Pediatric Critical Care Medicine

Critical Illness and Cardiac Dysfunction in Anthracycline-Exposed Pediatric Oncology Patients* Objectives: To determine if the presence of cardiac dysfunction in anthracycline-exposed pediatric oncology patients is associated with an increased frequency of PICU admission or mortality. Design: Retrospective parallel cohort study. Setting: PICU at an academic freestanding children's hospital. Subjects: Children with oncologic diagnoses who received anthracyclines between January 2006 and December 2014 and were admitted to the hospital within 1 year of completion of therapy. Interventions: None. Measurements and Main Results: Charts of 734 patients were reviewed and 545 were included in analysis. Anthracycline-exposed pediatric oncology patients with cardiac dysfunction were more likely to be admitted to the PICU than those without cardiac dysfunction (87% vs 37% rate of PICU admission). PICU admission was also associated with identified infection and higher cumulative anthracycline dose. Once admitted to the PICU, those anthracycline-exposed patients with cardiac dysfunction had significantly higher mortality (26% vs 6%) and longer length of stay (7 vs 2 d) than children without cardiac dysfunction. Patients with cardiac dysfunction were more likely to require mechanical ventilation (59% vs 18%), required more vasoactive medications for longer, and were more likely to develop fluid overload. Death within 1 year of ICU admission was associated with higher cumulative anthracycline dose. Conclusions: Children with cancer who received anthracyclines, especially at higher doses, and who develop cardiac dysfunction are at higher risk of critical illness, have higher rates of multiple organ dysfunction and higher rates of mortality than anthracycline-exposed patients without cardiac dysfunction.

Bleeding Scales Applicable to Critically Ill Children: A Systematic Review Objectives: To summarize current bleeding scales and their validation to assess applicability to bleeding in critically ill children. Data Sources: We conducted electronic searches of Ovid MEDLINE, Ovid EMBASE, Cochrane Library, and Web of Science Core Collection databases from database inception to 2017. Study Selection: Included studies contained a bleeding score, bleeding measurement tool, or clinical measurement of hemorrhage. Data Extraction: We identified 2,097 unique citations; 20 full-text articles were included in the final review. Data Synthesis: Of the 18 studies that included subjects (two others were expert consensus definitions), seven (39%) were pediatric-only, seven (39%) were adult-only, and four (22%) included both adults and children. Nine (50%) occurred with inpatients (two studies in critical care units), seven (39%) involved outpatients and two (11%) included both inpatients and outpatients. Thirty-nine percent of the scales were developed for those with idiopathic thrombocytopenic purpura and only two (12%) described critically ill patients. The majority (80%) included need for treatment (either RBC transfusion or surgical intervention). The majority (65%) did not report measures of reliability or validation to clinical outcomes. Conclusions: There is a lack of validated bleeding scales to adequately assess bleeding and outcomes in critically ill children. Validated scales of bleeding are necessary and urgently needed.

Ultrasound-Guided Femoral Arterial Cannulation in Neonates Undergoing Cardiac Surgery or Catheterization: Comparison of 0.014-Inch Floppy Versus 0.019-Inch Straight Guidewire Objectives: Percutaneous femoral artery cannulation can be technically challenging in small infants. Design: We designed a prospective randomized trial to compare the use of two different guidewires for femoral arterial cannulation in neonates undergoing cardiac surgery or catheterization. Settings: Cardiac ICU in a university hospital. Patients: One-hundred twenty-four children were enrolled in this prospective study, with 64 being randomized to the 0.019-inch straight guidewire group and 60 to the 0.014-inch floppy guidewire group. Interventions: Femoral artery cannulation. Measurements and Main Results: The study period was limited to 10 minutes at the first site of arterial puncture. The time to complete cannulation, number of successful cannulation on first attempt, number of attempts, and number of successful cannulations were compared. The number of successful cannulations and successful cannulations on first attempt were higher in 0.014-inch floppy guidewire group (p = 0.001; p = 0.002, respectively). The time to complete cannulation was significantly shorter, and the number of attempts was lower in 0.014-inch floppy guidewire group (p = 0.001). Among the neonates less than 2000g, the number of attempts and time to complete cannulation were significantly lower (p < 0.001), and number of successful cannulation on first attempt and number of successful cannulations were significantly higher (p < 0.028; p < 0.001, respectively) in the 0.014-inch floppy guidewire Conclusions: Using 0.014-inch floppy guidewire for femoral arterial cannulation in particularly very small neonates provides significant improvement in first attempt success, number of successful cannulations, number of attempts, time to complete cannulation.

Risk Factors for Recurrent Acute Kidney Injury in Children Who Undergo Multiple Cardiac Surgeries: A Retrospective Analysis Objectives: Determine the risk factors for repeated episodes of acute kidney injury in children who undergo multiple cardiac surgical procedures. Design: Single-center retrospective chart review. Setting: Cardiac ICU at a quaternary pediatric care center. Patients: Birth to 18 years who underwent at least two cardiac surgical procedures with cardiopulmonary bypass. Interventions: None. Measurements and Main Results: One-hundred eighty patients underwent two cardiac surgical procedures and 89 underwent three. Acute kidney injury was defined by the Kidney Disease: Improving Global Outcomes serum creatinine criteria. Acute kidney injury frequency was 26% (n = 46) after surgery 1, 20% (n = 36) after surgery 2, and 24% (n = 21) after surgery 3, with most acute kidney injury occurring on postoperative days 1 and 2. The proportion of patients with severe acute kidney injury increased from surgery 1 to surgery 3. Patients with acute kidney injury had a significantly longer duration of ventilation and length of stay after each surgery. The odds of acute kidney injury after surgery 3 was 2.40 times greater if acute kidney injury was present after surgery 1 or 2 (95% CI, 1.26–4.56; p = 0.008) after adjusting for confounders. The time between surgeries was not significantly associated with acute kidney injury (p = 0.85). Conclusions: In a heterogeneous population of pediatric patients with congenital heart disease undergoing multiple cardiopulmonary bypass surgeries, odds of acute kidney injury after a third surgery was increased by the presence of acute kidney injury after prior procedures. Time between surgery did not play a role in increasing odds of acute kidney injury. Further studies in a larger multicenter investigation are necessary to confirm these findings.

Population Pharmacokinetics and Dosing of Milrinone After Patent Ductus Arteriosus Ligation in Preterm Infants Objectives: The postoperative course of patent ductus arteriosus ligation is often complicated by postligation cardiac syndrome, occurring in 10–45% of operated infants. Milrinone might prevent profound hemodynamic instability and improve the recovery of cardiac function in this setting. The present study aimed to describe the population pharmacokinetics of milrinone in premature neonates at risk of postligation cardiac syndrome and give dosing recommendations. Design: A prospective single group open-label pharmacokinetics study. Settings: Two tertiary care neonatal ICUs: Tallinn Children's Hospital and Tartu University Hospital, Estonia. Patients: Ten neonates with postmenstrual age of 24.6–30.1 weeks and postnatal age of 5–27 days undergoing patent ductus arteriosus ligation and at risk of postligation cardiac syndrome, based on echocardiographic assessment of left ventricular output of less than 200 mL/kg/min 1 hour after the surgery. Interventions: Milrinone at a dose of 0.73 μg/kg/min for 3 hours followed by 0.16 μg/kg/min for 21 hours. Four blood samples from each patient for milrinone plasma concentration measurements were collected. Measurements and Main Results: Concentration-time data of milrinone were analyzed with nonlinear mixed-effects modeling software (NONMEM Version 7.3 [ICON Development Solutions, Ellicott City, MD]). Probability of target attainment simulations gave a dosing schedule that maximally attains concentration targets of 150–250 μg/L. Milrinone pharmacokinetics was described by a one-compartmental linear model with allometric scaling to bodyweight and an age maturation function of glomerular filtration rate. Parameter estimates for a patient with the median weight were 0.350 (L/hr) for clearance and 0.329 (L) for volume of distribution. The best probability of target attainment was achieved with a loading dose of 0.50 μg/kg/min for 3 hours followed by 0.15 μg/kg/min (postmenstrual age < 27 wk) or 0.20 μg/kg/min (postmenstrual age ≥ 27 wk). Conclusions: Population pharmacokinetic modeling and simulations suggest a slow loading dose followed by maintenance infusion to reach therapeutic milrinone plasma concentrations within the timeframe of the postligation cardiac syndrome.

Mortality Rate-Dependent Variations in the Timing and Causes of Death in Extremely Preterm Infants Born at 23–24 Weeks' Gestation* Objectives: To determine mortality rate-dependent variations in the timing and causes of death, and to subsequently identify the clinical factors associated with decreased mortality in extremely preterm infants born at 23–24 weeks' gestation. Design: A retrospective cohort study. Setting: Korean Neonatal Network registry that includes all level greater than or equal to 3 neonatal ICUs in Korea. Patients: Eligible, actively treated infants born at 23–24 weeks' gestation (n = 574) from January 2014 to December 2016 were arbitrarily categorized based on institutional mortality rates of less than or equal to 50% (group I, n = 381) and greater than 50% (group II, n = 193). The primary outcome was mortality before discharge and the timing and causes of death according to the mortality rate. Interventions: None. Measurements and Main Results: The overall mortality rate was significantly lower in group I (40.7%) than in group II (79.3%). Regarding causes of death, mortalities due to cardiorespiratory, infectious, and gastrointestinal causes were significantly lower in group I than in group II. Mortality rates were significantly lower in group I, including all the subgroups that were categorized according to the timing of death, than in group II. The multivariate analyses showed that antenatal corticosteroid use, absence of oligohydramnios, birth weight, and body temperature at admission to the neonatal ICU were significantly associated with reduced mortality. Conclusions: The reduced mortality rate among the infants born at 23–24 weeks' gestation was attributable to decreased mortality ascribed to cardiorespiratory, infectious, and gastrointestinal causes, and it was associated with antenatal steroid use and body temperature at admission to the neonatal ICU.

