Recovery In Adult Patients Research Articles

Sufentanil Sublingual Tablet System vs. Intravenous Patient-Controlled Analgesia with Morphine: Postoperative Pain Control and Its Impact in Quality of Recovery.

Patient-controlled analgesia (PCA) is commonly used for postoperative pain control. Although widely used, intravenous (IV) morphine PCA may not be suitable for all patients. Sufentanil sublingual tablet system (SSTS) PCA is a recent technique that has had success as a safe and effective alternative for acute pain management. This study aims to compare both the efficacy and safety of SSTS PCA versus IV morphine PCA in postoperative pain control and the quality of recovery in adult patients following scheduled gynecological or orthopedic surgery. Open-label, parallel-group, randomized controlled trial with 54 patients. The primary outcome was postoperative pain control, while the secondary outcomes included adverse effects associated with two analgesic modalities, total opioid dose required, patient satisfaction, and impact on the quality of postoperative recovery. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). The chi-squared test was used in categorical variables. When distribution was normal, T-student (mean ± standard deviation) was used in continuous variables. In contrast, when distribution was not normal, the Mann-Whitney test (median (minimal-maximal)) was used. The results showed that there was a statistically significant difference in the total dose of opioid used by patients at 24 hours postoperatively, with patients receiving SSTS PCA requiring a higher total dose when compared to those receiving IV morphine PCA. However, there were no statistically significant differences in pain scores, adverse events, or patient satisfaction. The study suggests that both IV morphine and sublingual sufentanil are safe and effective for postoperative pain management.

Quantifying Patient-Initiated Upper Extremity Movement After Surgical Reconstruction for Adult Pan-Brachial Plexus Injury.

Determining functional recovery in adult patients with traumatic pan-brachial plexus injury (pBPI) is hampered by the fact that most outcome measures are collected in the clinical setting and may not reflect arm use in the real world. This study's objectives were to demonstrate the feasibility of using wearable motion sensor technology to quantify spontaneous arm movement in adult patients with pBPI after surgical reconstruction and report the time and intensity with which the affected arm was used. Twenty-nine patients with pBPI who underwent surgical reconstruction at least 2 years prior were included in this study. Study participants wore an accelerometer on bilateral arms for 7 days. The vector time (VT) and magnitude with which each arm moved were collected and divided by the same values collected from the uninjured arm to generate a ratio (VT and vector magnitude [VM], respectively) to quantify differences between the arms. Correlations between VT, VM, and patient demographic and physician-elicited clinical measures were calculated. Patients were enrolled at Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan, and data analysis was performed at the University of Michigan. Twelve patients had pan-avulsion injuries, and 17 patients had C5 rupture with C6-T1 avulsion injuries. All underwent nerve reconstruction with contralateral C7 or ipsilateral C5 nerve roots as donors. At mean 7.3 years after surgery, the mean VT ratio was 0.54 ± 0.13 and the mean VM ratio was 0.30 ± 0.13. Both VT and VM ratios were significantly correlated with patient employment and movements at the elbow and forearm. Wearable motion detection technology can capture spontaneous, real-world movements of the arm in patients who have undergone surgical reconstruction for pBPI. Despite severe injuries, these patients are able to use their affected arm 50% of the time and with 30% of the intensity of their unaffected arm, which is positively correlated with return to work after injury. These data support the use of surgical reconstruction for pBPI.

Ultrasound-guided erector spinae plane block versus port site infiltration for postoperative pain and quality of recovery in adult patients undergoing laparoscopic cholecystectomy: An assessor-blinded randomised controlled trial.

Pain following laparoscopic cholecystectomy (LC) is common and results in poor quality of recovery. Our study aimed to compare the analgesic efficacy of port site local infiltration, novel erector spinae plane (ESP) block, and standard regimen in patients undergoing LC and its impact on functional recovery. After ethical approval and registering the trial, we randomly allocated 105 adult patients undergoing LC to three groups: Group I (n = 35), received multimodal analgesia; Group II (n = 35), received pre-incisional port site infiltration with 20 ml of 0.375% bupivacaine; and Group III (n = 35), preoperative bilateral ESP block with 20 ml of 0.375% bupivacaine bilaterally was administered. Pain severity, fentanyl consumption, and time to first rescue analgesia were recorded over 24 h. Quality of recovery (QoR-15) was assessed at baseline and 24 h postoperatively. Pain in the first 6 h was lowest in the ESP group (P < 0.001). Although static pain in the infiltration group was comparable with that in the ESP group after 6 h (P > 0.05), dynamic pain was better in the ESP group till 20 h postoperatively (P < 0.05). Fentanyl consumption was significantly lower in the ESP group (P < 0.001). Global and sub-dimensional QoR-15 scores were significantly higher only in the ESP group at 24 h compared to the other two groups (P < 0.001). The infiltration group did better than the control group in terms of total opioid requirement (P < 0.001) and Visual Analogue Scale (VAS) score after 6 h (P < 0.001). ESP block provided lower postoperative pain scores with opioid-sparing and better quality of recovery in patients undergoing LC.

