Standard Care Protocol Research Articles

Psychological factors related to resilience and vulnerability among youth with HIV in an integrated care setting

ABSTRACTApproximately 22% of HIV diagnoses in 2015 occurred among youth aged 13–24. Much is known about the risk factors and psychopathology present in youth living with HIV (YLWH), however, relatively little is known about resiliency in this population. The current study sought to assess factors related to resilience and vulnerability among YLWH as well as the impact of psychosocial factors on these constructs using existing clinical data from an integrated care clinic serving YLWH in the southeastern United States. Data included findings from mental health screeners administered as part of the standard protocol of care for youth aged 13–24 including information about anxiety (GAD-7), post-traumatic stress disorder (PC-PTSD), depression (PHQ-A or PHQ-9), substance use (CRAFFT), and medication adherence (BEHKA-HIV Action subscale) as well as viral load and demographic variables. Hierarchical linear regression was used to determine factors related to biological (viral load) and behavioral indicators of resilience and vulnerability (BEHKA-HIV Action subscale and CRAFFT). Results showed that anxiety was a significant covariate of both biological and behavioral indicators of resilience while gender was a significant factor associated with behavioral indicators of vulnerability. None of the psychological or demographic factors examined in this study were associated with substance use, a behavioral indicator of vulnerability and resilience. Our results support the need for clinicians to screen for and monitor anxiety symptoms among YLWH in integrated care settings in an effort to promote resilience and minimize vulnerability. Practical, evidence-based strategies should be applied in clinical settings to address medication adherence and anxiety among YLWH.

Abstract 2543: Concurrent chemotherapy and temozolomide-resistant CAR-T immunotherapy enhances glioblastoma clearance in experimental animals

Abstract Dismal long-term progression-free survival of glioblastoma (GBM) patients, who are concurrently treated with radiation and chemotherapy, demands development of alternative strategies for management of this disease. Recent clinical success of chimeric antigen receptors expressing T cells (CAR-T) in GBM patients, interest in tumor-directed immunotherapy has been reinvigorated. However as per standard care, immunotherapy must be concurrent with or following the standard care protocol for glioma therapy, which includes Temozolomide (TMZ) chemotherapy. Concurrent chemotherapy with TMZ reduces the efficacy of adoptive T cell immunotherapy by inducing severe lymphopenia, while post-chemotherapy treatment minimizes the window of opportunity for effective immunotherapy, because of inherent tumor heterogeneity resulting in an altered antigenic profile in recurrent GBMs. To address this, we have created a TMZ-resistant CAR-T cell directed against IL13Rα2+ GBM tumors by introducing a mutated O6-methylguanine-DNA methyltransferase (MGMT) moiety in the existing IL13CAR backbone. This specific mutation in MGMT (P140KMGMT) blocks the interaction of TMZ to MGMT and therefore protects the rapidly proliferating anti-GBM CAR-T cells from TMZ-induced lymphopenia. Activated P140KMGMT-IL13CAR-T cells were protected from TMZ-induced cytotoxicity in vitro without any loss of anti-tumor effects of these modified CAR-T cells. Experimental xenograft animals treated with P140KMGMT-IL13CAR-T cells and concurrent TMZ therapy showed 2-fold increase in median survival over groups that were treated with TMZ alone, and 2.8-fold increase in overall survival over groups that were treated with TMZ-sensitive second generation IL13CAR-T cells and concurrent TMZ. These encouraging results point us strongly in the direction of developing this CAR-T technology towards a promising future of concurrent chemotherapy and immunotherapy of GBM. Citation Format: Sadhak Sengupta, Mansour Gergi, Prajna Guha, Sudarshana Sengupta, Richard P. Junghans, Prakash Sampath. Concurrent chemotherapy and temozolomide-resistant CAR-T immunotherapy enhances glioblastoma clearance in experimental animals [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2543.

Evaluation for association between indwelling urethral catheter placement and risk of recurrent urethral obstruction in cats.