Risk of Severe Intraventricular Hemorrhage in the First Week of Life in Preterm Infants Transported Before 72 Hours of Age* Objectives: Evaluate the risk of severe intraventricular hemorrhage, in the first week of life, in preterm infants undergoing early interhospital transport. Design: Retrospective cohort study. Setting: Tertiary neonatal centers of the Trent Perinatal Network in the United Kingdom. Patients: Preterm infants less than 32 weeks gestation, who were either born within and remained at the tertiary neonatal center (inborn), or were transferred (transported) between centers in the first 72 hours of life. Interventions: None. Measurements and Main Results: Multivariable logistic regression models adjusting for key confounders were used to calculate odds ratios for intraventricular hemorrhage with 95% CIs for comparison of inborn and transported infants. Cranial ultrasound findings on day 7 of life. Secondary analyses were performed for antenatal steroid course and gestational age subgroups. A total of 1,047 preterm infants were included in the main analysis. Transported infants (n = 391) had a significantly higher risk of severe (grade III/IV) intraventricular hemorrhage compared with inborns (n = 656) (9.7% vs 5.8%; adjusted odds ratio, 1.69; 95% CI, 1.04–2.76), especially for infants born at less than 28 weeks gestation (adjusted odds ratio, 1.83; 95% CI, 1.03–3.21). Transported infants were less likely to receive a full antenatal steroid course (47.8% vs 64.3%; p < 0.001). A full antenatal steroid course significantly decreased the risk of severe intraventricular hemorrhage irrespective of transport status (odds ratio, 0.33; 95% CI, 0.2–0.55). However, transported infants less than 28 weeks gestation remained significantly more likely to develop a severe intraventricular hemorrhage despite a full antenatal steroid course (adjusted odds ratio, 2.84; 95% CI, 1.08–7.47). Conclusions: Preterm infants transported in the first 72 hours of life have an increased risk of early-life severe intraventricular hemorrhage even when maternal antenatal steroids are given. The additional burden of postnatal transport could be an important component in the pathway to severe intraventricular hemorrhage. As timely in-utero transfer is not always possible, we need to focus research on improving the transport pathway to reduce this additional risk.

Decision-Making About Intracranial Pressure Monitor Placement in Children With Traumatic Brain Injury* Objectives: Little is known about how clinicians make the complex decision regarding whether to place an intracranial pressure monitor in children with traumatic brain injury. The objective of this study was to identify the decisional needs of multidisciplinary clinician stakeholders. Design: Semi-structured qualitative interviews with clinicians who regularly care for children with traumatic brain injury. Setting: One U.S. level I pediatric trauma center. Subjects: Twenty-eight clinicians including 17 ICU nurses, advanced practice providers, and physicians and 11 pediatric surgeons and neurosurgeons interviewed between August 2017 and February 2018. Interventions: None. Measurements and Main Results: Participants had a mean age of 43 years (range, 30–66 yr), mean experience of 10 years (range, 0–30 yr), were 46% female (13/28), and 96% white (27/28). A novel conceptual model emerged that related the difficulty of the decision about intracranial pressure monitor placement (y-axis) with the estimated outcome of the patient (x-axis). This model had a bimodal shape, with the most difficult decisions occurring for patients who 1) had a good opportunity for recovery but whose neurologic examination had not yet normalized or 2) had a low but uncertain likelihood of neurologically functional recovery. Emergent themes included gaps in medical knowledge and information available for decision-making, differences in perspective between clinical specialties, and ethical implications of decision-making about intracranial pressure monitoring. Experienced clinicians described less difficulty with decision-making overall. Conclusions: Children with severe traumatic brain injury near perceived transition points along a spectrum of potential for recovery present challenges for decision-making about intracranial pressure monitor placement. Clinician experience and specialty discipline further influence decision-making. These findings will contribute to the design of a multidisciplinary clinical decision support tool for intracranial pressure monitor placement in children with traumatic brain injury.

Role of IV Immunoglobulin in Indian Children With Guillain-Barré Syndrome* Objectives: To evaluate the outcome of Indian children with Guillain-Barré syndrome who received IV immunoglobulin compared with those who did not receive any specific therapy. Design: Single center, prospective cross-sectional study. Setting: Tertiary care neurology teaching hospital. Patients: Children (≤ 18 yr old) with Guillain-Barré syndrome were included from a prospectively maintained Guillain-Barré syndrome registry from January 2008 to April 2017. Children were classified into acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, acute motor-sensory axonal neuropathy, and inexcitable motor nerves based on nerve conduction study. Interventions: Out of 138 pediatric Guillain-Barré syndrome, 50 received IV immunoglobulin and another 50 age and peak disability matched controls (who did not receive IV immunoglobulin or plasmapheresis) were selected from the same registry for comparison. Measurements and Main Results: Outcome at 3 and 6 months was defined on the basis of a 0–10 Clinical Grading Scale into complete (Clinical Grading Scale < 3), partial (Clinical Grading Scale 3–5), and poor (Clinical Grading Scale > 5) recovery. The primary outcome was proportion of patients with complete recovery at 3 and 6 months in IV immunoglobulin and non-IV immunoglobulin groups. Secondary outcomes included in-hospital deaths, duration of mechanical ventilation, and hospital stay. Subgroup analysis was done in acute motor axonal neuropathy and acute inflammatory demyelinating polyradiculoneuropathy groups. The baseline characteristics were similar except for shorter duration of illness and higher proportion of facial palsy in IV immunoglobulin group. Hospital deaths, duration of mechanical ventilation, hospital stay, and outcome at 3 and 6 months were not different between the two groups. Children with acute motor axonal neuropathy had better recovery at 6 months on IV immunoglobulin (58.3% vs 11.1%; p = 0.03), but not those with acute inflammatory demyelinating polyradiculoneuropathy (58.3% vs 72.2%; p = 0.22). In nonambulatory Guillain-Barré syndrome children, complete recovery at 6 months was similar in IV immunoglobulin and non-IV immunoglobulin group (57.4% vs 57.1%; p = 0.98). Conclusions: In Indian children with Guillain-Barré syndrome, the outcome at 6 months in IV immunoglobulin treated group was similar to non-IV immunoglobulin group. Children with acute motor axonal neuropathy responded better to IV immunoglobulin.

Inter-Rater Reliability Between Critical Care Nurses Performing a Pediatric Modification to the Glasgow Coma Scale* Objectives: Estimate the inter-rater reliability of critical care nurses performing a pediatric modification of the Glasgow Coma Scale in a contemporary PICU. Design: Prospective observation study. Setting: Large academic PICU. Patients/Subjects: All 274 nurses with permanent assignments in the PICU were eligible to participate. A subset of 18 nurses were selected as study registered nurses. All PICU patients were eligible to participate. Interventions: None. Measurements and Main Results: PICU nurses were educated and demonstrated proficiency on a pediatric modification of the Glasgow Coma Scale we created to make it more applicable to a diverse PICU population that included patients who are sedated, mechanically ventilated, and/or have developmental disabilities. Each study registered nurse observed a sample of nurses perform the Glasgow Coma Scale, and they independently scored the Glasgow Coma Scale. Patients were categorized as having developmental disabilities if their preillness Pediatric Cerebral Performance Category score was greater than or equal to 3. Fleiss' Kappa (κ), intraclass correlation coefficient, and percent agreement assessed inter-rater reliability for each Glasgow Coma Scale component (eye, verbal, motor) and age-specific scale (≥ 2 and < 2-yr-old). The overall percent agreement between study registered nurses and nurses was 89% for the eye, 91% for the verbal, and 79% for the motor responses. Inter-rater reliability ranged from good (intraclass correlation coefficient = 0.75) to excellent (intraclass correlation coefficient = 0.96) for testable patients. Agreement on the motor response was significantly lower for children with developmental disabilities (< 2 yr: 59% vs 95%; p = 0.0012 and ≥ 2 yr: 55% vs 91%; p = 0.0012). Agreement was significantly worse for intermediate range Glasgow Coma Scale motor responses compared with responses at the extremes (e.g., motor responses 2, 3, 4 vs 1, 5, 6; p < 0.05). Conclusions: A pediatric modification of the Glasgow Coma Scale performed by trained PICU nurses has excellent inter-rater reliability, although reliability was reduced in patients with developmental disabilities and for intermediate range Glasgow Coma Scale responses. Further research is needed to determine the effectiveness of this Glasgow Coma Scale modification to detect clinical deterioration.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

The Clinical Journal of Pain

Investigating the Causal Mechanisms of Symptom Recovery in Chronic Whiplash-associated Disorders Using Bayesian Networks Objectives: The present study's objective was to understand the causal mechanisms underpinning the recovery of individuals with whiplash-associated disorders (WAD). We applied Bayesian Networks (BN) to answer 2 study aims: (1) to identify the causal mechanism(s) of recovery underpinning neck-specific exercise (NSE), and (2) quantify if the cyclical pathway of the fear-avoidance model (FAM) is supported by the present data. Materials and Methods: We analyzed a prospective cohort data set of 216 individuals with chronic WAD. Fifteen variables were used to build a BN model: treatment group (NSE with or without a behavioral approach, or general physical activity), muscle endurance, range of motion, hand strength, neck proprioception, pain catastrophizing, fear, anxiety, depression, self-efficacy, perceived work ability, disability, pain intensity, sex, and follow-up time. Results: The BN model showed that neck pain reduction rate was greater after NSE compared with physical activity prescription (β=0.59 points per month [P<0.001]) only in the presence of 2 mediators: global neck muscle endurance and perceived work ability. We also found the following pathway of variables that constituted the FAM: anxiety, followed by depressive symptoms, fear, catastrophizing, self-efficacy, and consequently pain. Conclusions: We uncovered 2 mediators that explained the mechanisms of effect behind NSE, and proposed an alternative FAM pathway. The present study is the first to apply BN modelling to understand the causal mechanisms of recovery in WAD. In doing so, it is anticipated that such analytical methods could increase the precision of treatment of individuals with chronic WAD.