Nutritional status of patients with COVID-19 1-y post-ICU stay: A prospective observational study

ObjectivesPatients discharged from the intensive care unit (ICU) often experience physical complaints and poor nutritional intake, which negatively affect their nutritional status (NS). The aim of this study was to describe the NS of patients with COVID-19 1-y post-ICU stay. MethodsThis was an observational study of adult patients with COVID-19 1-y post-ICU stay. NS assessment (nutrient balance, body composition, and physical status) was performed. We examined nutritional intake and nutrition-related complaints. Nutritional requirements were determined with indirect calorimetry and body composition with bioelectrical impedance. Fat-free mass index (FFMI) and fat mass index (FMI) were calculated. Physical status was determined using handgrip strength, the 6-min walk test, and the 1-min sit-to-stand test. Descriptive statistics and paired sample t tests were used for analysis. ResultsWe included 48 patients (73% men; median age 60 y [IQR 52;65]). Median weight loss during the ICU stay was 13%. One-y post-ICU stay, 12% of weight was regained. Median body mass index was 26 kg/m2 and 23% of the patients were obese (body mass index >30 kg/m2 and high FMI). Of the patients, 50% had high FMI and 19% had low FFMI. Median reported nutritional intake was 90% of measured resting energy expenditure. Nutrition-related complaints were seen in 16%. Percentages of normal values reached in physical tests were 92% of handgrip strength, 95% of 6-min walking distance, and 79% of 1-min sit-to-stand test. ConclusionsDespite almost fully regained weight and good physical recovery in adult patients 1-y post-ICU stay, NS remained impaired because of elevated FMI, even though reported nutritional intake was below the estimated requirements.

Predictors of slow responsiveness and partial mucosal recovery in adult patients with celiac disease.

The present study aims to determine the rate of mucosal recovery and predictors of persistent mucosal damage after gluten free diet (GFD). Celiac disease (CD) is a complex multi-systemic autoimmune disease triggered by exposure to dietary gluten in genetically predisposed individuals. There is still little evidence on the best method for assessing GFD adherence and mucosal recovery during treatment. The retrospective study included only adult patients (age≥18 years old), with biopsy-proven CD evaluated at a tertiary referral centre between 2016 and 2021. We performed a logistic regression analysis to identify factors associated with partial mucosal recovery (MR) after GFD. We included in the multivariate analysis parameters available at the time of CD diagnosis. A total of 102 patients were enrolled, two thirds were females, median age of 39 years (yrs). The initial biopsy analysis showed different stages of villous atrophy (VA) in 79 (77.4%) cases, while in 23(22.5%) cases showed mild enteropathy (Marsh 1, 2). After at least 12 months of GFD, 26 (25.5%) patients had persistent VA despite good or excellent adherence to GFD. Younger patients (< 35yrs), who showed severe mucosal damage (Marsh 3c lesions) and who had increased anti-gliadin antibody (AGA) levels were at risk for failure to obtain mucosal recovery (MR). Logistic regression analysis demonstrated that complete mucosal atrophy (P=0.007) and high AGA antibody levels (cutoff 129 U/ml, P=0.001) were independent risk factors for lack of mucosal improvement after at least 12 months of GFD. Interestingly, genotype, tTG-IgA antibody levels, or duration of GFD levels did not influence the occurrence of MR. Although AGA seropositivity has lost much of their diagnostic significance in recent years due to the introduction of the more sensitive and specific antibody tests, our study reported that patients aged < 35 yrs, who showed severe mucosal damage (Marsh 3c lesions) and who had increased AGA antibody levels at diagnosis were at risk for failure to obtain MR. The elevated AGA levels at diagnosis could be used as a prognostic tool for assessing MR.