OBJECTIVE To test for an association between indwelling urethral catheter placement in cats with urethral obstruction (UO) and the short-term (30-day) risk of recurrent urethral obstruction (RUO). DESIGN Prospective cohort study. ANIMALS 107 client-owned male cats with UO. PROCEDURES Owners were offered standard care for their cats, including hospitalization, placement of an indwelling urethral catheter, IV fluid therapy, and other supportive treatments (inpatient group). One-time catheterization and outpatient care were offered (outpatient group) if standard care was declined. Data regarding signalment, measures of metabolic compromise and urinalysis findings at enrollment, catheterization-related variables, and supportive treatments of interest were collected. Risk of RUO ≤ 30 days after urethral catheter removal was determined for the outpatient vs inpatient group by OR and 95% confidence interval calculation. Other variables were compared between cats that did and did not develop RUO with Fisher exact and trend tests. RESULTS 91 cats completed the study; 19 (5/46 [11%] inpatients and 14/45 [31%] outpatients) developed RUO. Risk of RUO was significantly greater for cats of the outpatient group (OR, 3.7; 95% confidence interval, 1.2 to 11.4). Among inpatients, increasingly abnormal urine color at the time of catheter removal was significantly associated with RUO. No other significant associations were identified. CONCLUSIONS AND CLINICAL RELEVANCE Hospitalization and indwelling catheterization significantly reduced the risk for RUO ≤ 30 days after treatment for the population studied. Results suggested that removal of an indwelling catheter before urine appears grossly normal may be associated with development of RUO. One-time catheterization with outpatient care was inferior to the standard care protocol but was successful in many cats and may be a reasonable alternative when clients cannot pursue standard care.

2505 Mixed emotions: Health care personnel’s reactions to new accountabilities for health equity

OBJECTIVES/SPECIFIC AIMS: Calls for health care organizations to promote health equity, through reducing health care disparities and addressing the social determinants of health, are growing and disrupt assumptions about equal care and the role of the health care delivery system more generally. This paper uses qualitative data to explore the emotions that health care personnel express as they make sense of the newfound emphasis on equity. To do so, we consider the relationships between social identity, sense of control, emotion, cognition, and action. METHODS/STUDY POPULATION: The principle investigator conducted 21 semistructured interviews with senior leaders and equity team members and 7 focus groups with providers and staff employed at one of Minnesota’s largest health care system. The PI asked respondents to describe recent conversations about equity in their workplaces and to identify barriers and facilitators to addressing equity. Focus group participants were also asked to imagine colleagues’ reactions—“what would they say, think, and feel”—should they be asked to adapt practices to address the social determinants of health, community health, and healthcare disparities. Interviews and focus groups were audiotaped and transcribed. Two coders independently coded each transcript for themes and then compared and reconciled their coding. Reactions to equity work emerged inductively during the coding process. RESULTS/ANTICIPATED RESULTS: Findings suggest that discourses on health equity can disrupt personal and professional identities and trigger a mixture of emotions, including fear, sadness, and excitement. Personnel with broad, or flexible, constructions of their work roles experienced less disruption, and more positive emotions, than those personnel who constructed narrow, or rigid, professional identities. Those who expressed a stronger sense of control also expressed more positive emotions, such as happiness and hope, and were excited about the prospect of greater accountabilities related to equity. Those who doubted the existence of disparities were defensive and pointed to cues such as standardized care protocols and perceptions of colleagues’ professionalism to oppose change. Those who perceived low organizational self-efficacy, due to a lack of time, skills, or knowledge, often expressed frustration and helplessness. Their sensemaking focused on the lack of progress and sought sensegiving about ways to “make it workable.” DISCUSSION/SIGNIFICANCE OF IMPACT: Discussions about equity are new in healthcare and trigger mixed reactions, drawing out provider and staff’s hopes, fears, and anxieties. Variations in emotional reactions may be related to differing perceptions about sense of control over disparities and the social determinants of health. If we want to enlist health care providers, nurses, and managers in efforts to improve health equity, we need to understand these emotions and sensemaking processes.

