Efficacy of rehabilitation interventions evaluated in common neurological conditions in improving participation outcomes: A systematic review.

OBJECTIVE: Modern clinical rehabilitation practice aligned to the International Classification of Functioning, Disability and Health and the Convention on the Rights of Persons with Disabilities highlights the importance of attention to participation in the rehabilitation formulation. This systematic review investigates the efficacy of rehabilitation interventions evaluated in common neurological disorders reported to influence participation outcomes. DATA SOURCES: PubMed, Web of Science and PsycINFO databases were searched from inception to 25 April 2023. Only randomised controlled trials were considered for inclusion. REVIEW METHODS: The data were extracted by two independent reviewers in the following categories: characteristics of the included study publications, description of intervention and outcome measures. RESULTS: A total of 1248 unique article records were identified through the databases. Twenty-eight randomized controlled trials were included with 15 publications having participation as a primary outcome measure. Articles were related to multiple sclerosis (N = 4), spinal cord injury (N = 2), stroke (N = 16) and traumatic brain injury (N = 6). Four publications showed significant differences in pre- and post-intervention within experimental groups. All four articles described participation as primary outcome measure. CONCLUSION: There is a limited evidence of the identified rehabilitation interventions to improve participation in common neurological conditions. However, there was a paucity of articles involving individual with Parkinson's disease that met the inclusion criteria.

Video-Assisted Thoracic Surgery Evacuation of Retained Hemothorax; Timing May Not Increase Thoracoscopic Failure.

INTRODUCTION: Current guidelines for retained hemothorax (rHTX) in trauma patients recommend video-assisted thoracic surgery (VATS) within 4 days. However, this recommendation is currently based upon evidence from small observational studies. The aim of this study is to further evaluate the association between timing of VATS and clinical outcomes in rHTX following trauma. METHODS: Using the 2017-2019 Trauma Quality Improvement Program database, adult (≥15 years-old) trauma patients with rHTX who underwent evacuation of rHTX through VATS were included. Multivariable linear and logistic regression were used to evaluate the association between the timing of VATS and clinical outcomes. Postponing/delaying evacuation through VATS was defined in our analysis as performing the surgery 1 day later in time. RESULTS: 793 patients were included. VATS was performed at a median 4.5 days (Interquartile range = 2.4, 8.4). A 1.17 day increase in hospital length of stay (P = <0.001), a 0.17 day increase in postoperative hospital length of stay (P = 0.007), a 0.48 day increase in ventilation days (P = <0.001), and a 0.66 day increase in intensive care unit length of stay (P = <0.001) was found for each day that VATS was delayed. Additionally, a 1.10 odds ratio for infectious complications (P = <0.001) and a 0.96 odds ratio for discharge to home (P = 0.006) was seen for each day VATS was delayed. There was no significant association between the timing of VATS failure of VATS (defined as requiring additional procedures such as a secondary VATS or progressed to thoracotomy after initial VATS) and mortality (P > 0.05). CONCLUSIONS: While delaying VATS was statistically associated with increased hospital length of stay, and other secondary outcomes, the clinical significance of the increase in these variables were less dramatic compared to the results of other studies, thus tempering the urgency of evacuation. Additionally, there was no association found between the timing of VATS and mortality, discharge disposition, or the need for additional VATS and/or thoracotomy. Therefore, in the appropriate clinical context, the evacuation of rHTX through VATS can be delayed if clinically necessary, without an associated increase in mortality or the requirement for additional procedures.

Facilitators and barriers to evidence-based practice in central venous access device insertion and management in an intensive care unit: A qualitative study.