Ganglion cell inner plexiform layer thickness measured by optical coherence tomography to predict visual outcome in chiasmal compression

We evaluated the prognostic value of the preoperative macular ganglion cell inner plexiform layer (mGCIPL) thickness along with peripapillary retinal nerve fiber layer (pRNFL) thickness measured by optical coherence tomography (OCT) and estimated an optimal cut-off value to predict postoperative visual field (VF) recovery in adult patients with chiasmal compression after decompression surgery. Two hundred forty eyes of 240 patients aged 20 years or older for which preoperative high-definition Cirrus OCT parameters and pre- and postoperative visual function data were available. The prognostic power of pRNFL and mGCIPL thicknesses for complete postoperative VF recovery or significant VF improvement (improvement ≥ 2 dB in the mean deviation) were assessed. The cut-off values for OCT parameters for VF recovery were estimated. The study found that the higher the preoperative pRNFL and mGCIPL thicknesses, the higher the probability of complete postoperative VF recovery (p = 0.0378 and p = 0.0051, respectively) or significant VF improvement (p = 0.0436 and p = 0.0177, respectively). The area under the receiver operating characteristic analysis of preoperative OCT parameters demonstrated that the mGCIPL thickness showed an area under the curve (AUC) of more than 0.7 for complete VF recovery after decompression surgery (AUC = 0.725, 95% CI: 0.655, 0.795), and the optimal mGCIPL thickness cut-off value for complete VF recovery was 77.25 µm (sensitivity 69% and specificity 69%). Preoperative mGCIPL thickness was a powerful predictor of visual functional outcome after decompression surgery for chiasmal compression.

Enhanced education for adult patients with persistent post-concussion headaches: a randomized controlled trial.

We conducted a randomized clinical trial to determine if an e-learning intervention can enhance recovery in adult patients with persistent post-concussion headaches (PPCH). The intervention consisted of three e-learning modules administered at baseline, 6 and 12 weeks. Data were collected on symptoms, community integration, quality of life and healthcare utilization at baseline and 12-week follow-up. ANCOVA was conducted to compare changes. No statistically significant difference was observed on symptoms although we observed a trend toward reduced healthcare utilization and improved quality of life in the intervention group. E-learning modules for patients experiencing PPCH warrant further investigation with data on participant compliance and measures focusing on simpler short-term outcomes.Clinical Trial Registration: NCT03391583 (ClinicalTrials.gov).

Effects of virtual reality in improving upper extremity function after stroke: A systematic review and meta-analysis of randomized controlled trials

Objective To investigate the effect of virtual reality on arm motor impairment, activity limitation, participation restriction, and quality of life in patients with stroke. To determine potential moderators that affect the efficacy of virtual reality. Data sources CINAHL, Medline, PubMed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang Data from inception to October 23, 2021. Review methods Randomized controlled trials that investigated the effect of virtual reality on arm recovery in adult patients with stroke compared to conventional therapy or sham control were included. Physiotherapy Evidence Database Scale was used to assess the methodological quality of each study. Results Forty studies with 2018 participants were identified. Quality of included studies was fair to high. Virtual reality exhibited better effects on overall arm function (g = 0.28, p < 0.001), motor impairment (g = 0.36, p < 0.001) and activity limitation (daily living) (g = 0.24, p < 0.001) compared with the control group. No significant improvement was observed in participation restriction and activity limitation (specific task). The result for quality of life was described qualitatively. Subgroup analyses demonstrated that immersive virtual reality produced a greater beneficial effect (g = 0.60, p < 0.001). Patients with moderate to severe arm paresis could make more progress after training (g = 0.71, p < 0.001). Conclusion Virtual reality is recommended for improving motor impairment and activities of daily living after stroke and is favorable to patients with moderate to severe paresis. An immersive design could produce greater improvement.

The effect of perioperative dexmedetomidine on postoperative bowel function recovery in adult patients receiving general anesthesia.

Dexmedetomidine has opioid sparing actions but its effect on bowel recovery is controversial. Primary aim of this review was to evaluate the effect of perioperative dexmedetomidine on postoperative bowel recovery. Secondary aim was to evaluate the effect of dexmedetomidine on hospital discharge. Randomized controlled trials in English language reporting any or all of the following parameters of bowel recovery; time to first bowel sounds, first flatus, first feces, or time to oral diet were included. Twelve hundred and thirty-five patients from 13 studies were analyzed. There were insufficient studies evaluating bowel sounds. Perioperative dexmedetomidine usage significantly reduced the time to first flatus [MD -5.61 h (95% CI: -8.61 to -2.60); P=0.0003; I2=95%], first feces [MD -12.70 h (95% CI: -19.11 to -6.29); P=0.0001; I2=76%] and the composite outcome of bowel recovery (flatus, feces, oral diet) [MD -7.44 h (95% CI: -10.31 to -4.57); P<0.00001; I2=96%]. No difference was seen in the time to oral diet [MD -6.29 h (95% CI: -13.48 to 0.91); P=0.09; I2=88%] or hospital discharge [MD -0.47 days (95% CI: -1.27 to 0.33); P=0.25; I2=86%]. Perioperative dexmedetomidine usage significantly shortens the time to first flatus, feces and composite bowel recovery but does not result in a shorter time to oral diet or earlier hospital discharge in adult patients receiving general anesthesia. Strength of evidence is however very low for the effect of dexmedetomidine on bowel recovery.