Association of Standardized Tracheostomy Care Protocol Implementation and Reinforcement With the Prevention of Life-Threatening Respiratory Events

ImportanceMucus plugging after tracheostomy is a preventable cause of respiratory distress. Implementation of standardized tracheostomy care guidelines may reduce the occurrence of fatal respiratory compromise.ObjectiveTo determine the effect of implementing and reinforcing a standardized tracheostomy care protocol on the occurrence of acute life-threatening respiratory events.Design, Setting, and ParticipantsRetrospective cohort study of adult patients who received a tracheostomy between May 2014 and August 2016 at a tertiary care center.Main Outcomes and MeasuresPatient demographics, tracheostomy indication, rapid response for mucus plugging and other acute events, duration of hospital stay, and levels of care that the patients received were recorded through examination of clinical logs. Statistical analysis was conducted between patients before protocol implementation and patients after protocol implementation in terms of rapid-response use, and intragroup comparison of the mean length of stay in various hospital units was also analyzed.ResultsA total of 247 patients (89 women [36%]; mean [SD] age, 58.5 [12.3] years), 117 preprotocol and 130 postprotocol, met inclusion criteria. Of the 130 patients in the postprotocol cohort, 123 (93%) were on the new tracheostomy care protocol. Preprotocol rapid-response rate was 21 of 117 patients (17.9%) and postprotocol response rate was 12 of 130 patients (9.2%) for a difference of 8.7% (95% CI, 0.2%-18.0%). In terms of mucus plugging, preprotocol rate was 8 of 117 patients (6.8%) and the postprotocol rate was 1 of 130 patients (0.8%) for a difference of 6.0% (95% CI, 1.3%-12.2%). Intragroup difference of the mean time spent (days) in various care units between patients in the no rapid-response group vs rapid-response group demonstrated clinically meaningful longer stay for rapid responses in both preprotocol and postprotocol groups for the intensive care unit (preprotocol, 2.03; 95% CI, 1.03-3.03 vs postprotocol, 3.02; 95% CI, 1.49-4.45) and step down units (preprotocol, 1.40; 95% CI, 0.77-2.02 vs postprotocol, 2.11; 95% CI, 0.78 to 3.44).Conclusions and RelevanceImplementation and reinforcement of a standardized tracheostomy care protocol was associated with a reduction in the occurrences of rapid-response calls for life-threatening mucus plugging and is recommended for clinical practice. In addition, length of stay in the intensive care unit and intermediate surgical care unit was increased in a clinically meaningful way for patients who experienced a rapid-response event.

Predicting and Modifying Risk for Development of Renal Failure in Boys with Posterior Urethral Valves.

The purpose of this review is to bring the reader up to date on the current risk factors for the development of renal deterioration in the boys with posterior urethral valves (PUV) and approaches to modify this risk. Renal bladder ultrasound (RBUS) is routinely performed in boys with PUV and recent advancements allow imaging processing that can more accurately quantify renal parenchyma and correlate this with risk for renal loss. Refinement of urine studies may improve our ability to stratify patients into renal loss categories. Use of videourodynamics (VUDS) allows refined assessment of the valve bladder to identify those who might benefit from secondary procedures and/or the addition of targeted pharmacotherapy to improve bladder emptying or dangerous storage pressures. All boys with a history of PUV are at a significant long-term risk of renal deterioration. The literature suggests that several technical advances have improved our ability to predict this risk, although there needs to be further refinement and validation before widespread use. Utilization of close follow-up, VUDS, pharmacotherapy, and bladder drainage provide the best methods to improve care to this group of patients and if more studies confirm their utility, adoption of these as part of standard of care protocols may be warranted.

Tissue Engineering: An Analogous Platelet Rich Fibrin for Coronal Pulpotomy in Revival of Pulp Tissue Vitality in Adult Molar with Pulpitis, a Case Report

Aim: management of a clinical case with irreversible pulpitis for young adult molar with closed apices using analogous blood derivative PRF and evaluating the clinical and radiographic success for coronal pulpotomy. Summary: A 18 years old male patient reported to the screening clinic, was referred to endodontic clinic with acute pulpitis diagnosed in left first molar tooth. Deep occlusal caries involving pulp, with history of spontaneous lingering pain associated with sign and symptoms of pulpitis. Standard clinical care protocol was strictly implemented, rubber dam isolation was followed by coronal pulpotomy. Blood drawn from cuboidal vein. Platelet rich fibrin membrane placed over the remaining pulp and restored with MTA and finally with Glass ionomer cement. Follow-up results clinically and radio-graphically were encouraging and successful at day 1 to 24 months. No post-operative pain, the treated tooth responded to pulp sensibility test and radiographs revealed periapical healing. However, for standardization of the clinical procedure well designed research study is further needed.