INTRODUCTION: Research evidence and clinical practice guidelines exist on preventing central line-associated bloodstream infections. However, there is limited knowledge about the barriers and facilitators to evidence-based central venous access device care. AIM: The aim of this study was to investigate the facilitators and barriers to evidence-based central venous access device care in the adult intensive care setting. METHOD: This exploratory qualitative study involved focus groups and interviews with registered nurses and physicians involved in central venous access device insertion and management in a tertiary Australian intensive care unit. Purposive sampling was used to recruit staff (n = 26) with varying years of clinical experience and clinical positions. Six focus groups and three individual interviews were conducted. Interviews were audio recorded, transcribed verbatim and analysed using content analysis. RESULTS: Three overarching categories emerged: work structures to support optimal performance; processes to optimise quality of care, and factors influencing staff members' behaviour. Perceived facilitators to optimal central venous access device care included explicit language use in procedure documents, work-system integrated strategies, research evidence dissemination, audit, and feedback. However, there was a lack of consistency in practices such as audit, feedback, and patient participation. CONCLUSION: To bring about effective improvement in central venous access device care, future interventions should be tailored to address identified barriers, including integrating audit and feedback into clinicians' work processes. Additionally, future research is needed to explore the role of patients and their families in central venous access device care. IMPLICATIONS FOR CLINICAL PRACTICE: When developing practice policies or procedure manuals, it is important to use explicit language to ensure clear communication of evidence-based recommendations to clinicians. Strategies integrated into work processes can enhance adherence to evidence-based practice. Large departments with limited educators should explore innovative methods like online education to ensure optimal central venous access device care.

ABO Incompatible Kidney Transplantation Without B-cell Depletion is Associated With Increased Early Acute Rejection: A Single-Center Australian Experience.

We performed a single-center retrospective cohort study of 66 consecutive ABO incompatible kidney transplants (ABOiKT) performed without B-cell depleting therapy. Outcomes were compared to an earlier era performed with rituximab (n = 18) and a contemporaneous cohort of ABO compatible live donor transplants (ABOcKT). Acute rejection within 3 months of transplant was significantly more common after rituximab-free ABOiKT compared to ABOiKT with rituximab (OR 8.8, p = 0.04) and ABOcKT (OR 2.9, p = 0.005) in adjusted analyses. Six recipients of rituximab-free ABOiKT experienced refractory antibody mediated rejection requiring splenectomy, and a further two incurred early graft loss with no such episodes amongst ABOiKT with rituximab or ABOcKT cohorts. Patient and graft survival were similar between groups over a median follow-up of 3.1 years. This observational evidence lends strong support to the continued inclusion of rituximab in desensitization protocols for ABOiKT.

Everolimus-Eluting Stents or Bypass Surgery for Multivessel Disease in Diabetics: The BEST Extended Follow-Up Study.

BACKGROUND: Diabetes mellitus is associated with more complex coronary artery diseases. Coronary artery bypass grafting (CABG) is a preferred revascularization strategy over percutaneous coronary intervention (PCI) in diabetics with multivessel coronary artery disease (MVD). OBJECTIVES: This study sought to examine the different prognostic effects of revascularization strategies according to the diabetes status from the randomized BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) trial. METHODS: Patients (n = 880) with MVD were randomly assigned to undergo PCI with an everolimus-eluting stent vs CABG stratified by diabetics (n = 363) and nondiabetics (n = 517). The primary endpoint was the composite of death, myocardial infarction, or target vessel revascularization during a median follow-up of 11.8 years (IQR: 10.6-12.5 years). RESULTS: In diabetics, the primary endpoint rate was significantly higher in the PCI group than in the CABG group (43% and 32%; HR: 1.53; 95% CI: 1.12-2.08; P = 0.008). However, in nondiabetics, no significant difference was found between the groups (PCI group, 29%; CABG group, 29%; HR: 0.97; 95% CI: 0.67-1.39; P = 0.86; Pinteraction= 0.009). Irrespective of the presence of diabetes, no significant between-group differences were found in the rate of a safety composite of death, myocardial infarction, or stroke and mortality rate. However, the rate of any repeat revascularization was significantly higher in the PCI group than in the CABG group. CONCLUSIONS: In diabetics with MVD, CABG was associated with better clinical outcomes than PCI. However, the mortality rate was similar between PCI and CABG irrespective of diabetes status during an extended follow-up. (Ten-Year Outcomes of Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease [BEST Extended], NCT05125367; Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease [BEST], NCT00997828).