Comparing Novel and Existing Measures of Sensitivity to Physical Activity Among People With Chronic Musculoskeletal Pain: The Importance of Tailoring Activity to Pain Objectives: Increasing pain during physical activity is an important, but often poorly assessed, barrier to engaging in activity-based rehabilitation among people with chronic musculoskeletal pain. Preliminary work has addressed this problem by developing new clinical measures of sensitivity to physical activity (SPA). Indices of SPA are generated by evaluating how pain changes in relation to brief physical tasks. Three strategies have been identified for structuring SPA-related physical tasks (self-paced, standardized, and tailored). This cross-sectional study aimed to comparatively estimate the extent of the 3 SPA tasks' evoked pain responses, predictive value of pain severity and pain interference, and their underlying psychological and sensory constructs, among 116 adults with chronic musculoskeletal pain. Materials and Methods: Testing included questionnaires, quantitative sensory testing, and the 3 SPA measures (self-paced, standardized, and tailored). The primary analysis estimated the predictive value of each SPA measure for pain severity and pain interference. Correlational analyses were first conducted between all variables of interest to determine what variables will be included in the hierarchical regression analysis, which in turn was conducted for each outcome. Results: Analyses revealed that the tailored SPA index was most effective at evoking activity-related pain, was uniquely associated with temporal summation of pain, and was a unique predictor of pain and pain-related interference, even when controlling for established psychological and sensory risk factors. Discussion: This study further emphasizes SPA as an important and unique attribute of the pain experience and reveals the added value of using a tailored approach to assess SPA.

Deficient Inhibitory Endogenous Pain Modulation Correlates With Periaqueductal Gray Matter Metabolites During Chronic Whiplash Injury Objectives: This study examined predictive correlations between periaqueductal gray (PAG) and anterior cingulate cortex (ACC) metabolite levels with deficient inhibitory endogenous pain modulation (EPM), including sensory and affective measures of pain during chronic whiplash injury (WHI). Materials and Methods: Healthy patients, and participants with chronic WHI, without (WHI-noP) or with pain (WHI-P), were screened with the Douleur Neuropathique 4 tool (DN4). EPM was assessed with C6 tonic heat pain stimuli with a Conditioned Pain Modulation (CPM) protocol. Magnetic resonance spectroscopy quantified ACC and PAG metabolite levels. Results: WHI-P participants were characterized with high pain intensity and interference, and lower quality of life scores, compared with WHI-noP. Inhibitory CPM at 30 seconds was identified in the healthy noninjured (−45±16%; P<0.001) and WHI-noP groups (−36±8%; P<0.001). However, inhibitory EPM was not detected in the WHI-P group (−25±15%; P=0.06). Best fit and stepwise multiple regression revealed that the PAG glutamate/myoinositol metabolite ratio (P=0.01) and total creatine levels (P=0.02) predicted loss of EPM in the WHI-P group (r2=0.71, α=0.97). Although myoinositol predicted loss of EPM in the ACC (P=0.04), this was below statistical power (r2=0.31; α=0.56). The ACC N-acetyl-aspartate/myoinositol ratio (P=0.006) predicted chronic pain (DN4, r2=0.53; α=0.87). Discussion: The results of this study demonstrate deficient EPM at 30 seconds during tonic heat pain stimulation in WHI-P participants, compared with noninjured healthy volunteers or individuals with WHI-noP. In addition, quantification of PAG and ACC metabolites related to glutamate and glia predicted central chronic pain mechanisms related to loss of inhibitory EPM, while ACC metabolites characterized chronic pain described by descriptors and sensory changes.

Trajectories of Pain Intensity Over 1 Year in Adults With Disabling Subacute or Chronic Neck Pain Objectives: The objectives of this study were to describe the 1-year trajectories of disabling subacute or persistent neck pain and to investigate whether baseline age, sex, pain characteristics, and depressive symptoms are associated with such trajectories. Study Design and Setting: Participants (n=617) included in a randomized controlled trial provided weekly pain intensity ratings by responding to text messages over 1 year. We used latent class mixed model analyses to identify clusters of individual trajectories. Thereafter, we used logistic regression to determine the association between baseline age, sex, pain characteristics, depressive symptoms and treatment, and trajectories of neck pain. Results: Six different clusters of trajectories were identified. Most participants (73%) followed a trajectory of decreasing pain throughout follow-up. The remaining experienced unfavorable trajectories: persistent pain of high intensity (22%) and slightly (3%) or highly (2%) fluctuating levels of pain reaching high levels of pain intensity. Pain intensity at baseline: odds ratio (OR): 3.76 (95% confidence interval [CI]: 2.49-5.68), depressive symptoms: OR: 3.46 (95% CI: 2.01-5.95), younger age: OR: 2.29 (95% CI: 1.48-3.54), female sex: OR: 1.51 (95% CI: 1.01-2.26), and sudden onset of pain: OR: 1.74 (95% CI: 1.13-2.69) were associated with unfavorable trajectories. Conclusions: Most individuals with disabling subacute or chronic neck pain show improvement in pain intensity over a year. However, a quarter present unfavorable trajectories. High pain intensity at baseline, depressive symptoms, younger age, female sex, and sudden onset of pain are factors associated with unfavorable trajectories.

Patient-controlled Analgesia For Vaso-Occlusive Crisis: A Cohort Study Background: Sickle cell disease (SCD) accounts for over 68,000 hospital admissions each year in the United States, with long inpatient length of stays (LOS) and frequent readmission common. Patient-controlled analgesia (PCA) has been used to treat patients admitted with vaso-occlusive crisis (VOC), but it is unknown if PCA is associated with shorter LOS and reduced risk of readmission. Methods: We examined all admissions for acute VOC treated with parenteral opioids to an urban, academic health system over 3 years. We compared LOS, 30-day readmission, and discharges against medical advice between admissions treated with PCA versus standard therapy in unadjusted and adjusted analyses using generalized estimating equations to adjust for demographic and clinical characteristics. Results: Of 823 admissions included, 536 (65.1%) were treated with PCA and 287 (34.9%) were treated with standard nurse-administered opioid therapy. Treatment with PCA was associated with significantly shorter LOS in the unadjusted analyses (7.46 vs. 9.42 d, P=0.001), but the difference was not significant after adjustment (adjusted difference: 1.47 d, P=0.06). Treatment with PCA was also associated with significantly decreased risk of 30-day readmission in unadjusted analysis (odds ratio [OR]unadj: 0.69; 95% confidence interval [CI]: 0.54-0.89, P=0.004), but after adjustment the association was no longer significant (ORadj: 0.76; 95% CI: 0.54-1.06, P=0.11). Finally, treatment with PCA was not associated with increased risk of discharge against medical advice in Generalized Estimating Equation modeled unadjusted (ORunadj: 1.10; 95% CI: 0.69-1.76, P=0.68), or adjusted analysis (ORadj: 1.19; 95% CI: 0.73-1.94, P=0.49). Conclusions: Treatment with PCA may be associated with shorter LOS and may be considered as the primary modality for opioid-based pain control for patients with SCD who are admitted with painful VOC.

Remifentanil for Procedural Sedation and Analgesia in Central Venous Catheter Insertion: A Randomized, Controlled Trial Objective: Central venous catheter (CVC) insertion is a common practice for anesthetists, but this invasive procedure generates anxiety and pain in patients that are often underestimated. We compared target-controlled infusion of remifentanil and local lidocaine infiltration with placebo and local lidocaine infiltration to decrease pain scores during CVC placement. Materials and Methods: We included conscious, adult patients without contraindication to remifentanil or lidocaine. We excluded pregnant women, emergency situations, and opioid abuse. Patients requiring CVC were randomly assigned, using computer-generated allocation numbers stored in sealed envelopes, to receive target-controlled infusion of remifentanil or placebo—all patients received local anesthesia with lidocaine. All patients were hospitalized in a recovery room or intensive care unit, monitored, and received 4 L/min of oxygen. The primary outcome was global pain (Verbal Numeric Rating Pain Scale) during the procedure. Secondary outcomes were pain perceived at every stage of the procedure, anxiety, patient satisfaction, operational ease, and side effects. Results: In this double-blind study, we included 90 patients (split into 2 groups of 45 patients). Global pain was significantly reduced in the remifentanil group: 20 of 100 (95% confidence interval, 16-40) versus 50 of 100 (95% confidence interval, 40-60) in the placebo group; P=0.0009. No major adverse events were observed during this study, and there were no significant differences between both groups regarding side effects. Discussion: Target-controlled infusion of remifentanil is an effective drug to reduce pain during CVC insertion in association with lidocaine-based local anesthesia, in conscious patients.

