent an alternative to conventional single-chain variable fragment based chimeric antigen receptor T cells. Preclinical studies of a D-domain based targeting B cell maturation antigen (CART-ddBCMA) have demonstrated effective anti-tumor response in both&nbsp;<em>in vitro</em>&nbsp;and tumor models. These studies currently support a first-in-human clinical study of CART-ddBCMA in multiple myeloma patients. Interim Phase 1 data presented at American Society of Hematology 2021 Annual Meeting further demonstrates the promising potential of CART-ddBCMA cells in the treatment of multiple myeloma. Herein, we present an overview of chimeric antigen receptor T cell therapies including challenges in chimeric antigen receptor T therapies, advances in CAR design, structural and functional properties of novel D domain-based chimeric antigen receptor T cells, and an update on the development of CART-ddBCMA in multiple myeloma patients.

The National Blood Shortage-An Impetus for Change.

The National Blood Shortage-An Impetus for Change.

Clinical update on COVID-19 for the emergency clinician: Presentation and evaluation.

IntroductionCoronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved.ObjectiveThis first in a two-part series on COVID-19 updates provides a focused overview of the presentation and evaluation of COVID-19 for emergency clinicians.DiscussionCOVID-19, caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality worldwide. Several variants exist, including a variant of concern known as Delta (B.1.617.2 lineage) and the Omicron variant (B.1.1.529 lineage). The Delta variant is associated with higher infectivity and poor patient outcomes, and the Omicron variant has resulted in a significant increase in infections. While over 80% of patients experience mild symptoms, a significant proportion can be critically ill, including those who are older and those with comorbidities. Upper respiratory symptoms, fever, and changes in taste/smell remain the most common presenting symptoms. Extrapulmonary complications are numerous and may be severe, including the cardiovascular, neurologic, gastrointestinal, and dermatologic systems. Emergency department evaluation includes focused testing for COVID-19 and assessment of end-organ injury. Imaging may include chest radiography, computed tomography, or ultrasound. Several risk scores may assist in prognostication, including the 4C (Coronavirus Clinical Characterisation Consortium) score, quick COVID Severity Index (qCSI), NEWS2, and the PRIEST score, but these should only supplement and not replace clinical judgment.ConclusionThis review provides a focused update of the presentation and evaluation of COVID-19 for emergency clinicians.

Clinical Research Updates.

Clinical Research Updates.

A Review of Current Clinical Concepts in the Pathophysiology, Etiology, Diagnosis, and Management of Hypercalcemia.

Calcium is the most abundant extracellular cation in the body, and it is responsible for structural and enzymatic functions. Calcium homeostasis is regulated by 3 factors: calcitonin, vitamin D, and parathyroid hormone (PTH). Hypercalcemia is defined by a serum calcium concentration >10.5 mg/dL, and it is classified into mild, moderate, and severe, depending on calcium values. Most cases are caused by primary hyperparathyroidism and malignancies. Various mechanisms are involved in the pathophysiology of hypercalcemia, such as excessive PTH production, production of parathyroid hormone-related protein (PTHrp), bone metastasis, extrarenal activation of vitamin D, and ectopic PTH secretion. The initial approach is similar in most cases, but a definitive treatment depends on etiology, that is why etiological investigation is mandatory in all cases. The majority of patients are asymptomatic and diagnosed during routine exams; only a small percentage of patients present with severe manifestations which can affect neurological, muscular, gastrointestinal, renal, and cardiovascular systems. Clinical manifestations are related to calcium levels, with higher values leading to more pronounced symptoms. Critically ill patients should receive treatment as soon as diagnosis is made. Initial treatment involves vigorous intravenous hydration and drugs to reduce bone resorption such as bisphosphonates and, more recently, denosumab, in refractory cases; also, corticosteroids and calcitonin can be used in specific cases. This review aims to provide a clinical update on current concepts of the pathophysiology of calcium homeostasis, epidemiology, screening, clinical presentation, diagnosis, and management of hypercalcemia.