KTE-X19 for relapsed or refractory adult B-cell acute lymphoblastic leukaemia: phase 2 results of the single-arm, open-label, multicentre ZUMA-3 study

Despite treatment with novel therapies and allogeneic stem-cell transplant (allo-SCT) consolidation, outcomes in adult patients with relapsed or refractory B-precursor acute lymphoblastic leukaemia remain poor, underlining the need for more effective therapies. We report the pivotal phase 2 results of ZUMA-3, an international, multicentre, single-arm, open-label study evaluating the efficacy and safety of the autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy KTE-X19 in adult patients with relapsed or refractory B-precursor acute lymphoblastic leukaemia. Patients were enrolled at 25 sites in the USA, Canada, and Europe. Eligible patients were aged 18 years or older, with Eastern Cooperative Oncology Group performance status of 0-1, and morphological disease in the bone marrow (>5% blasts). After leukapheresis and conditioning chemotherapy, patients received a single KTE-X19 infusion (1 × 106 CAR T cells per kg bodyweight). The primary endpoint was the rate of overall complete remission or complete remission with incomplete haematological recovery by central assessment. Duration of remission and relapse-free survival, overall survival, minimal residual disease (MRD) negativity rate, and allo-SCT rate were assessed as secondary endpoints. Efficacy and safety analyses were done in the treated population (all patients who received a dose of KTE-X19). This study is registered with ClinicalTrials.gov, NCT02614066. Between Oct 1, 2018, and Oct 9, 2019, 71 patients were enrolled and underwent leukapheresis. KTE-X19 was successfully manufactured for 65 (92%) patients and administered to 55 (77%). The median age of treated patients was 40 years (IQR 28-52). At the median follow-up of 16·4 months (13·8-19·6), 39 patients (71%; 95% CI 57-82, p<0·0001) had complete remission or complete remission with incomplete haematological recovery, with 31 (56%) patients reaching complete remission. Median duration of remission was 12·8 months (95% CI 8·7-not estimable), median relapse-free survival was 11·6 months (2·7-15·5), and median overall survival was 18·2 months (15·9-not estimable). Among responders, the median overall survival was not reached, and 38 (97%) patients had MRD negativity. Ten (18%) patients received allo-SCT consolidation after KTE-X19 infusion. The most common adverse events of grade 3 or higher were anaemia (27 [49%] patients) and pyrexia (20 [36%] patients). 14 (25%) patients had infections of grade 3 or higher. Two grade 5 KTE-X19-related events occurred (brain herniation and septic shock). Cytokine release syndrome of grade 3 or higher occurred in 13 (24%) patients and neurological events of grade 3 or higher occurred in 14 (25%) patients. KTE-X19 showed a high rate of complete remission or complete remission with incomplete haematological recovery in adult patients with relapsed or refractory B-precursor acute lymphoblastic leukaemia, with the median overall survival not reached in responding patients, and a manageable safety profile. These findings indicate that KTE-X19 has the potential to confer long-term clinical benefit to these patients. Kite, a Gilead Company.

CD19 CAR T cells for adults with relapsed or refractory acute lymphoblastic leukaemia