PLASTIC BAG WRAP FOR PREVENTION OF HYPOTHERMIA IN PRETERM AND LOW-BIRTH WEIGHT INFANTS

Introduction. Hypothermia is low-body temperature (less than 36,5°C) that can caused morbidity and mortality in premature newborn and or low-birth weight newborn. Plastic has often been used to prevent the heat loss in newborn.The aim of study was to measure the effectiveness of plastic bag wrap to prevent hypothermia in preterm and low-birth weight infant. Method. The study design was quasy expertment non randomized pretest-posttest with control group. In intervention group, there were five premature and or low-birth weight newborns that were being wrapped with special design plastic bag from neck to toe after been given neonatal standard care protocol. While, in control group, there were six newborns with the same baseline criteria as intervention group without plastic bag wrap. The measurement of body temperature used digital thermometer on babies’ axilla before and after one-hour intervention. Data analysis used t test. Result. The result showed there was almost significant difference in body temperature in newborn before and after intervention (pvalue 0.056). Discussion. Plastic bag wrap is effective to prevent hypothermia in premature and or low-birth weight newborn as much as 60% with body temperatur changes +0.4°C. Keywords: Plastic Bag Wrap, Hypothermia, Preterm, Low-Birth weight

Contemporary Burn Survival

The standard of burn treatment today reflects major advances. We sought to quantitate the impact of these advances on burn survival via age-stratified mortality ratios compared with other reported mortality analyses in burns. Age, percent of the total body surface area (TBSA) burned, presence of inhalation injury, length of stay, and survival status were recorded at admission and at discharge for all new burn admissions between 1989 and 2017. The expected mortality probability was calculated using historical multiple regression techniques and compared with observed data. We developed a prediction model for our observed data. Between 1989 and 2017, there were 10,384 consecutive new burn admissions, with 355 mortalities (median age, 13 years; median percent TBSA burn, 11%). We saw a significant decrease in our observed mortality data compared to historical predictions (p < 0.0001), and a 2% reduction per year in mortality during the 3 decades. The prediction model of mortality for the data is as follows: Pr(dying)= ex/(1+ ex) where x= -6.44 - 0.12 age+ 0.0042 age2 - 0.0000283 age3+ 0.0499 TBSA+ 1.21 Inhalation Injury+ 0.015 third degree TBSA. The reduction in mortality over time may be attributed to successful changes in standard of care protocols in the burn center that improved the outlook for burned individuals, including protocols for management of inhalation injury, nutrition, resuscitation, and early excision and grafting.

Cost-effectiveness of using a collagen-containing dressing plus compression therapy in non-healing venous leg ulcers.

To estimate whether collagen-containing dressings could potentially afford the UK's National Health Service (NHS) a cost-effective intervention for the management of non-healing venous leg ulcers (VLUs). This was a modelling study performed from the perspective of the UK's NHS. A combination of published clinical outcomes, resource utilisation estimates and utilities for VLUs enabled the construction of a decision model, depicting the management of a chronic VLU with standard care or with a collagen-containing dressing plus compression therapy followed by standard care, over a period of 6 months. The model estimated the incremental cost-effectiveness of the two interventions in terms of the incremental cost per quality-adjusted life year (QALY) gained at 2015/16 prices. The treatment of VLUs of >6 months' duration with a collagen-containing dressing plus compression therapy followed by standard care, instead of standard care, is expected to increase the probability of healing from 0.11 to 0.49 by 6 months and increase health-related quality of life at 6 months from 0.331 to 0.373 QALYs per patient. Additionally, treatment with a collagen-containing dressing plus compression therapy followed by standard care has the potential to reduce management costs by 40% over 6 months when compared with standard care (from £6328 to £3789 per patient). Within the study's limitations, including a collagen-containing dressing into a standard care protocol compared with standard care potentially affords the NHS a cost-effective (dominant) treatment since it improves outcomes for less cost.