Parental Report of Self and Child Worry During Acute Pain: A Critical Factor in Determining Parental Pain Judgment Objective: The objective of this study was to determine which variables predict parental postvaccination pain ratings. It was hypothesized that after child behavior, parental sensitivity, and parental reports of worry would be the strongest predictors. Methods: Data for 215 parent-child dyads were analyzed from a longitudinal cohort at the preschool (4 to 5 y of age) vaccination. Preschoolers' pain behaviors 15 seconds, 1 minute 15 seconds, and 2 minutes 15 seconds after the painful immunization were observed and rated. Parental sensitivity, as well as parental own worry and their assessment of their child's worry, were assessed before and after the needle. Three regression models were used to determine the impact of these variables on parental pain assessment. Results: Preschoolers' pain behaviors moderately accounted for variance in parental pain judgment (R2=0.23 to 0.28). Parental sensitivity was not a significant unique predictor of parental pain rating at the preschool age. Parental assessment of their own worry and worry about their preschoolers after the needle were critical contributors to parental pain judgment. Post hoc analyses suggest that parents who report low child worry, are more congruent with their child during regulatory phases postvaccination. However, both parents with high and low self-worry had more congruent pain ratings with child pain behavior scores during the reactivity phase. Discussion: The study suggests that the majority of variance in parent pain ratings was not predominantly based on preschoolers' pain behaviors. Parental worry levels and their assessment of their child's worry were also significant predictors. Clinical implications are discussed.

The Impact of Psychological Interventions on Posttraumatic Stress Disorder and Pain Symptoms: A Systematic Review and Meta-Analysis Objectives: Posttraumatic stress disorder (PTSD) and pain often co-occur, introducing clinical challenges and economic burden. Psychological treatments are considered effective for each condition, yet it is not known which therapies have the potential to concurrently address PTSD and pain-related symptoms. Materials and Methods: To conduct a systematic review and meta-analysis, databases were searched for articles published between January 2007 and December 2017 describing results from clinical trials of interventions addressing PTSD and pain-related symptoms in adults. Two independent reviewers finalized data extraction and risk of bias assessments. A random-effects model was used for meta-analysis and to calculate pooled and subgroup effect sizes (ESs) of psychological-only (single modality) and multimodal interventions. Results: Eighteen trials (7 uncontrolled, 11 randomized controlled trials, RCTs), totaling 1583 participants, were included in the systematic review. RCT intervention types included exposure-based, cognitive-behavioral, and mindfulness-based therapies. Data from 10 RCTs (N=1, 35) were available for meta-analysis, which demonstrated moderate effect for reduced PTSD severity (ES=−0.55, confidence interval [CI]: −0.83, −0.26) and nonsignificant effect for pain intensity (ES=−0.14, CI: −0.43, 0.15) and pain interference (ES=−0.07, CI: −0.35, 0.20) outcomes. Findings from uncontrolled trials supported meta-analytic results from RCTs. Using GRADE assessment, the quality of evidence was deemed as moderate for RCTs and low for non-RCTs. Discussion: Findings indicated that the majority of the interventions appeared to have a greater impact on reducing PTSD rather than pain-related symptoms. There remains a need to further develop interventions that consistently impact PTSD and pain-related outcomes when these 2 conditions co-occur.

The Validity of Skin Conductance For Assessing Acute Pain in Infants: A Scoping Review Objectives: Measuring pain in infants is important but challenging, as there is no "gold standard." The measurement of skin conductance (SC) is considered to be a measure of stress and as a surrogate indicator of pain. The objectives of this study were to identify the extent of research conducted and to synthesize the validity evidence of SC for assessing acute pain in infants. Methods: The Arksey and O'Malley framework for scoping reviews was followed, and 9 electronic databases were searched. Data were analyzed thematically and presented descriptively including the following main categories: study information/details, sampling information, characteristics of participants and settings, SC outcome measures, and validity evidence. Results: Twenty-eight studies with 1061 infants were included, including 23 cross-sectional observation studies and 5 interventional studies. The most studied infants were those with mild severity of illness (n=13) or healthy infants (n=12). The validity evidence of SC was tested in relation to referent pain measures (13 variables), stimuli (13 variables), age (2 variables), and other contextual variables (11 variables). SC was not significantly correlated with vital signs, except for heart rate in 2 of the 8 studies. SC was significantly correlated with the unidimensional behavioral pain assessment scales and crying time rather than with multidimensional measurements. Fourteen of 15 studies (93.3%) showed that SC increased significantly during painful procedures. Conclusions: Inconsistent findings on validity of SC exist. Future research should aim to identify the diagnostic test accuracy of SC compared with well-accepted referent pain measures in infants, study the validity evidence of SC in critically ill infants, and utilize rigorous research design and transparent reporting.

Presurgical Comorbidities as Risk Factors For Chronic Postsurgical Pain Following Total Knee Replacement: More Details, More Significance No abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Ophthalmic Plastic & Reconstructive Surgery

Congenital Dacryocystocele: A Major Review Purpose: To provide a systematic review of the literature on congenital dacryocystoceles (CDCs) and summarize their presentations, investigations, management, and outcomes. Methods: The authors performed a PubMed search of all articles published in English on CDCs. Data captured include demographics, clinical presentations, investigations, management modalities, complications, and outcomes. Fourteen major series (10 or more than 10 cases) and 89 isolated case reports/series on CDCs with a collective patient pool of 1,063 were studied in detail. Specific emphasis was laid on addressing the controversial issues including initial conservative versus surgical management and the role of endoscopic evaluation. Results: Numerous terminologies have been used to describe CDC. Congenital dacryocystoceles are rare variants of congenital nasolacrimal duct obstructions and comprise of 0.1% to 0.3% of all such cases. There is a female predilection (64.2%, 683/1,063) and the mean age at presentation is at 7 days of birth. Initial conservative treatment can be a viable option in the absence of an acute dacryocystitis or a respiratory distress. Endoscopy-assisted probing appears to have better outcomes as compared with the in-office probing. Congenital dacryocystoceles with acute dacryocystitis are preferably managed with intravenous antibiotics and an early probing under endoscopy guidance to avoid missing intranasal cysts. Marsupialization is the preferred technique in the management of intranasal cysts. Silicone intubation was rarely used and has no definitive indications. Dacryocystorhinostomy is very rarely needed in the management of CDC. Conclusions: Congenital dacryocystocele is a commonly accepted term and its use should be advocated to enhance uniformity in reporting. Endoscopic evaluation of CDC is useful in the diagnosis and treatment of associated intranasal cysts and enhances the rates of successful outcomes.

A Prospective Comparative Study Between Subcuticular and Sutureless Technique of Skin Closure Following External Dacryocystorhinostomy Purpose: To compare the cosmetic outcome of the surgical scar of external dacryocystorhinostomy by the subcuticular versus sutureless technique. Methods: This was a prospective interventional randomized control study conducted at tertiary level hospital. Fifty patients of primary-acquired nasolacrimal duct obstruction were included in this study. The control group patients underwent the technique of wound closure in 2 layers, subcutaneous interrupted suture with 6-0 vicryl and superficial skin with 6-0 prolene continuous subcuticular sutures. In the case group, interrupted subcutaneous sutures with 6-0 vicryl with Steristrip for skin apposition was used. The surgical scars were assessed and graded by still photographs on a computer screen by 2 independent observers unaware of the surgical technique used at 2, 6 and 12 weeks postoperatively. Results: The mean scar assessment score by the 2 observers were 2.60 (0.57), 2.04 (0.64), and 1.16 (0.89) in control group and 2.02 (0.65), 1.44 (0.70), and 0.44 (0.61) in case group at 2, 6, and 12 weeks, respectively. Scar grades were analyzed using chi-square test between the 2 group and Wilcoxon signed rank test within the group. The difference between the 2 groups were found to be statistically significant at 2, 6, and 12 weeks (P < 0.05). Thus, the technique of wound closure with steristrip lead to comparatively less scarring as compared with subcuticular technique. Conclusion: The authors recommend the sutureless technique of wound closure using steristrip in Ext DCR as it has superior cosmetic results as compared with subcuticular technique of external dacryocystorhinostomy.

Fractionated Stereotactic Radiotherapy for Cavernous Venous Malformations of the Orbital Apex Purpose: The objective of this study was to investigate the efficacy and safety of fractionated stereotactic radiotherapy in the treatment of cavernous venous malformation of the orbital apex. Methods: The authors reviewed a prospective database from a single center of patients with cavernous venous malformation of the orbital apex who had treatment with fractionated stereotactic radiotherapy. The authors compared the symptoms, visual function and the size of the tumor pre- and posttreatment as well as reviewed the treatment details and the incidence of complications. Results: Six patients received treatment with fractionated stereotactic radiotherapy for cavernous venous malformation involving the orbital apex. The median age was 48 (range, 32–63), and 50% were female. Patients received a dose of 45 to 50.4 Gy in 1.8 to 2 Gy fractions. Median follow up was 33 months (range, 18–66 months). The average tumor volume reduction at posttreatment imaging after 12 months was 63%. All lesions reduced in size postradiotherapy and remained controlled for the duration of follow up. All patients who had proptosis or a visual field defect had an improvement in the symptoms posttreatment. There were no complications of the treatment. Conclusion: Fractionated stereotactic radiotherapy appears to be a safe and effective management option for cavernous venous malformation of the orbital apex and leads to a sustained reduction of the volume of the lesion with associated improvement in symptoms and visual function.