CD19-directed chimeric antigen receptor (CAR) T cells first showed potency in adults with chronic lymphocytic leukaemia 1 Porter DL Levine BL Kalos M Bagg A June CH Chimeric antigen receptor-modified T cells in chronic lymphoid leukemia. N Engl J Med. 2011; 365: 725-733 Crossref PubMed Scopus (2417) Google Scholar and with acute lymphoblastic leukaemia 2 Brentjens RJ Davila ML Riviere I et al. CD19-targeted T cells rapidly induce molecular remissions in adults with chemotherapy-refractory acute lymphoblastic leukemia. Sci Transl Med. 2013; 5177ra38 Crossref PubMed Scopus (1390) Google Scholar a decade ago, but clinical development of CAR T cells in these two disease populations stalled. Chronic lymphocytic leukaemia did not respond to CAR T cells as frequently as hoped, in part because of challenges with making the product from patients whose T cells were not as fit, either due to the underlying disease or exposure to years of chemotherapy. 3 Porter DL Hwang WT Frey NV et al. Chimeric antigen receptor T cells persist and induce sustained remissions in relapsed refractory chronic lymphocytic leukemia. Sci Transl Med. 2015; 7303ra139 Crossref PubMed Scopus (1024) Google Scholar , 4 Frey NV Gill S Hexner EO et al. Long-term outcomes from a randomized dose optimization study of chimeric antigen receptor modified T cells in relapsed chronic lymphocytic leukemia. J Clin Oncol. 2020; 38: 2862-2871 Crossref PubMed Scopus (36) Google Scholar In adults with acute lymphoblastic leukaemia, severe toxic effects led to delays in order to test modified dosing strategies, 5 Frey NV Shaw PA Hexner EO et al. Optimizing chimeric antigen receptor T-cell therapy for adults with acute lymphoblastic leukemia. J Clin Oncol. 2020; 38: 415-422 Crossref PubMed Scopus (65) Google Scholar or even complete halting of trials. 6 Cancer DiscoveryJCAR015 in ALL: a root-cause investigation. Cancer Discov. 2018; 8: 4-5 Google Scholar The toxic effects were a result of the high potency of CAR T cells, which led to remarkable cytokine elevations and permeability of the blood–brain barrier that resulted in cerebral oedema in a series of high-profile cases. 6 Cancer DiscoveryJCAR015 in ALL: a root-cause investigation. Cancer Discov. 2018; 8: 4-5 Google Scholar Toxicity seemed to be particularly lethal with more chemotherapy lymphodepletion, with CAR T cells bearing the CD28 costimulatory signalling domain (so-called sprinter CAR T cells) or in the setting of a coincident infection, which is a fairly frequent occurrence in this patient population. Children and young adults with relapsed or refractory acute lymphoblastic leukaemia seemed to tolerate these cytokine elevations much better than adults, 7 Grupp SA Kalos M Barrett D et al. Chimeric antigen receptor-modified T cells for acute lymphoid leukemia. N Engl J Med. 2013; 368: 1509-1518 Crossref PubMed Scopus (2268) Google Scholar and the first pivotal study and approval from the US Food and Drug Administration (FDA) were secured in this population with a CAR T-cell product (tisagenlecleucel) bearing the 4-1BB costimulatory domain (so-called marathoner CAR T cells). 8 Maude SL Laetsch TW Buechner J et al. Tisagenlecleucel in children and young adults with B-cell lymphoblastic leukemia. N Engl J Med. 2018; 378: 439-448 Crossref PubMed Scopus (1950) Google Scholar The FDA has since approved both CD28-bearing and 4-1BB-bearing CAR T cells targeting the CD19 antigen for adults with large-cell lymphoma (CD28-bearing: axicabtagene cilolecuel; 4-1BB-bearing: tisagenlecleucel and lisocabtagene maraleucel), mantle cell lymphoma (CD28-bearing: brexucabtagene autoleucel), and follicular lymphoma (CD28-bearing: axicabtagene cilolecuel). KTE-X19 for relapsed or refractory adult B-cell acute lymphoblastic leukaemia: phase 2 results of the single-arm, open-label, multicentre ZUMA-3 studyKTE-X19 showed a high rate of complete remission or complete remission with incomplete haematological recovery in adult patients with relapsed or refractory B-precursor acute lymphoblastic leukaemia, with the median overall survival not reached in responding patients, and a manageable safety profile. These findings indicate that KTE-X19 has the potential to confer long-term clinical benefit to these patients. Full-Text PDF

Does erector spinae plane block result in improved postoperative analgesia and enhanced recovery in adult patients after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether erector spinae plane block (ESPB) resulted in improved postoperative analgesia and enhanced recovery in adult cardiac surgical patients. A total of 333 papers were found using the reported search of which, 7 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient groups studied, study type, relevant outcomes and results of these papers are tabulated. The cardiac surgical procedures included off-pump coronary artery bypass surgery (1 study), mitral/tricuspid valve repair (1 study), robotic minimally invasive coronary artery bypass surgery (1 study) and other cardiac surgeries (4 studies). ESPB was compared to intravenous analgesia (5 studies), thoracic epidural analgesia (1 study) and serratus anterior plane block and paravertebral block (1 study). With ESPB, there was significant improvement in postoperative pain scores (4 studies), decreased opioid requirement/rescue analgesia (3 studies), increased duration of analgesia (1 study), decreased time to extubation (3 studies), less increase in postoperative Troponin T (1 study), earlier ambulation (2 studies), earlier oral intake (1 study), earlier chest drain removal (1 study), better patient satisfaction (1 study), reduced adverse events (1 study) and decreased intensive care unit stay (3 studies). We conclude that ESPB may be associated with improved postoperative analgesia and enhanced recovery after adult cardiac surgery based on the available evidence. However, there is a need for better quality randomized controlled trials to consolidate these findings.