Effects of cerebral near-infrared spectroscopy on the outcome of patients undergoing cardiac surgery: a systematic review of randomised trials

ObjectivesGoal-directed optimisation of cerebral oxygenation using near-infrared spectroscopy (NIRS) during cardiopulmonary bypass is widely used. We tested the hypotheses that the use of NIRS cerebral oximetry results in reductions in...

A simplified prevention bundle with dual hand hygiene audit reduces early-onset ventilator-associated pneumonia in cardiovascular surgery units: An interrupted time-series analysis.

BackgroundTo investigate the effect of a simplified prevention bundle with alcohol-based, dual hand hygiene (HH) audit on the incidence of early-onset ventilation-associated pneumonia (VAP).MethodsThis 3-year, quasi-experimental study with interrupted time-series analysis was conducted in two cardiovascular surgery intensive care units in a medical center. Unaware external HH audit (eHH) performed by non-unit-based observers was a routine task before and after bundle implementation. Based on the realistic ICU settings, we implemented a 3-component bundle, which included: a compulsory education program, a knowing internal HH audit (iHH) performed by unit-based observers, and a standardized oral care (OC) protocol with 0.1% chlorhexidine gluconate. The study periods comprised 4 phases: 12-month pre-implementation phase 1 (eHH+/education-/iHH-/OC-), 3-month run-in phase 2 (eHH+/education+/iHH+/OC+), 15-month implementation phase 3 (eHH+/education+/iHH+/OC+), and 6-month post-implementation phase 4 (eHH+/education-/iHH+/OC-).ResultsA total of 2553 ventilator-days were observed. VAP incidences (events/1000 ventilator days) in phase 1–4 were 39.1, 40.5, 15.9, and 20.4, respectively. VAP was significantly reduced by 59% in phase 3 (vs. phase 1, incidence rate ratio [IRR] 0.41, P = 0.002), but rebounded in phase 4. Moreover, VAP incidence was inversely correlated to compliance of OC (r2 = 0.531, P = 0.001) and eHH (r2 = 0.878, P < 0.001), but not applied for iHH, despite iHH compliance was higher than eHH compliance during phase 2 to 4. Compared to eHH, iHH provided more efficient and faster improvements for standard HH practice. The minimal compliances required for significant VAP reduction were 85% and 75% for OC and eHH (both P < 0.05, IRR 0.28 and 0.42, respectively).ConclusionsThis simplified prevention bundle effectively reduces early-onset VAP incidence. An unaware HH compliance correlates with VAP incidence. A knowing HH audit provides better improvement in HH practice. Accordingly, we suggest dual HH audit and consistent bundle performance does matter in quality-of-care VAP prevention.

Description and Results of a Comprehensive Care Protocol for Overnight-Stay Spine Surgery in Adults.

This is a prospective cohort study. The aim of this study was to define the probability of successful morning-after discharge after adult spine surgery achieved with a standard care protocol as applied to patients with a large variety of common degenerative spine disorders. Qualifying criteria for ambulatory or overnight-stay adult spine surgery are not well defined in either the spine or anesthesia literature. Most reports simply go to American Society of Anesthesiology risk classification or surgical technique alternatives and do not present a clearly defined patient care and case management protocol. A standardized protocol of patient preparation, preoperative comorbidities optimization, and perioperative care was applied in a prospective cohort of 126 patients including 83 lumbar and 41 cervical procedures. Office and hospital chart records were reviewed for relevant outcomes. Fully 122 of 124 appropriately selected cases were able to successfully achieve uneventful same-day discharge without any need for readmission, unscheduled early emergency room or clinic visits, or other major complications. Both failures were for urinary retention in senior males and resolved after a single-day admission to the main hospital. A wide variety of common degenerative spinal pathology in adults can be routinely and safely managed on an overnight-stay basis without requirement for formal hospital inpatient admission in patients appropriately selected and pre-educated to the experience and whose major comorbidities are preoperatively optimized. N/A.