Anthropometric Analysis on the Ocular Region Morphology of Children and Young Adults in Chinese Han Population Purpose: The periocular features vary in different age groups and ethnic populations. In this study, the authors sought to determine whether age-related differences exist for certain periocular parameters between children and young adults of Chinese Han population. Methods: OU of 310 children (aged 7–10 years) and 301 young adults (aged 20–30 years) were evaluated by 2-dimensional photogrammetry. All the subjects were of Chinese Han population. The eyelid crease profiles were classified according to their morphology. Periocular measurements, including 11 linear and 3 angular parameters were acquired from standardized photographs, 3 indices were further derived. The presence of epicanthal fold was also recorded. Each of the parameters was compared between the age groups. Results: A statistical difference was found between the 2 age groups for the distribution of eyelid crease types. Statistical significances existed between the age groups for various parameters, these include palpebral fissure height and width, margin reflex distance, intercanthal and outercanthal width, distance from the medial end of the eyebrow to the medial canthus, distance from the lateral end of the brow to the lateral canthus, crease height and eyebrow height, angle of endocanthion and exocanthion, palpebral fissure inclination, palpebrae fissure index, canthal index, and angular index (p < 0.05). The incidence of epicanthal fold tended to decrease with increase of age. Conclusions: Age differences exist in periocular features between children and young adults of Chinese Han population. Standards of periocular measurements based on age and race could provide reliable guidelines for clinical examination and planning periocular surgery.

Study on the Aging Dynamics of the Periorbital Region: From Observation to Knowledge of Physiopathology Purpose: Several anatomical and physio-pathologic studies of eyelid region have allowed the creation of theories on facial tissues aging dynamics, which have not been clarified yet. We assessed the signs of aging in the region over the time by observing the characteristics in the same person at different times of his/her life. Methods: We compared the position of the main anatomical landmarks of the eyelid region of 80 patients by overlaying their photographs when they were 20, 40, and 60 years old. Then we made comparisons in the group of men (40 people) and in the group of women (40 people) and between men and women. Results: The medial portion of the eyebrow was higher in the photograph taken at 60 years of age than in the one taken at 20 years old in 56.2% of cases; it was higher in 47.5% of cases when comparing the images at 20 and 40. The lateral portion of the eyebrow was seen higher in women in the 20 to 40 group, and it was seen lower in men at 60 years in statistical significance. In more than half of the patients observed, there was not a real descent of the eyebrow and the presence of a more or less accentuated form of upper eyelid's ptosis in the photograph at 60 (globally 47.5%, 55.0% of women and 40.0% of men). This condition was observed in 27.5% of the photographs at 40. There were changes in the horizontal dimension of the palpebral fissure (shortening in 53.7%, preserved in 33.7%, and increased in 12.5% of cases at 60 years old). The position of lateral canthus appeared lower in 40.0% of patients photographed at 60, but it was stable in those photographed at 40. The herniation of the upper eyelid bags was observed in 31.2% of the patients photographed at 60 years old but only in 13.7% at 40. Dermatochalasis of the upper eyelid was present in 67.5% of the people at 60 years old and in 55.0% of those seen when they were 40. Comparing men and women groups 20 to 40, dermatochalasis is more present in men than women at 40 years old with statistical significance. The eyelid-cheek junction was seen to be lower in 75.0% of cases at 60 and in 48.7% of cases at 40, and it is more represented in men than in women. Conclusion: We have highlighted some interesting elements, partly agreeing with the data already recorded by other authors', and our data suggest an important role of the eyelid structures senescence and its impact on the surrounding structures.

Acquired Obliteration of the Proximal Lacrimal Drainage System Purpose: We present a series of patients with acquired obliteration of one or more components of the proximal lacrimal drainage system, including puncta and canaliculi. This finding was noted with and without other obstructions or stenoses of the lacrimal drainage system. Review of these patients in search of possible risk factors for this condition and histopathology of two patients are presented. Methods: Medical records of patients treated at the Massachusetts Eye and Ear Infirmary between 2010 and 2016 with diagnosis codes of lacrimal punctum stenosis, stenosis of unspecified lacrimal punctum, epiphora due to insufficient drainage, and epiphora not otherwise specified were retrospectively reviewed. Patients were excluded if there was a history of congenital punctal agenesis, trauma, or any other identifiable etiology of lacrimal system obstruction. Results: Twelve patients were identified with obliterated puncta. Most patients were female (n = 11, 91.7%) and Caucasian (n = 9, 75%). The mean age was 61 years (median 62, range 22–90 years). Clinical findings ranged from one involved punctum to all four puncta, and associated ipsilateral canalicular obstruction was noted in 4 patients (33.3%). The inferior puncta were the more frequently affected structures (61.5%) compared to the superior puncta (38.5%). Nine patients (75%) reported use of topical ophthalmic medications prior to onset of symptoms. The most frequent class of medication implicated was topical antibiotics; however, patients often used a combination of medications. In 2 cases, pathological specimens of the canaliculi revealed absence of a canalicular lumen. Conclusions: Although various combinations of lacrimal system stenoses and obstructions have been described, acquired punctal obliteration is an under-recognized entity. These cases differ from typical punctal stenosis in that the puncta are completely obliterated, and no indication of a punctal opening is clinically detectable. In this study, 3 patients had previously documented normal lacrimal irrigation. The ipsilateral canaliculi were also found to be obstructed in a third of patients. Two patients had complete absence of a canalicular lumen on histopathology. The predominance of inferior punctum involvement, patient history of symptom onset after ipsilateral medication use, and known prior patent irrigation in several cases support the hypothesis that these cases represent a severe yet insidious idiosyncratic reaction to topical medication.

Perfusion Monitoring Shows Minimal Blood Flow From the Flap Pedicle to the Tarsoconjunctival Flap Background: A previous study in pigs has shown that the pedicle of the tarsoconjunctival flap does not appear to have adequate blood perfusion. The aim of this study was to monitor perfusion in tarsoconjunctival flaps in patients with large lower eyelid defects resulting from tumor surgery. Methods: The modified Hughes procedure was performed in 13 patients. Blood perfusion was monitored using laser Doppler velocimetry and laser speckle-contrast imaging. Results: Blood flow decreased gradually from the pedicle base to the end of the flap and was 19% at the flap base, 11% in the middle of the flap, and 4% in the distal end of the flap. The flaps survived, and there was no tissue necrosis. Conclusions: Tarsoconjunctival tissue survival does not seem to be dependent on a conjunctival flap. Free tarsoconjunctival grafts or composite grafts might be considered as viable alternatives in reconstruction of major eyelid defects.

Impact of Food and Drug Administration Approval of Vismodegib on Prevalence of Orbital Exenteration as a Necessary Surgical Treatment for Locally Advanced Periocular Basal Cell Carcinoma Purpose: To test the hypothesis that the US Food and Drug Administration approval of vismodegib in early 2012 has reduced the prevalence of orbital exenteration for locally advanced periocular basal cell carcinoma (BCC). Methods: Following institutional review board approval, the authors reviewed clinical and pathological data of patients with locally advanced periocular BCC (T4 per the eyelid carcinoma classification in the 8th edition of the AJCC Cancer Staging Manual) treated by the senior author during 2006–2018. Patients were grouped into those who were treated before February 2012 ("before vismodegib approval") and those who presented later ("after vismodegib approval"). Results: Forty-two patients with locally advanced periocular BCC were treated during the study period, of whom 31 were men. The median age at presentation was 66 years (range, 43–90). Twenty-two patients had T4a and 20 had T4b tumors. Thirteen patients were treated before and 29 were treated after vismodegib approval. The 2 groups did not differ in age distribution (p = 0.164), sex distribution (p = 0.270), prevalence of recurrent tumor at presentation (p = 0.317), or duration of treatment with vismodegib (p = 0.605). Orbital exenteration was significantly more prevalent in patients treated before vismodegib approval than after (46% vs. 10%, p = 0.016), and vismodegib treatment was significantly more prevalent in patients treated after vismodegib approval than before (when vismodegib was given in clinical trials; 69% vs. 23%, p = 0.008). There was a trend toward more patients retaining their eyes at last follow-up in patients treated after vismodegib approval (83% vs. 54%, p = 0.066). Conclusions: The prevalence of orbital exenteration as a necessary surgical procedure in patients with a locally advanced periocular BCC has fallen since the Food and Drug Administration approval of vismodegib. Although vismodegib is not specifically approved for organ-sparing, it has changed the authors' practice and enabled eye preservation in patients with locally advanced periocular BCC, who would otherwise require an orbital exenteration.