Lower platelet count and metastatic tumor are associated with increased risk of spontaneous bleeding in critically ill patients with cancer: An observational study.

BACKGROUND: Thrombocytopenia is common in critically ill patients with cancer. However, the association of platelet count with spontaneous bleeding is controversial in critically ill patients and the association with cancer-related characteristics is unknown. METHODS: This observational study includes patients with active cancer and severe thrombocytopenia. A logistic regression model adjusted for confounders was used to evaluate the association of daily platelet count and cancer-related characteristics (type of cancer and presence of metastasis) with spontaneous bleeding. Confounders were identified using directed acyclic graphs. RESULTS: We screened 5822 patients, 255 (4.4%) met eligibility criteria resulting in 1401 daily observations. Fifty-three patients (20.8%) had spontaneous bleeding during the intensive care unit stay, 64% presenting minor, and 36% major bleeding. The adjusted odds ratio (OR) for spontaneous bleeding with platelet count between 49 and 20 × 109 /L was 4.6 (1.1-19.6), with platelet count between 19 and 10 × 109 /L was 14.2 (3.1-66.2), and with platelet count below 10 × 109 /L was 39.6 (6.9-228.5). The adjusted OR for spontaneous bleeding in patients with hematologic malignancies was 0.6 (0.4-1.2), and 4.3 (2.0-9.0) for patients with metastatic tumor. CONCLUSIONS: In critically ill patients with active cancer and severe thrombocytopenia, lower counts of platelets and presence of metastasis are associated with increased risk of spontaneous bleeding, while hematologic malignancy is not associated with increased risk of spontaneous bleeding.

Teamwork and mental workload in postsurgical pediatric patient handovers: Prospective effect evaluation of an improvement intervention for OR-PICU patient transitions.

Postsurgical handover of pediatric patients from operating rooms (OR) to pediatric intensive care units (PICU) is a critical step. This transition is susceptible to errors and inefficiencies particularly if poor multidisciplinary teamwork occurs. Despite wide adoption of standardized handover interventions, comprehensive investigations into joint effects for patient care and provider outcomes are scarce. We aimed to improve OR-PICU handovers quality and sought to evaluate the intervention with particular attention to patient care effects and provider outcomes. A prospective, before-after-study design with an interrupted-series and a multi-source, mixed-methods evaluation approach was established. Drawing upon a participative plan-do-study-act approach, a standardized, checklist-based handover process was designed and implemented. For effect assessments, we observed OR-PICU handovers on site (pre implementation: n = 31, post: n = 30), respectively, with standardized expert observation and provider self-report tools (n = 111, n = 110). Setting was a tertiary Pediatric University Hospital. Supplementary qualitative, semi-structured interviews were conducted, and a general inductive content analysis approach was used to identify key facilitators and barriers on implementation. Improvement efforts focused on stepwise implementation of (1) standardized handover process and (2) a checklist for multi-professional OR-PICU handover communication. We observed significant increases in team and patient setup (pre: 79.3%, post: 98.6%, p < .01), enhanced team engagement (pre: 50%, post: 81.7%, p < .01), and comprehensive information transfer by the anesthesia sub-team (pre: 78.6%, post: 87.3%, p < .01). Expert-rated teamwork outcomes were consistently higher, yet self-reported teamwork did not change over time. Provider perceived stress and disruptions did not change, mental workload tended to decrease over time (pre: M = 3.2, post: 2.9, p = .08). Comprehensiveness of post-operative patient information reported by PICU physician increased significantly: pre: 65.9%, post: 76.2%, p < .05. After implementation, providers acknowledged the importance of standardized handover practices and associated benefits for facilitation of information transfer and comprehensiveness. Among reported barriers were obstacles during implementation as well as insufficient consideration of professionals' individual workflow after surgery. CONCLUSION:  A multidisciplinary intervention for postsurgical pediatric patient handovers was associated with improved expert-rated teamwork and fewer omissions of key patient information over time. Inconsistent results were obtained for provider-rated mental workload and teamwork outcomes. The findings contribute to a better understanding concerning the interplay of teamwork and provider cognitions in the course of establishing safe patient transitions in pediatric care. WHAT IS KNOWN: • Transfer of critically ill children conveys significant challenges for interprofessional communication and teamwork. Prospective research into interventions for safe and efficient handover practices of OR PICU patient transitions is necessary. • Checklists are assumed to facilitate cognitive load among providers in acute clinical environments. WHAT IS NEW: • A standardized, checklist-based handover intervention was associated with improvements in team set-up and information transfer. Provider outcomes such as mental workload and stress did not change over time. • The combination of teamwork and provider assessments allows a more nuanced understanding of implementation barriers and sustainable effects in course of OR-PICU handover interventions.