Outcomes in a nurse-led peripherally inserted central catheter program: a retrospective cohort study.

Peripherally inserted central catheters (PICCs) provide enormous benefit to patients. However, recent publications have highlighted relatively high PICC-associated complication rates. We report on patient and device outcomes from a nurse-led program. We performed a retrospective analysis of a prospective cohort of consecutive patients undergoing PICC insertion at The Ottawa Hospital between Jan. 1, 2013 and Dec. 31, 2014. Of the 8314 BioFlo PASV PICCs inserted, we randomly selected a sample of 700 and obtained a complete data set for 656. We measured the cumulative incidence of major complications (catheter-related bloodstream infections and deep vein thrombosis) and use of a thrombolytic to alleviate occlusions. The total number of catheter days was 58 486, and the median dwell time 45 days. We observed 4 cases of catheter-related bloodstream infection (0.6% [95% CI 0.17%-1.55%]) (0.07/1000 catheter days). Ten patients (1.5% [95% CI 0.83%-2.78%]) (0.17/1000 catheter days) had catheter-related deep venous thrombosis. At least 1 dose of thrombolytic was required in 75 catheters (11.4% [95% CI 8.61%-13.39]), 31 (7.1%) of the 436 single-lumen catheters and 113 (25.7%) of the 440 lumina of dual-lumen catheters (p < 0.001). We attribute our low rates of major complications to a nurse-led expert insertion team, standardized care and maintenance protocols, high insertion volumes, novel catheter material and continuous quality-improvement initiatives that are implemented and evaluated regularly. We conclude that the considerable benefits PICCs provide to patients are attained with a low risk of major complications.

Association of Modified Frailty Index Score With Perioperative Risk for Patients Undergoing Total Laryngectomy

Objective preoperative risk assessment tools, such as the Modified Frailty Index (mFI), may inform patient and physician decision making when considering total laryngectomy. Estimation of outcomes may help to set realistic expectations about recovery and outcomes and facilitate optimal resource management. To evaluate the association between the mFI score as a measure of frailty and outcomes following total laryngectomy. Retrospective evaluation using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a risk- and case-mix-adjusted national quality assessment program. The ACS NSQIP database identified 595 patients who underwent total laryngectomy between 2006 and 2012. Patients were assessed for demographics and comorbidity and were stratified on the basis of calculated mFI score. Outcomes, including postoperative complications, length of hospitalization, and discharge destination, were evaluated as a function of increasing frailty using multivariable logistic regression and Cox proportional hazards regression models. Risk of postoperative complications, length of hospitalization, and discharge disposition. After exclusion of patients who experienced significant deviation from standard care protocols and those with missing or incomplete data, 343 individuals were included in the analysis. Of these, 278 (81.0%) were men, and the mean age was 63 years (95% CI, 61.9-64.4 years). Increasing frailty resulted in a nonlinear but progressive rise in incidence of postoperative adverse events. Overall, 96 (28.0%) patients experienced a postoperative complication, and patients with an mFI score of 3 or higher were more likely to develop postoperative complications than were patients with an mFI score of 0 (50.0% vs 16.7%; OR, 3.83; 95% CI, 1.72- 8.51). Patients in the highest frailty group experienced a longer mean duration of hospitalization (14.2 vs 9.5 days; difference, 4.7; 95% CI, 1.3-8.1 days) and were more likely to require skilled care after discharge (33.3% vs 3.2%; difference, 30.1%; 95% CI, 7.4%-52.9%). An mFI score of 3 or higher is associated with increased risk for postoperative complications, longer hospitalization, and need for postdischarge skilled care following total laryngectomy. The mFI provides a personalized risk assessment to better inform patients, physicians, and payers when planning a total laryngectomy.