The Incidence of Lacrimal Drainage Disorders Across a Tertiary Eye Care Network: Customization of an Indigenously Developed Electronic Medical Record System—eyeSmart Purpose: To assess the incidence of lacrimal drainage disorders across a tertiary eye care network in India. Methods: A 5-year retrospective review of all the patients who were diagnosed with lacrimal drainage disorders across the tertiary care network of L.V. Prasad Eye Institute was performed from January 2013 to December 2017. All the patient data were retrieved using all the diagnostic terms assigned to the lacrimal drainage disorders in the in-house electronic medical record system eyeSmart. The incidence of each disorder, demographic details, and clinical presentations were captured. Results: A total of 20,102 patients were diagnosed with lacrimal drainage disorders in the 5-year period. The 2 most prevalent disorders were primary acquired nasolacrimal duct obstruction (n = 10,364, 51.56%) followed by congenital nasolacrimal duct obstruction (CNLDO; n = 5394, 26.83%). The most frequently encountered proximal lacrimal disorder was punctal stenosis (n = 603, 3%). More than 2/3rd of the patients presented with epiphora as their presenting complaint (n = 13,907, 69.18%) followed by a discharge (n = 4023, 20.01%). Although two-thirds of the patient with primary acquired nasolacrimal duct obstruction were females (n = 7081, 68.32%), the same was not true for the CNLDO group, where there was a near equal gender distribution (M:F = 1.06:1). Predisposition to laterality was neither noted in primary acquired nasolacrimal duct obstruction nor in CNLDO. The prevalence of complex CNLDO was 16.80% (n = 907), the rest being simple CNLDO. It was easy to capture the incidence of lacrimal disorders with the electronic medical record system; however, the same was not true for the surgical details. The reasons for this were lack of clarity with surgical codes, no separate drop downs for success/failure or complications, and variations in the documentation. Conclusions: This study depicts the incidence of various lacrimal drainage disorders in a very large cohort of patients. There is a need to modify the International Classification of Diseases (ICD) classification to incorporate all the diagnostic terminologies commonly used so as to capture the real global scenario. The present study helped to further customize the electronic medical record system that caters to the intricacies of lacrimal disorders.

Preoperative Intravenous Ketorolac Safely Reduces Postoperative Pain in Levator Advancement Surgery Purpose: To assess the impact of intravenous ketorolac (IVK) on self-reported pain scores, requirements for opioid analgesic and anti-emetic medications, and bleeding complications in the setting of levator advancement surgery Methods: A prospective randomized controlled trial was performed among adult patients undergoing levator advancement surgery. Pain scores were measured immediately after surgery, prior to discharge from the surgical facility, and on the first postoperative day. The requirements for postoperative analgesic and anti-emetic medications were recorded. Statistical comparisons were performed via a dedicated computerized software package. Results: Fifty patients (20 males, 30 females, mean age = 65.7 years, standard deviation = 11.9 years) underwent levator advancement without IVK and acted as controls. An additional 50 patients received IVK (19 males, 31 females, mean age = 64.6 years, standard deviation = 12.0 years). As compared with control patients, IVK resulted in statistically significant reductions in pain score immediately after surgery (4.62 vs. 1.44, p = 0.0001) and on postoperative day 1 (3.22 vs. 1.24, p = 0.0001). Fourteen patients (28%) in the control and 4 patients (8%) in the group that received IVK required opioid analgesics (p = 0.017). Seven patients (14%) in the control group and 1 patient in the group that received IVK required anti-emetic medications (p = 0.059). No patient experienced a hemorrhagic complication. Conclusions: In the setting of levator advancement surgery, IVK results in a dramatic reduction in self-reported pain score immediately after surgery and on postoperative day 1 and the requirement for opioid analgesics. This medication may be safely utilized for ptosis repair.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Cornea

Medication Burden for Patients With Bacterial Keratitis Purpose: To understand medication use and patient burden for treatment of bacterial keratitis (BK). Methods: A retrospective study was conducted examining medical records of adult patients with BK in an academic cornea practice. Data collected included medications used in the treatment of BK, dosing of medications, and the number and total duration of clinical encounters. Costs of medications were estimated using the average wholesale pharmacy price. Linear regression analysis was used to investigate associations of medication use with patient demographics and corneal culture results and reported with beta estimates (β) and 95% confidence intervals (95% CIs). Results: Forty-eight patients with BK (56% female) were studied. Patients were treated for a median of 54 days with 10 visits, 5 unique medications, 587 drops, and 7 prescriptions. The estimated median medication cost was $933 (interquartile range: $457–$1422) US dollars. Positive bacterial growth was significantly associated with more visits (β: 6.16, 95% CI: 1.75–10.6, P = 0.007), more days of treatment (β: 86.8, 95% CI: 10.8–163, P = 0.026), more prescribed medications (β: 2.86, 95% CI: 1.04–4.67, P = 0.003), and more doses of medications (β: 796, 95% CI: 818–1412, P = 0.012) compared with patients who did not undergo corneal scraping. Patients were prescribed 132 more drops of medication for every 10 years of older age (β: 132, 95% CI: 18.2–246, P = 0.024). Sex and income were not associated with medication burden or treatment length. Conclusions: Older patients and those with positive cultures incur the most medication burden in treatment of BK. Providers should be aware of medication usage and cost burden as it may affect compliance with treatment.

Microbial Keratitis in Stevens–Johnson Syndrome: A Prospective Study Purpose: To evaluate the microbiological profile and outcome in cases with infective keratitis in Stevens–Johnson syndrome (SJS). Methods: Eighty-three eyes of 68 patients with SJS presenting with microbial keratitis were recruited and managed with standard antimicrobial therapy. Results: Microbial keratitis developed in 34% of patients with SJS (83 eyes, 68 patients) over a period of 5 years. Four eyes (4.8%) had a history of concurrent topical steroid use at the onset of keratitis. Mean baseline best-corrected visual acuity was 1.8 ± 0.9 logMAR units. The site of corneal ulceration was central in 52 eyes (62.6%), paracentral in 17 eyes (20.5%), and peripheral in 14 eyes (16.8%). The mean ulcer area was 3.9 ± 2.7 mm2. Approximately 15 of 24 (62.5%) culture-positive eyes had bacterial infection, most of which (80%) were caused by Gram-positive bacteria. Polymicrobial infection was noted in 7 of 24 eyes (29.1%). Although 57 of 83 (68.6%) eyes healed with medical therapy, 26 of 83 (31.3%) eyes had corneal perforation and were managed with cyanoacrylate glue application (30.7%) or therapeutic keratoplasty (69.3%). Systemic infection as an inciting factor of SJS and an early presentation for keratitis were the major risk factors associated with corneal perforation. Large mean ulcer size, paracentral ulcers, and punctal involvement were associated with a good visual outcome. Conclusions: Infective keratitis in SJS is common, and unlike routine cases, surgical intervention is often required. However, the antibiotic sensitivity pattern suggests that resistance is not that high.

Anterior Segment Optical Coherence Tomography Images in Microsporidial Keratoconjunctivitis Purpose: To describe the findings of anterior segment optical coherence tomography (AS-OCT) in patients with microsporidial keratoconjunctivitis. Methods: The observational study included 13 eyes from 13 patients. Slit-lamp photography and AS-OCT were performed using the Swept source OCT before corneal scraping. All cases were positive for Gram-chromotrope (modified trichrome) staining for Microsporidia spp. Results: Three significant AS-OCT findings were observed. First, hyperreflective dots were limited to the epithelial layers of the cornea, and second, there were no extensions into the stromal layer in all cases. Last, hyperreflective dots slightly raised above the epithelial surface were observed in most cases (12/13%, 92.3%). Conclusions: AS-OCT represents an alternative, noninvasive tool to diagnose microsporidial keratoconjunctivitis, especially if corneal scraping is not possible.

Toxic Keratitis After Application of Custard Apple Seed for Head Lice Infestation Purpose: To report the clinical features and outcomes of toxic keratitis after application of powdered custard apple seeds for hair washing for head lice infestation. Methods: Retrospective review of all patients with toxic keratitis after application of powdered custard apple seed for head lice infestation during the time period from January 2015 to December 2017. Demographic details, clinical features, and visual outcomes were documented. Results: Thirty-one eyes of 19 patients with toxic keratitis after application of crushed custard apple seeds for head lice infestation were included in the study. Eighteen females and 1 male with a median age of 14 years [interquartile range (IQR) 12–34 years] presented with severe epiphora, congestion, photophobia, and defective vision (median logMar visual acuity 0.4, IQR 0.2–0.8) after application of custard apple seed powder for hair washing. Ten eyes (32.2%) had an epithelial defect (median size 9 mm2, IQR 5–12 mm2), and 21 (67.7%) eyes had punctate epithelial erosions. All the patients were treated with topical antibiotics, and at 3 days follow-up, all of them had resolution of symptoms and signs with a median logarithm of the minimum angle of resolution (logMAR) visual acuity of 0 (IQR 0–0.2). Conclusions: Health education about the harmful effect of this traditional practice for head lice infestation will prevent further similar events.