A Systematic Review of Interventions With an Educational Component Aimed at Increasing Enrollment and Participation in Cardiac Rehabilitation.

OBJECTIVE: The aim of this study was to systematically review the impact and characteristics of interventions with an educational component designed to improve enrollment and participation in cardiac rehabilitation (CR) among patients with cardiovascular disease. REVIEW METHODS: Five electronic databases were searched from data inception to February 2023. Randomized controlled trials and controlled, cohort, and case-control studies were considered for inclusion. Title, abstract, and full text of records were screened by two independent reviewers. The quality of included studies was rated using the Mixed Methods Assessment Tool. Results were analyzed in accordance with the Synthesis Without Meta-analysis reporting guideline. RESULTS: From 7601 initial records, 13 studies were included, six of which were randomized controlled trials ("high" quality = 53%). Two studies evaluated interventions with an educational component for health care providers (multidisciplinary team) and 11 evaluated interventions for patient participants (n = 2678). These interventions were delivered in a hybrid (n = 6; 46%), in-person (n = 4; 30%), or virtual (n = 3; 23%) environment, mainly by nurses (n = 4; 30%) via discussion and orientation. Only three studies described the inclusion of printed or electronic materials (eg, pamphlets) to support the education. Eleven of 12 studies reported that patients who participated in interventions with an educational component or were cared for by health care providers who were educated about CR benefits (inhospital and/or after discharge) were more likely to enroll and participate in CR. CONCLUSION: Interventions with an educational component for patients or health care providers play an important role in increasing CR enrollment and participation and should be pursued. Studies investigating the effects of such interventions in people from ethnic minority groups and living in low-and-middle-income countries, as well as the development of standard educational materials are recommended.

Pulmonary Rehabilitation Exercise Based on Wearable Device Pedometer Improved Lung Cancer Patients with Impaired Pulmonary Function.

Objective: Lung cancer patients mostly had different degrees of impaired pulmonary function, and these damage also significantly affect quality of life. The concept of pulmonary rehabilitation applicable to patients with chronic respiratory diseases is also applicable to patients with lung cancer. The current application of pulmonary rehabilitation for lung cancer is inconsistent, and reliable guidelines are lacking. The purpose of this study was to investigate the effect of pulmonary rehabilitation exercise based on wearable device pedometer on lung cancer patients with impaired pulmonary function, and to find a suitable pulmonary rehabilitation program for patients with lung cancer. Methods: In this retrospective study, 100 lung cancer patients with impaired pulmonary function were included. Among them, 51 patients received pulmonary rehabilitation exercise based on a wearable device pedometer (Experiemental group), while 49 received routine nursing mode (Control group). The respiratory function, quality of life, and sports endurance of the two groups were observed. Results: The incidence of postoperative atelectasis, pulmonary infection, hypoxemia, postoperative oxygen therapy time, chest tube indwelling time, and postoperative hospital stay in the experimental group were significantly lower than those in the control group (P < .05); The FEV1, FVC and FVE1% of the experimental group were significantly higher than those of the control group after intervention (all P < .05). Conclusion: Pulmonary rehabilitation exercise based on a wearable device pedometer can effectively improve the respiratory function and exercise endurance of lung cancer patients with impaired pulmonary function and can improve the quality of life and reduce the length of hospital stay.