Knowledge, Attitude and Practices in Management of Trauma Victims: A Questionnaire Based Study

Background: Trauma care represents a challenge to clinicians managing trauma patients. With standard trauma care protocols such as ATLS in place, it is important to acquire and adopt protocol based knowledge and implement it the routine management of trauma patients. It is clinician’s responsibility to participate in such programs and update their knowledge and hence improve their practices. Aims: In this cross sectional study among clinicians we aim to evaluate their knowledge of trauma management protocols, practices based on such knowledge in the management of trauma patients and attitude towards acquiring this knowledge by attending standard trauma teaching programs. Methods: This study was conducted by distributing questionnaires among 83 doctors across various hospitals. Those respondents who had scored ≥ 10 were considered to have adequate knowledge of management of trauma patients and were used in analyzing correct response rate. The results were analyzed statistically by applying the Fischer-exact test or Chi- square test. Results: The overall correct response rate for the study was 25%. The statistical correlation (p-value) for the correct response rate among clinicians with clinical experience of more or less than 5 yrs; whether routinely managing trauma patients or not and whether or not working in a trauma centre were 0.53, 1.00, 0.29 respectively. The p value for correlation of correct response rate among clinicians who had attended structured trauma course and those who had not was 0.00. Conclusion: The exposure to standard trauma teaching programs improves the knowledge and hence knowledge based practices of clinicians for trauma victims’ management.

Incidence of and factors associated with catheter-related bloodstream infection in patients with advanced solid tumors on home parenteral nutrition managed using a standardized catheter care protocol

BackgroundCatheter-related bloodstream infections (CRBSIs) are associated with high morbidity and mortality as well as increased medical costs. Cancer patients, who are often immunocompromised, are susceptible to CRBSI while receiving home parenteral nutrition (HPN). We evaluated the incidence of and factors associated with CRBSIs in cancer patients undergoing HPN managed using a standardized catheter care protocol.MethodsThis is a retrospective cohort study of 335 cancer patients receiving HPN between January 2012 and July 2015. The primary outcome of interest was the incidence of CRBSI expressed as events per 1000 HPN days. HPN days were calculated from the start date with the home infusion provider until the discontinuation of HPN, or the removal of the venous access device (VAD), or the death of the patient. The VADs used were either peripherally inserted central catheters (PICCs) or a subcutaneous implanted port or tunneled central catheters (TCCs). Univariate Poisson regression analyses were used to determine the variables associated with CRBSIs.ResultsOf 335 patients, 193 were females and 142 were males. The most common cancer types were colorectal, pancreatic, ovarian and stomach. A total of 408 VADs in 335 patients were studied, covering a total of 29,403 HPN days. Of 408 VADs, 206 (50.5%) were ports, 191 (46.8%) were PICCs, and 7 (2.7%) were TCCs. The median duration of HPN was 54 days. A total of 16 CRBSI episodes were recorded (8 in ports, 7 in PICCs and 1 in TCCs). The median duration from the start of HPN to the development of CRBSI episodes was 43.5 days. The overall incidence of CRBSI per 1000 HPN days was 0.54 (95% confidence interval: 0.32–0.86). Upon univariate analysis, no variables were found to be statistically significantly associated with CRBSI incidence.ConclusionsWe found a low rate of CRBSI following a standardized catheter maintenance protocol in a high-risk oncology population undergoing HPN.

MDM2 Degrades Deacetylated Nucleolin Through Ubiquitination to Promote Glioma Stem-Like Cell Enrichment for Chemotherapeutic Resistance.

Glioblastoma multiforme (GBM) is the most fatal of all brain cancers, and the standard care protocol for GBM patients is surgical tumor resection followed by radiotherapy and temozolomide (TMZ)-mediated chemotherapy. However, tumor recurrence frequently occurs, and recurrent GBM exhibits more malignancy and less sensitivity in response to chemotherapy. The malignancy and drug resistance primarily reflect the small population of glioma stem-like cells (GSC). Therefore, understanding the mechanism that controls GSC enrichment is important to benefit the prognosis of GBM patients. Nucleolin (NCL), which is responsible for ribosome biogenesis and RNA maturation, is overexpressed in gliomas. However, the role of NCL in GSC development and drug resistance is still unclear. In this study, we demonstrate that NCL attenuated GSC enrichment to enhance the sensitivity of GBM cells in response to TMZ. In GSC enrichment, NCL was significantly reduced at the protein level as a result of decreased protein stability. In particular, the inhibition of HDAC activity by suberoylanilide hydroxamic acid rescued NCL acetylation accompanied by the loss of mouse double minute 2 homolog (MDM2)-mediated ubiquitination. In addition, we found that NCL ubiquitination resulted from the activation of STAT3- and JNK-mediated signaling in GSC. Moreover, NCL inhibited the formation of stem-like spheres by attenuating the expression of Sox2, Oct4, and Bmi1. Furthermore, NCL sensitized the response of GBM cells to TMZ. Based on these findings, NCL expression is a potential indicator to predict chemotherapeutic efficiency in GBM patients.