Remdesivir Reduces Time to Recovery in Adults Hospitalized With COVID-19: A Meaningful Step in Therapeutic Discovery

J H Beigel et al conduct a study to examine the clinical efficacy and safety of remdesivir in hospitalized adults with laboratory-confirmed COVID-19 and with evidence of lower respiratory tract involvement The double-blinded, randomized, placebo-controlled, multicenter trial took place between Feb 21, 2020 and Apr 19, 2020 at 60 trial sites and 13 subsites in the US, Denmark, the UK, Greece, Germany, Korea, Mexico, Spain, Japan, and Singapore Participants had evidence of lower respiratory tract infection at the time of enrolment The study found that remdesivir, compared to placebo, significantly shortened time to recovery in adult patients hospitalized with COVID-19 who had evidence of lower respiratory tract infection

Prognostic factors for heart recovery in adult patients with acute fulminant myocarditis and cardiogenic shock supported with extracorporeal membrane oxygenation

BackgroundExtracorporeal membrane oxygenation (ECMO) is an effective support method for acute fulminant myocarditis (AFM) with cardiogenic shock. However, deciding whether to bridge to a left ventricular assist device (LVAD) or to maintain ECMO support until heart recovery is still controversial. Material and methodsThis was a retrospective observational study from a single center. Eighty-eight adults with AFM and ECMO support between 2006 and 2018 were included. The primary endpoint was heart recovery without heart transplantation or long-term LVAD support. ResultsThe heart recovery group contained 43 patients, of whom 41 were discharged after being weaned off ECMO and the other two after LVAD. Five patients with heart transplants and one with long-term LVAD support were discharged, accounting for an overall survival of 55.7%. Multivariate logistic regression revealed that peak CK-MB level, severe intraventricular conduction disturbance (asystole) and malignant arrhythmia (VT or VF) were prognostic factors for nonrecovery (P = .027 and 0.017, respectively), while early intravenous immunoglobulin (IVIG) use before ECMO was highly likely to have a protective effect with a trend toward statistical significance (P = .079). A risk score was developed: 4 points for VT/VF/asystole, 1 point for every 100 μg/L increase in the peak CK-MB level, up to a maximum of 5 points, and −3 points for early IVIG use. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.818. ConclusionHigh CK-MB levels and VT/VF/asystole in patients with AFM are associated with poor heart recovery. Early IVIG use shows a potentially protective effect.

Motor stroke recovery after tDCS: a systematic review.

The purpose of the present study was to investigate the effects of transcranial direct current stimulation (tDCS) on motor recovery in adult patients with stroke, taking into account the parameters that could influence the motor recovery responses. The second aim was to identify the best tDCS parameters and recommendations available based on the enhanced motor recovery demonstrated by the analyzed studies. Our systematic review was performed by searching full-text articles published before February 18, 2019 in the PubMed database. Different methods of applying tDCS in association with several complementary therapies were identified. Studies investigating the motor recovery effects of tDCS in adult patients with stroke were considered. Studies investigating different neurologic conditions and psychiatric disorders or those not meeting our methodologic criteria were excluded. The main parameters and outcomes of tDCS treatments are reported. There is not a robust concordance among the study outcomes with regard to the enhancement of motor recovery associated with the clinical application of tDCS. This is mainly due to the heterogeneity of clinical data, tDCS approaches, combined interventions, and outcome measurements. tDCS could be an effective approach to promote adaptive plasticity in the stroke population with significant positive premotor and postmotor rehabilitation effects. Future studies with larger sample sizes and high-quality studies with a better standardization of stimulation protocols are needed to improve the study quality, further corroborate our results, and identify the optimal tDCS protocols.

Immunonutrition for patients undergoing surgery for head and neck cancer.