Nephrology consultation improves the clinical outcomes of patients with acute kidney injury.

Background: Acute kidney injury (AKI) is prevalent in critically ill patients and is associated with an increased risk of in-hospital mortality. Nephrology consultation may be protective, but this has rarely been evaluated in South Korea. Methods: This multicenter retrospective study was based on the electronic medical records (EMRs) of two third-affiliated hospitals. We extracted the records of patients admitted to intensive care units (ICUs) between 2011 and 2020, and retrospectively detected AKI using the modified serum creatinine criteria of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. The AKI diagnosis date was defined as the first day of a significant change in serum creatinine level (≥0.3 mg/dL) within 48 hours. Nephrology consultation status was retrieved from the EMRs. Results: In total, 2,461 AKI patients were included; the median age was 65 years (interquartile range [IQR], 56-75 years), 1,459 (59.3%) were male, and 1,065 (43.3%) were of AKI stage 3. During a median of 5 days (IQR, 3-11 days) of ICU admission, nephrology consultations were provided to 512 patients (20.8%). Patients who received such consultations were older, had more comorbidities, and more commonly required dialysis. In a multivariable model, nephrology consultation reduced the risk of in-hospital mortality by 30% (hazard ratio, 0.71; 95% confidence interval, 0.57-0.88). Other factors significant for in-hospital mortality were older age, a higher sequential organ failure assessment (SOFA) score, sepsis, diabetes, hypertension, heart disease, and cancer. Conclusion: For AKI patients in ICUs, nephrology consultation reduced the risk of in-hospital mortality, particularly among those with multiple comorbidities. Therefore, nephrology consultation should not be omitted during ICU care.

An optimized procedure for Luminex-based human platelet antigen-specific antibody screening and identification (PakLx assay) with a cost-effective approach and improved sensitivity.

BACKGROUND AND OBJECTIVES: Detection of anti-platelet antibodies is required for the diagnosis of foetal/neonatal alloimmune thrombocytopaenia. The most commonly used methods for anti-platelet antibody detection are the monoclonal antibody-specific immobilization of platelet antigens (MAIPA) and the Luminex bead assay (PakLx). However, for economic reasons, the use of the PakLx assay is limited. MATERIALS AND METHODS: In the present study, we evaluated the performance of an optimized protocol based on a half-volume of PakLx reagents. We compared two alternative procedures: one with a half-volume of all components including patient samples, and another based on a half-volume of reagents but a standard volume of patient sample. RESULTS: Our results obtained with a panel of 67 samples demonstrate improved sensitivity when using a standard sample volume. CONCLUSION: In the event of an inconclusive result with this optimized protocol (e.g., incomplete panel of positive Luminex beads), we recommend testing the sample with an alternative protocol (e.g., MAIPA or the original PakLx protocol).

Rehabilitation improves persistent symptoms of COVID-19: a non-randomized, controlled, open study in Brazil.