A system-wide approach from the community to the hospital for improving neurologic outcomes in out-of-hospital cardiac arrest patients.

In the present study, we aimed to determine the effects of a system-wide approach from the community to the hospital in improving the neurologic outcomes in out-of-hospital cardiac arrest (OHCA) patients within Sungbuk in Korea. This study used a before-after design. In 2011, compression-only cardiopulmonary resuscitation (CPR) for citizens, a state-wide standard dispatcher assisted-CPR protocol, medical control for regional emergency medical service (EMS), provision of high-quality advanced cardiac life support (ACLS) with capnography and extracorporeal CPR, and the standard postcardiac arrest care protocol were implemented in the system-wide CPR program. CPR provision and outcomes were compared between the 2009-2010 and the 2012-2013 periods. A multivariate logistic regression model for good outcome of OHCA was used to identify interventions with a significant impact. In total, 581 adult nontraumatic OHCA patients who received resuscitation attempts from 2009 to 2013 were selected for the analysis of CPR provision and outcomes. CPR provision improved significantly, as indicated by the following results from 2009-2010 to 2012-2013: from 15.9 to 50.4% for bystander CPR (P<0.001), 6.0 to 0% for the proportion of no documented arrest rhythm by EMS (P=0.004), 41.4 to 62.2% for ACLS with capnography (P=0.008), 1.4 to 10.5% for extracorporeal CPR (P=0.052), 3.7 to 34.4% for successful therapeutic hypothermia in coma patients (P<0.001), and 61.5 to 87.1% for immediate coronary angiography for presumed cardiac etiology (P=0.005). Moreover, the proportion of OHCA patients who received early EMS activation, bystander CPR, appropriate attempt of defibrillation at the prehospital level, high-quality ACLS, and standard postcardiac arrest care increased from 0.5% in 2009-2010 to 8.5% in 2012-2013 (P<0.001). The rates of discharge with a good neurologic outcome improved from 3.3% in 2009-2010 to 8.5% in 2012-2013 (P<0.001). The system-wide CPR program was associated with enhancements in CPR performance at both the prehospital and the hospital level, and yielded improved neurologic outcomes in OHCA patients in a small region.

Care pathways for patients with bipolar disorders at Psychiatry Clinic Affektiva, Gothenburg: Identifying and solving issues for a more efficient and safe care

IntroductionThe Psychiatry Clinic Affektiva has developed a care pathway for patients with bipolar disorder (BD). It consists of one outpatient clinic and two inpatient wards. Clinical observations suggest that patients with BD benefit from treatment in a dedicated unit with tailored care programs and that better outcomes are achieved in terms of reduced average length of stay and safer transitions to outpatient care for this group.AimsThe aim is to improve the care of bipolar patients by increasing bed-availability and overall continuity in the care pathway and monitoring core aspects in the management of outpatients in order to reduce admissions and to facilitate standardized treatment and collaboration between in- and outpatients unit.MethodWe developed a structure to monitor and measure specific outcomes such as readmission within 28 days, relapse within 12 months and the use of lithium in this group. We also developed a standardized care protocol in order to improve the safety and the equality.ResultsAt this stage our preliminary results from our efforts are promising but further monitoring is needed to confirm our hypothesis. More data will be collected during 2017.ConclusionsAffektiva Psychiatry Clinic has developed a model for continuously monitoring several essential aspects in the care of patients with BD and providing a specific care program.Disclosure of interestThe authors have not supplied their declaration of competing interest.