Clinical update in critical care of pulmonary medicine 2021

In this review, we outlined the clinical studies in critical care field of pulmonary medicine from November 1, 2020 to September 30, 2021. A Chinese retrospective study for critically ill patients with COVID-19 showed that corticosteroid therapy was associated with a reduced 28-day mortality in patients with the hyperinflammatory phenotype. In hospitalized patients with COVID-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization, and early sedation with dexmedetomidine exhibited a high probability of reduced 90-day mortality in older patients regardless of operative or non-operative cluster status. High-flow nasal cannula (HFNC) improved the prognosis compared with conventional oxygen therapy in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients with acute compensated hypercapnic respiratory failure. For COVID-19 patients suffering from acute respiratory failure with HFNC therapy, awake prone positioning reduces the incidence of treatment failure and the need for intubation. Compared with pressure-volume curve guiding positive end-expiratory pressure (PEEP) titration for acute respiratory distress syndrome (ARDS) patients, PEEP titration guided with EIT (Electrical impedance tomography) might be associated with improved driving pressure and survival rate. Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe ARDS patients, but the survival among ECMO-assisted patients with COVID-19 is strongly associated with a centre's experience in ECMO during the previous year and early ECMO management. Compared to conventional lung-protective mechanical ventilation (MV), neurally adjusted ventilatory assist (NAVA) decreased duration of MV. These findings also provide evidence for improving the clinical management in critical care of pulmonary medicine.

Pharmacotherapy of Painful Diabetic Neuropathy: A Clinical Update.

The rising prevalence of diabetes mellitus (DM) leads on to an increase in chronic diabetic complications. Diabetic peripheral neuropathies (DPNs) are common chronic complications of diabetes. Distal symmetric polyneuropathy is the most prevalent form. Most patients with DPN will remain pain-free; however, painful DPN (PDPN) occurs in 6–34% of all DM patients and is associated with reduced health-related-quality-of-life and substantial economic burden. Symptomatic treatment of PDPN and diabetic autonomic neuropathy is the key treatment goals. Using certain patient related characteristics, subjects with PDPN can be stratified and assigned targeted therapies to produce better pain outcomes. The aim of this review is to discuss the various pathogenetic mechanisms of DPN with special reference to the mechanisms leading to PDPN and the various pharmacological and non-pharmacological therapies available for its management. Recommended pharmacological therapies include anticonvulsants, antidepressants, opioid analgesics, and topical medications.

A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock.

This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.

Low Intensity Pulsating Electromagnetic Field as an Adjunctive Therapy for Bone Regeneration around Fractures, Dental Implants and Orthodontic Therapy- A Clinical Update

Low Intensity Pulsating Electromagnetic Field as an Adjunctive Therapy for Bone Regeneration around Fractures, Dental Implants and Orthodontic Therapy- A Clinical Update

Synthetic opioids: a review and clinical update.

The term 'opioids' refers to both the natural compounds ('opiates') which are extracted from the opium poppy plant (Papaver somniferum) and their semi-synthetic and synthetic derivatives. They all possess relatively similar biochemical profiles and interact with the opioid receptors within the human body to produce a wide range of physiological effects. They have historically been used for medicinal purposes, their analgesic and sedative effects, and in the management of chronic and severe pain. They have also been used for non-medicinal and recreational purposes to produce feelings of relaxation, euphoria and well-being. Over the last decade, the emergence of an illegal market in new synthetic opioids has become a major global public health issue, associated with a substantial increase in unintentional overdoses and drug-related deaths. Synthetic opioids include fentanyl, its analogues and emerging non-fentanyl opioids. Their popularity relates to changes in criminal markets, pricing, potency, availability compared to classic opioids, ease of transport and use, rapid effect and lack of detection by conventional testing technologies. This article expands on our previous review on new psychoactive substances. We now provide a more in-depth review on synthetic opioids and explore the current challenges faced by people who use drugs, healthcare professionals, and global public health systems.

Knowledge and Attitude Towards Radiation Hazards and Protection among Dental Students in Latur, Maharashtra, India: A Cross-sectional Study

Introduction: In our day-to-day clinical practice, X-radiation plays a vital role in oral diagnosis and treatment planning in dentistry. However, radiations are harmful and cause biological damage to the human body. Hence to have the benefits outweigh the risks, it is essential to inculcate awareness regarding radiation protection measures among the dental students. Aim: To evaluate the knowledge and attitude towards radiation hazards and protection among the dental students. Materials and Methods: A cross-sectional study was conducted on 200 randomly selected undergraduate including final year and third year dental students and interns, who had completed their 30 days rotatory posting in the Department of Oral Medicine and Radiology in Maharashtra Institute of Dental Science and Research, Latur, Maharashtra, India from the month February to July 2021. A prevalidated close ended questionnaire consisting of 25 questions was distributed among the students and data were collected and analysed using the Chi-square test. The p-value was set significant at 0.05. Results: Out of 200 student participants, 91 (45.5%) were interns, 71 (35.5%) were final year students and 38 (19%) were third year students. The response of these participants was found to be non uniform and the knowledge and attitude towards radiation hazards and protection was highest in dental interns followed by final and third year students. Conclusion: It is the need of hour to create awareness among dental students about radiation protection and safety in day-today clinical practice and update their knowledge by conducting relevant workshops.