OBJECTIVE: This study aimed to investigate the effects of an 8-week face-to-face rehabilitation program on subjects with persistent symptoms of COVID-19 compared to a remote monitoring group. DESIGN: Clinical, non-randomized, controlled, and open study. The face-to-face supervised rehabilitation lasted eight consecutive weeks, twice a week. The remote monitoring group received health guidance. The allocation was carried out by preference due to the emergency period without vaccination during the pandemic. Fatigue, dyspnea (Pulmonary Functional Status and Dyspnea Questionnaire), and exercise capacity (Incremental Shuttle Walk Test) were the primary outcome measures. Lung function, functional status (Post-COVID-19 Functional Status), symptoms of anxiety and depression (Hospital Anxiety and Depression Scale), attention (d2-R), memory (Rey's Auditory-Verbal Learning Test), handgrip strength, and knee extensor strength were secondary outcome measures. RESULTS: 37 subjects (24.3% hospitalized) completed the baseline and final assessment, rehabilitation [n = 22, 40.8 (SD 10.0) years, 54.5% female], or remote guidance [n = 15, 45.4 (SD 10.5) years, 40% female]. Both groups showed improved fatigue and exercise capacity. Exercise rehabilitation improved dyspnea, anxiety, attention, and short-term memory. CONCLUSION: Rehabilitation is essential for dyspnoea in subjects with persistent symptoms of COVID-19 while fatigue naturally reverses.

Pain Assessment and Management Practices via Education & Reinforcement (PAMPER): A Quality Improvement Initiative.

OBJECTIVES: To establish neonatal pain management practices as an essential developmental supportive measure at a tertiary care unit. METHODS: This quality improvement initiative was conducted as per Point-of-Care-Quality-Improvement Model over 6 mo, followed by 2 y of sustenance phase at a Neonatal Intensive Care Unit (NICU) in northern India. Infants of birth weight ≤1800 g were included and assessed for pain. Pain Assessment and Management Practices via Education and Reinforcement (PAMPER) group was created by resident doctors and nursing staff. The Premature Infant Pain Profile score was used for the assessment of pain. Limiting factors were analyzed using a fishbone diagram and interventions were done in multiple Plan-Do-Study-Act cycles. RESULTS: At the end of interventions, 100% of procedures were assessed for pain. The mean (standard deviation) documented pain score for the first seven days was reduced from 12.8 (0.3) in the baseline phase to 7 (2.5). These interventions helped to sustain the practice in >70% of infants in the next 2 y. CONCLUSIONS: Low-cost interventions improved the pain assessment and management policy of authors' NICU with the establishment of a standard protocol. Audits and reinforcement at regular intervals helped in its long-term sustenance.

Strategies supporting parent-delivered rehabilitation exercises to improve motor function after paediatric traumatic brain injury: A systematic review.

AIM: To identify and analyse ways in which parents are supported to deliver rehabilitation exercises to their child after traumatic brain injury (TBI), conceptualized as strategies. METHOD: A systematic search was completed using seven online databases and three grey literature databases, from inception to November 2021. The included studies focused on physical rehabilitation in children after TBI with the involvement of parents as hands-on deliverers or facilitators of rehabilitation (e.g. supervising the exercise). Intervention descriptions were reviewed to identify strategies; this was followed by fine-grained analysis using the Behaviour Change Wheel to identify intervention components. Risk of bias was analysed using the revised Cochrane Risk-of-Bias Tool for Randomized Trials or the Risk Of Bias In Non-randomized Studies - of Interventions. RESULTS: Six interventions including 211 participants and one trial protocol met the inclusion criteria. All studies included a proportion of children diagnosed with TBI and four studies included mixed samples of acquired brain injury or cerebral palsy. All interventions included elements of goal setting and instruction. INTERPRETATION: Interventions focus heavily on the initiation of physical rehabilitation, but focus less on the longer-term maintenance of rehabilitation delivery. Further research should integrate perspectives from parents to inform the development of new interventions.

Impact of obesity on the conversion of immediate-release tacrolimus to extended-release tacrolimus in kidney transplant recipients.