Patients with head and neck cancer are often malnourished. Surgery for such cancers is complex and may be undertaken after a course of radiotherapy. As a result, patients may have postoperative complications such as fistulae and wound infections, as well as more generalised infections such as pneumonia. One possible way to enhance recovery, and reduce the incidence of these complications, is by improving nutrition. Nutritional formulas that deliver basic nutrients as well as amino acids (arginine and glutamine), ribonucleic acid (RNA) and/or lipids (omega-3 fatty acids) are known as immunonutrition. To assess the effects of immunonutrition treatment, compared to standard feeding, on postoperative recovery in adult patients undergoing elective (non-emergency) surgery for head and neck cancer. The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 February 2018. We included randomised controlled trials (RCTs) comparing immunonutrition given either preoperatively, postoperatively or perioperatively to adult patients (18 years of age or older) undergoing an elective surgical procedure for head and neck cancer, compared with a control group receiving either standard polymeric nutritional supplements or no supplements. We used the standard methodological procedures expected by Cochrane. The primary outcomes were: length of hospital stay (days), wound infection, fistula formation and adverse events/tolerance of feeds, as defined by trial authors. Secondary outcomes were: all-cause mortality and postoperative complications (as defined by trial authors). We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. We included 19 RCTs (1099 participants). The mean age of participants ranged from 47 to 66 years. Most studies (12/19) had fewer than 25 patients in each treatment group. Most studies (16/19) used immunonutrition formulas containing arginine, but there was variation in the actual products and amounts used, and in the length of intervention postoperatively. Follow-up time for outcome measurement varied considerably across studies, ranging from five days to greater than or equal to 16 months.Primary outcomesWe found no evidence of a difference in the length of hospital stay (mean difference -2.5 days, 95% confidence interval (CI) -5.11 to 0.12; 10 studies, 757 participants; low-quality evidence). Similarly, we found no evidence of an effect of immunonutrition on wound infection (risk ratio (RR) 0.94, 95% CI 0.70 to 1.26; 12 studies, 812 participants; very low-quality evidence). Fistula formation may be reduced with immunonutrition; the absolute risks were 11.3% and 5.4% in the standard care and immunonutrition groups, with a RR of 0.48 (95% CI 0.27 to 0.85; 10 studies, 747 participants; low-quality evidence). We found no evidence of a difference in terms of tolerance of feeds ('adverse events') between treatments (RR 1.33, 95% CI 0.86 to 2.06; 9 studies, 719 participants; very low-quality evidence).Secondary outcomesWe found no evidence of a difference between treatments in all-cause mortality (RR 1.33, 95% CI 0.48 to 3.66; 14 studies, 776 participants; low-quality evidence). Other postoperative complications such as pneumonia and urinary tract infections were not commonly reported. The risk of postoperative fistula formation may be reduced with immunonutrition, but we found no evidence of an effect of immunonutrition on any of the other outcomes that we assessed. The studies included in this review were generally small or at high risk of bias (or both). We judged the overall quality of the evidence to be low for the outcomes length of hospital stay and all-cause mortality, and very low for wound infection and adverse events. Further research should include larger, better quality studies.

Effect of detection time interval for out-of-hospital cardiac arrest on outcomes in dispatcher-assisted cardiopulmonary resuscitation: A nationwide observational study

IntroductionThe association between the detection time interval (DTI) from the call for ambulance to the detection of out-of-hospital cardiac arrest (OHCA) by the dispatcher and the neurological outcome in dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is unclear. MethodsAdults who sustained OHCA with cardiac etiology received DA-CPR between 2013 and 2016 were analyzed. The main predictor was DTI defined as the time interval from the beginning of the emergency call to identification of OHCA by the dispatcher. The primary outcomes were the good cerebral performance category (CPC) 1 or 2. Multivariable logistic regression analysis was performed to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for outcomes, adjusting for potential confounders, by the 10- and 30-s DTI delay and three DTI groups; Short (0–90 s), Middle (91–180 s), and Long (181–1,200 s) groups. Interaction analysis for DTI and urbanization level (megacity with 10 million or more population in urban region, metropolis with 1 to 5 million population in urban region, and Rural province with less than 2 million population in urban, suburban, and rural region) was performed to compare the effect size of DTI group according to urbanization level. ResultsOf 116,374 adults with an OHCA, 11,833 were finally analyzed. Overall, the number (%) of survival to discharge was 1380 (11.4%), and the good CPC was 945 (8.0%). For good cerebral performance category, the AOR (95% CIs) for good CPC was 0.99 (0.98–1.00) by 10-s DTI delay and 0.97 (0.95–0.99) by 30-s DTI delay. The AORs (95% CIs) for good CPC were 0.84 (0.71–1.00) for the Middle and 0.79 (0.66–0.96) for the Long DTI groups compared with Short DTI. The AORs (95% Cl) for good CPC compared with Short DTI group were 0.93 (0.68–1.27) by Middle DTI and 0.84 (0.59–1.20) by Long DTI in megacity, 0.60 (0.44–0.81) by Middle DTI and 0.60 (0.44–0.82) by Long DTI in metropolis, and 0.43 (0.31–0.60) by Middle DTI and 0.38 (0.26–0.56) by Long DTI in Rural province, respectively. ConclusionA longer DTI in DA-CPR showed significantly lower good neurological recovery in adult patients with witnessed OHCA. A 30 s delay in DTI was associated with a 3% decrease of a good CPC score. The DTI effect on good CPC was significant in metropolis and Rural province while not in megacity region.