Tuck-In Tenon Patch Graft in Corneal Perforation Purpose: To describe the outcomes of tuck-in tenon patch graft (TPG) in the management of corneal perforation up to 5-mm size. Methods: Thirty-one cases of sterile corneal perforation (3–5 mm) underwent autologous TPG. The technique included, freshening of the edges, measuring the size of defect, creating a 360-degree stromal pocket around the perforation margin, harvesting the tenon graft followed by tucking into the stromal pocket, and application of cyanoacrylate glue or suturing the graft using 10-0 monofilament nylon suture. The main outcome measure was rate of healing (percentage of cases healed). Results: The mean age was 52.3 ± 8.9 years with 22 male and 9 female patients. The various etiologies of corneal perforation included trauma (n = 10), neurotrophic keratitis (n = 11), and peripheral ulcerative keratitis (n = 10). The mean size of corneal perforation was 4.2 ± 0.6 mm (range 3–5 mm). The mean duration of epithelial healing was 25.7 ± 6.7 days. Best-corrected visual acuity improved from 1.8 ± 0.4 to 1.2 ± 0.4 logarithm of the minimum angle of resolution units at 4 weeks after surgery (P ≤ 0.01). Twenty-seven (87.1%) cases healed with formation of a leucomatous scar at 16.9 ± 2.7 weeks, whereas 4 cases had a flat anterior chamber. In three-fourths of the cases, a corneal graft was performed. In one case, graft resuturing was performed for post-op aqueous leak, which healed with the formation of a corneo-iridic scar. Conclusions: TPG is a safe, simple, inexpensive, and an effective technique for the management of corneal perforations. The advantages include the autologous nature of the graft, cost effectiveness, and easy availability.

Safety and Efficacy of Supratarsal Triamcinolone for Treatment of Vernal Keratoconjunctivitis in Ireland Purpose: To describe the clinical features, risk factors, and treatment outcomes after supratarsal injection of triamcinolone for vernal keratoconjunctivitis (VKC). Methods: A retrospective review of all patients treated with supratarsal triamcinolone for VKC between February 2002 and May 2017 at the Royal Victoria Eye and Ear Hospital and Our Lady's Children Hospital Crumlin, Dublin, Ireland, was performed. Results: Twenty-five patients, 46 eyes, and 145 injections were included for analysis. The mean age at first injection was 9.1 ± 5.7 years. Ninety-six percent of the patients were male. A seasonal variation was noted, with 59 injections (41%) of triamcinolone administered for acute and refractive cases of VKC in the summer compared with 35 (24%), 35 (24%), and 16 (11%) in the spring, autumn, and winter months, respectively. The most common presenting complaint was red eye, which was seen in all cases. Hay fever (64%) was the most common associated systemic disease. Each eye required, on average, 3.2 injections (range 1–9 injections), and the mean duration from the onset of symptoms to final treatment was 3.03 years (range 0–7.9 years). The mean presenting and final visual acuities were 0.33 and 0.11 logarithm of the minimum angle of resolution, respectively (P < 0.0001). During our study period, no patient experienced intraocular pressure rise requiring treatment, development of lenticular opacity, or ptosis after supratarsal injection of triamcinolone. Conclusions: In this case series, supratarsal triamcinolone was used in cases of VKC in which topical medications had failed to control the disease process. All patients reported improvement after treatment. There were no cases of intraocular pressure rise, lenticular opacity, or ptosis development after treatment.

Subtenon Bupivacaine for Postoperative Pain in Patients Undergoing Pterygium Excision: A Double-Blinded Randomized Control Trial Purpose: Patients undergoing primary pterygium excision with autologous conjunctival autograft and human tissue adhesive in New Zealand, currently receive subconjunctival anesthesia with oral postoperative analgesia for pain. Our aim was to investigate the potential added benefit of intraoperative subtenon bupivacaine to this regimen. Methods: A double-blinded, placebo-controlled, randomized trial was conducted at 2 centers. All patients received topical and subconjunctival anesthesia intraoperatively, with standardized oral analgesia as required postoperatively. Participants were allocated to receive subtenon bupivacaine 0.5% or placebo at the conclusion of surgery. Corneal epithelial defect and conjunctival graft size were recorded. Pain and ocular surface irritation were assessed (Likert scale) immediately postoperatively at 3, 6, 12, 24, and 36 hours. Cumulative oral analgesia consumption (doses) was reported at 24 and 36 hours. Results: Forty-two patients were randomized with participants evenly matched at baseline. Postoperative pain at all time points ≤24 hours was significantly less (2.4 vs. 1.2; P < 0.04) in the bupivacaine arm with no difference at 36 hours (P = 0.27). Ocular surface irritation was also significantly less at all time points ≤12 hours (4.8 vs. 1.3; P < 0.01) with no difference at 24 hours (P = 0.10). Analgesia consumption was less in the bupivacaine arm at 24 (6.5 vs. 2.5; P < 0.01) and 36 hours (7.6 vs. 3.4; P < 0.01). No complications were observed. Conclusions: Intraoperative subtenon bupivacaine improves patient comfort after pterygium excision by reducing pain, irritation, and requirement for oral analgesia after surgery.

Changes in Corneal Biomechanical Properties After Descemet Membrane Endothelial Keratoplasty Purpose: To evaluate the course of corneal biomechanical properties (corneal hysteresis and corneal resistance factor) after Descemet membrane endothelial keratoplasty (DMEK) in patients with Fuchs endothelial dystrophy (FECD). Methods: In this prospective study, we consecutively included 49 patients with FECD with an indication for DMEK. Central corneal thickness, measured using the Oculus Pentacam, and corneal hysteresis (CH) and corneal resistance factor (CRF), both measured using the Reichert Ocular Response Analyzer, were examined preoperatively, 3 months, and 6 months after DMEK. Results: CH was significantly increased 6 months postoperatively (8.66 ± 2.50 mm Hg) compared with preoperative baseline (7.43 ± 1.56 mm Hg). Preoperative CRF (7.89 ± 1.68 mm Hg) increased significantly 6 months after DMEK (8.49 ± 1.71 mm Hg). Preoperative central corneal thickness showed a significant decrease from 629 ± 58 μm to 550 ± 40 μm after 3 months and 535 ± 40 μm after 6 months postoperatively. Conclusions: DMEK affects both measured corneal biomechanical properties in patients with FECD: CH and CRF. This has to be taken into account for the accuracy of intraocular pressure measurements.

Effect of Graft Shift Direction on Graft Detachment and Endothelial Cell Survival After Descemet Membrane Endothelial Keratoplasty Purpose: To investigate the effects of graft shift orientation on clinical outcomes after Descemet membrane endothelial keratoplasty (DMEK). Methods: This study used intraoperative video images to retrospectively examine the effect of graft shift direction in 50 eyes of 50 patients. Correlations were assessed between graft shift direction and multiple parameters. Results: The graft detachment rate was higher in eyes with an inferior graft shift than in those without (superior, 0% and 5.0%; nasal, 0% and 20.0%; inferior, 16.7% and 55.0%; temporal, 16.7% and 45.0%; and any segment, 23.3% and 65.0%; for graft shift–negative and graft shift–positive cases, respectively). Postoperative endothelial cell density reduction was higher in eyes with an inferior graft shift (1 month, 23.6% ± 13.7% and 37.5% ± 18.8%; 3 months, 31.6% ± 16.4% and 45.2% ± 15.2%; and 6 months, 39.8% ± 14.9% and 50.7% ± 16.6%; for graft shift–negative and graft shift–positive cases, respectively). Eyes with a superior graft shift had lower postoperative endothelial cell density reduction than those without (1 month, 36.9% ± 16.6% and 20.0% ± 13.1%; 3 months, 45.3% ± 13.3% and 27.4% ± 16.2%; and 6 months, 51.3% ± 14.6% and 35.9% ± 14.5%; for graft shift–negative and graft shift–positive cases, respectively). Graft shift direction did not affect postoperative best-corrected visual acuity or central corneal thickness. Conclusions: Graft shift direction in DMEK, especially inferior graft shift, affected the postoperative graft detachment rate. Superior graft shift had a beneficial effect on postoperative corneal endothelial values. These data suggest that inferior graft shift should be avoided in DMEK.

Anterior Chamber Rebubbling With Perfluoropropane (C3F8) After Failed Rebubbling Attempts for Persistent Descemet Membrane Endothelial Keratoplasty Graft Detachments Purpose: To describe the clinical outcomes of using C3F8 as a tamponade agent for the attachment of partially detached Descemet membrane endothelial keratoplasty (DMEK) grafts after failure of previous rebubbling attempts. Methods: Interventional case series. We reviewed the medical records of all DMEK surgeries performed at Rabin Medical Center (Petach Tikva, Israel) between January 2016 and December 2018 in which 10% C3F8 tamponade was used for graft reattachments. Patient demographic details, indication for surgery, early postoperative endothelial cell loss, postoperative visual acuity, intraoperative and postoperative complications as well as graft survival were noted. Results: Five patients were included in this case series. Indications for DMEK were pseudophakic bullous keratopathy (n = 3), failed penetrating graft (n = 1), and Fuchs endothelial dystrophy (n = 1). In 4 of 5 cases, SF6 tamponade was used at the end of the initial DMEK surgery. In 1 case, air tamponade was used. In all cases, partial graft detachment was seen 1 to 2 weeks postoperatively, and anterior chamber rebubbling was performed using 20% SF6 gas. A second C3F8-assisted rebubbling was performed 10 to 70 days after the primary DMEK surgery. In all cases, complete graft attachment was achieved, and the corneas cleared. Early endothelial cell loss rates averaged at 44% ± 26% (range 20%–74%). One case which had a previous trabeculectomy with chronic preoperative and postoperative hypotony had failed 6 months after surgery. All the other grafts were clear at last visit. Conclusions: Tamponade using nonexpansile 10% C3F8 gas can attach partially detached DMEK grafts after the failure of previous air- or SF6-assisted rebubbling attempts.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Trauma Nursing