A Prospective Evaluation of the Influence of an Electronic Clinical Practice Guidelines on Concussion Patients’ Future Activities and Outcomes

BackgroundPatients with mild traumatic brain injury or concussion commonly present to the emergency department for assessment; providing patients with information on usual symptoms and their progression may encourage faster recovery. ObjectivesThis study aimed to document the role of an electronic clinical practice guideline (eCPG) patient handout on concussion recovery in adult patients discharged from the hospital. MethodsA prospective cohort study was carried out in 3 Canadian urban emergency departments. Adults (≥17 years of age) with a Glasgow Coma Scale score of 13 to 15 who sustained a concussion were recruited by on-site research assistants. Physician use of a concussion-specific eCPG was documented from physician and patient reports. Patient follow-up calls at 30 and 90 days documented return to work/school activities and patient symptoms. Multivariate analyses were performed using logistic regression methods. ResultsOverall, 250 patients were enrolled; the median age was 35 (interquartile range 23–49) and 52% were female. Approximately half (n = 119, 48%) of patients received the eCPG handout, and return to work/school recommendations varied. Symptoms persisted in 60% of patients at 30 days; patients in the eCPG group had fewer symptoms (odds ratio 0.57, 95% confidence interval 0.33–0.99). At 90 days, 40% of patients reported persistent symptoms, with no significant difference between groups. ConclusionAn eCPG handout improved patients’ short-term outcomes; however, physician use and adherence to guideline recommendations was low. To further facilitate physician compliance and therefore patient recovery, barriers to use of the eCPG handout need to be identified and addressed.

Motor and Perceptual Recovery in Adult Patients with Mild Intellectual Disability.

Introduction The relationship between intellectual disability (ID) and hand motor coordination and speed-accuracy, as well as the effect of aging on fine motor performance in patients with ID, has been previously investigated. However, only a few data are available on the impact of the nonpharmacological interventions in adult patients with long-term hand motor deficit. Methods Fifty adults with mild ID were enrolled. A group of thirty patients underwent a two-month intensive ergotherapic treatment that included hand motor rehabilitation and visual-perceptual treatment (group A); twenty patients performing conventional motor rehabilitation alone (group B) served as a control group. Data on attention, perceptual abilities, hand dexterity, and functional independence were collected by a blind operator, both at entry and at the end of the study. Results After the interventions, group A showed significantly better performance than group B in all measures related to hand movement from both sides and to independence in activities of daily living. Discussion Multimodal integrated interventions targeting visual-perceptual abilities and motor skills are an effective neurorehabilitative approach in adult patients with mild ID. Motor learning and memory-mediated mechanisms of neural plasticity might underlie the observed recovery, suggesting the presence of plastic adaptive changes even in the adult brain with ID.

The PULSAR primary care protocol: a stepped-wedge cluster randomized controlled trial to test a training intervention for general practitioners in recovery-oriented practice to optimize personal recovery in adult patients.

BackgroundGeneral practitioners (GPs) in Australia play a central role in the delivery of mental health care. This article describes the PULSAR (Principles Unite Local Services Assisting Recovery) Primary Care protocol, a novel mixed methods evaluation of a training intervention for GPs in recovery-oriented practice. The aim of the intervention is to optimize personal recovery in patients consulting study GPs for mental health issues.MethodsThe intervention mixed methods design involves a stepped-wedge cluster randomized controlled trial testing the outcomes of training in recovery-oriented practice, together with an embedded qualitative study to identify the contextual enablers and challenges to implementing recovery-oriented practice. The project is conducted in Victoria, Australia between 2013 and 2017. Eighteen general practices and community health centers are randomly allocated to one of two steps (nine months apart) to start an intervention comprising GP training in the delivery of recovery-oriented practice. Data collection consists of cross-sectional surveys collected from patients of participating GPs at baseline, and again at the end of Steps 1 and 2. The primary outcome is improvement in personal recovery using responses to the Questionnaire about the Process of Recovery. Secondary outcomes are improvements in patient-rated measures of personal recovery and wellbeing, and of the recovery-oriented practice they have received, using the INSPIRE questionnaire, the Warwick-Edinburgh Mental Well-being Scale, and the Kessler Psychological Distress Scale. Participant data will be analyzed in the group that the cluster was assigned to at each study time point. Another per-protocol dataset will contain all data time-stamped according to the date of intervention received at each cluster site. Qualitative interviews with GPs and patients at three and nine months post-training will investigate experiences and challenges related to implementing recovery-oriented practice in primary care.DiscussionRecovery-oriented practice is gaining increasing prominence in mental health service delivery and the outcomes of such an approach within the primary care sector for the first time will be evaluated in this project. If findings are positive, the intervention has the potential to extend recovery-oriented practice to GPs throughout the community.Trial registrationAustralian and New Zealand Clinical Trial Registry (ACTRN12614001312639). Registered: 8 August 2014.