The Year Ahead No abstract available

Ethics at Work: What Nurses Really Do on the Job No abstract available

Nurse Practitioners' Role in Improving Service for Elderly Trauma Patients Preexisting conditions and decreased physiological reserve in the elderly frequently complicate the provision of health care in this population. A Level 1 trauma center expanded its nurse practitioner (NP) model to facilitate admission of low-acuity patients, including the elderly, to trauma services. This model enabled NPs to initiate admissions and coordinate day-to-day care for low-acuity patients under the supervision of a trauma attending. The complexity of elderly trauma care and the need to evaluate the efficacy of management provided by NPs led to the development of the current study. Accordingly, this study endeavored to compare outcomes in elderly patients whose care was coordinated by trauma NP (TNP) versus nontrauma NP (NTNP) services. Patients under the care of TNPs had a 1.22-day shorter duration of hospitalization compared with that of the NTNP cohort (4.38 ± 3.54 vs. 5.60 ± 3.98, p = .048). Decreased length of stay in the TNP cohort resulted in an average decrease in hospital charges of $13,000 per admission ($38,053 ± $29,640.76 vs. $51,317.79 ± $34,756.83, p = .016). A significantly higher percentage of patients admitted to the TNP service were discharged home (67.1% vs. 36.0%, p = .002), and a significantly lower percentage of patients were discharged to skilled nursing facilities (25.7% vs. 51.9%, p = .040). These clinical and economic outcomes have proven beneficial in substantiating the care provided by TNPs at the study institution. Future research will focus on examining the association of positive outcomes with specific care elements routinely performed by the TNPs in the current practice model.

Nurse Practitioners' Role in Improving Service for Elderly Trauma Patients No abstract available

Implementation of a Health Literacy Universal Toolkit to Improve Postdischarge Care at an Urban Trauma Center Topic: Low health literacy impacts the financial burden of hospitals up to $238 billion annually. A trauma center located on the East Coast implemented a Transitional Care Management (TCM) model targeting individuals at risk for readmission, but not every patient receives this service. Purpose: A gap analysis of the facility's discharge process identified a deficit in the formal evaluation of health literacy upon discharge. The purpose of this project was to implement a Health Literacy Universal Toolkit to assess and improve medication education for low literacy patients. Included in the toolkit were the Rapid Estimate of Adult Literacy in Medicine Short Form (REALM-SF), an evidence-based health literacy screening tool, and 2 interventions, additional education on their inpatient or discharge medication list, and a Brown Bag Medicine Review of medications at a postdischarge clinic appointment. Conclusion: Seventy-one patients were screened using the REALM-SF. Sixty-two percent (n = 44) of patients scored at a high school reading level, 30% (n = 21) scored at a seventh- to eighth-grade reading level, and 8% (n = 6) scored at or below a sixth-grade reading level. Eight percent of patients scored as having low health literacy, 30% scored as having marginal health literacy, and 62% scored as having adequate health literacy. Twenty patients received additional medication education with My Medicines Form or a Brown Bag Medicine Review. Key Points: Regardless of literacy level, patients appreciated the additional medication education interventions. Health care providers should observe universal health literacy precautions regardless of literacy level.

Hypocalcemia and Massive Blood Transfusions: A Pilot Study in a Level I Trauma Center Trauma is a leading cause of death in the United States, and uncontrolled hemorrhage is often the primary cause of mortality. Massive transfusions provide lifesaving treatment for the bleeding trauma patient; yet, this is not a benign intervention. Calcium levels can be significantly decreased with rapidly transfused blood products due to the citrate preservative that is added. Citrate binds to the patient's endogenous calcium when blood products are administered, rendering calcium inactive. As a result, undesirable physiological effects can occur. Although there is a plethora of evidence reporting the negative effects of hypocalcemia during resuscitation, the research for standardization of calcium monitoring and replacement during a massive transfusion event is less robust. Consequently, monitoring and replacement of this vital electrolyte are often overlooked. Trauma department employees at an urban academic hospital were given a pretest to assess their knowledge of calcium monitoring and replacement during a massive transfusion. On the basis of test results and a need for staff education, a short, animated video was designed and distributed for viewing. Following the educational video, a posttest was administered and yielded higher scores when compared with the pretest (p = .001). Lack of knowledge and national standards may be root causes for hypocalcemia. Educational interventions such as innovative, brief videos can be effective for enhancing staff members' knowledge and improving patient care.

Bridging the Gap: Utilizing a Pediatric Trauma Care Coordinator to Reduce Disparities for Pediatric Trauma Follow-Up Care An American College of Surgeons–verified Level I pediatric trauma center found that some children with severe and complex injuries experienced disruptions in trauma follow-up care because of the lack of centralized care coordination after hospital discharge. A review of the literature identified little guidance to address this issue. A quality improvement project assessed the gaps in care, identified high-risk patients, and developed a novel pediatric trauma care coordinator (PTCC) nursing position to bridge the gap. Enhancements to the trauma registry software helped create a log of family and provider communication events with and interventions by the PTCC. High-risk patients were defined as those with either a traumatic brain injury plus 1 other organ system injury requiring surgical specialist follow-up, or those with 3 or more different organ system injuries requiring follow-up with a surgical specialist. Costly return to health care (CRH), which we defined as emergency department visits for 72 hr or less or unplanned readmissions of 30 day or less after hospital discharge was selected as the primary outcome measure and assessed during the pre- and postimplementation periods. In the 12-month preimplementation period, 14 patients had a CRH rate of 14%, compared with the 12-month postimplementation period in which 18 patients had a CRH rate of 0%. Patients received a mean of 21.2 communication events and 14.1 intervention events from the PTCC in the postimplementation period. This report details the process of developing and implementing a PTCC nursing position, the tasks involved, and the initial results of this novel program.

Comparisons of Trauma Outcomes and Injury Severity Score Trauma is a global health problem and a leading cause of mortality. One of the major predictors of trauma mortality is the Injury Severity Score (ISS). Theoretically, as the ISS increases, the probability of survival decreases; ISS = 75 is considered to be not survivable. Studies have shown that some deaths are preventable and some potentially preventable. Hemorrhagic shock is a potentially preventable cause of trauma mortality. A retrospective database review was conducted of the Mississippi Trauma Registry and point-by-serial correlational analyses were conducted to determine the direction of any significant relations between blood product usage, traditional vital signs, and shock index. Pearson correlation, logistic regressions, and odds ratio calculation results revealed that shock index can signal impending hemorrhagic compromise better than traditional vital signs; thus, facilitating early intervention, specifically, as heart rate and shock index increase, the use of blood products increases, and as blood pressure increases, the use of blood products decreases. Independent t tests for shock index and ISS revealed significant differences in the means with relationship to the subgroups "Dead" and "Alive." Higher ISS were found to correlate with higher shock indices. Evaluation of ISS and survivability demonstrates that ISS = 75 is survivable and should not lead one to reflexively assume otherwise. A total mortality finding of only 1.58% (n = 2,010) was unexpected but very encouraging.

Trauma Team Activation: Accuracy of Triage When Minutes Count: A Synthesis of Literature and Performance Improvement Process Accuracy and timeliness of trauma activations are vital to patient safety. The American College of Surgeons mandates the trauma surgeon's presence within 15 min of the patient's arrival to the emergency department (ED) 80% of the time. In 2015, at this Level II Pediatric Trauma Center, average mean activation times were approximately 16 min and activation accuracy (over- and undertriage) affected 27% of the trauma patient activations. This evidence-based quality improvement project set out to determine the most efficient method of Emergency Medical Services (EMS) intake. Communication Center (Com. Center) recordings were carefully reviewed to identify time when EMS notifies the Com. Center and actual time of trauma activation page. A timeline was formulated with assessment of time to activation and patient triage accuracy. An educational curriculum was developed as an intervention for the Com. Center staff. Education included a decision tree for trauma activations and the development of templates for our electronic health record and prompts to improve accurate activations. After additional focus groups analyzed present ED performance and the industry standard, a policy requiring only paramedic-trained staff was put in place. After implementation of the aforementioned intervention, the Com. Center performance revealed reduction in incorrect activations from 27.3% to 10.7% from 2015 to 2016. Mean activation time in January 2015 was 48.5 min before the intervention and 4.71 min postintervention in December 2016; this is a staggering reduction in activation times of 90%!

Trauma Response Nurse: Bringing Critical Care Experience and Continuity to Early Trauma Care Multitrauma patients can benefit significantly from specialized care. Prior to mid-2016, this hospital's trauma team did not include a surgical intensive care unit (SICU) nurse. As the value of bringing this expertise to the patient upon arrival was realized, the role of the trauma response nurse (TRN) was developed. The TRN role was designed to provide a dedicated SICU nurse to care for trauma patients from emergency department (ED) arrival through disposition. The integration of the TRN role into the trauma team sought to improve quality and safety, as well as communication and collaboration, and enhance continuity of care. The primary responsibilities of the TRN were to assist with clinical interventions, transport patients fromthe ED to tests and procedures, and assume care through disposition. Additional TRN duties included education, community outreach, and performance improvement. TRNs now respond to all trauma activations that occur on weekday day shift. This role has improved collaboration between nursing disciplines, improved the overall function of the trauma team, and enhanced the safety of trauma patients during transport. TRNs make valuable contributions to the education and outreach missions of the trauma program and ensure that patients are receiving the highest level of trauma care.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com