Outcomes analyzing conversion from IR-tacrolimus (IR) to LCP-tacrolimus (LCP) in obesity are limited. This was a retrospective longitudinal cohort study of patients converted from IR to LCP from June 2019 to October 2020. Primary outcomes were conversion ratios for weight-based dose at a steady-state therapeutic level and identification of appropriate dosing weight. Other outcomes included tacrolimus coefficient of variation (CV), time in therapeutic range (TITR), adverse events, infections, donor specific antibodies (DSAs), and acute rejection. A total of 292 patients were included; 156 and 136 patients with a BMI < 30 and BMI ≥ 30 kg/m2 , respectively. Baseline characteristics were similar, except for pancreas transplant, diabetes, and HLA mismatch. IR to LCP conversion ratio ranged from .73 to .79. Mean LCP dose was similar (.08 vs. .07 mg/kg/day for BMI < 30 and BMI ≥ 30 kg/m2 , respectively); there was a significant difference in IR and LCP mg/kg dosing at steady state with TBW (.11 mg/kg vs.09 mg/kg and .08 mg/kg vs. .06 mg/kg, respectively). The most appropriate dosing weight was adjusted body weight (AdjBW), consistent across IR and LCP steady-state doses, and might yield more accurate steady-state dosing requirements. In multivariable modeling, BMI was a significant predictor of steady state mg/kg dosing at therapeutic goal for total body weight (TBW), but not ideal body weight (IBW) or AdjBW.

SO,MCT,OO,FO-ILE Is Associated With Better Side Effect Profile Than SO-ILE in Critically Ill Children Receiving Parenteral Nutrition.

OBJECTIVES: This study aimed to evaluate the side effect profile of soybean oil lipid injectable emulsion -(SO-ILE) and soybean oil, medium-chain triglyceride, olive oil, fish oil lipid injectable emulsion (SO,MCT,OO,FO-ILE) in critically ill children requiring parenteral nutrition (PN). METHODS: This is an observational study of children admitted to our pediatric intensive care unit requiring PN for ≥7 days. Patients were divided into 2 cohorts: SO,MCT,OO,FO-ILE (n = 34) and SO-ILE (n = 111). Outcomes included development of hypertriglyceridemia (HTG), intestinal failure-associated liver disease (IFALD), length of stay, and mortality. Logistic regression was performed after controlling for duration and maximum dose of lipids. RESULTS: The median maximum lipid dose was significantly higher in the SO,MCT,OO,FO-ILE cohort (2.7 vs 3 g/kg; p = 0.01). Prevalence of baseline HTG was similar in both cohorts. After excluding patients with baseline HTG, incidence of HTG upon PN introduction was higher in the SO-ILE cohort (51.2% vs 26.7%; p = 0.02). The SO-ILE cohort also had significantly higher triglyceride concentrations at peak and upon discontinuation of PN (p < 0.05). Direct bilirubin and C-reactive protein were significantly higher in the SO-ILE cohort after stopping PN. Five patients (3.4%) developed IFALD, 4 of whom were in the SO-ILE cohort (p = 0.85). Upon logistic regression, mortality rate and incidence of HTG remained significantly higher in the SO-ILE cohort (adjusted odds ratio, 2.3 [95% CI, 1.1-5.3]; p = 0.04; and adjusted odds ratio, 2.0 [95% CI, 1.3-5.1]; p = 0.03, respectively). CONCLUSIONS: In critically ill children requiring PN, SO-ILE was associated with a higher risk of HTG, -elevated direct bilirubin, inflammatory markers and mortality compared with SO,MCT,OO,FO-ILE.

Comparative analysis of xenogeneic collagen matrix and autogenous subepithelial connective tissue graft to increase soft tissue volume around dental implants: a systematic review and meta-analysis.

OBJECTIVE: The gold standard for a soft tissue augmentation around implants is a subepithelial connective tissue graft (CTG), but the xenogeneic collagen matrices (XCM) started to be used as an alternative. This systematic review aimed to assess the effectiveness XCM in comparison to CTG for the increasing the thickness of the soft tissue around implants. DATA: All studies included at least two parallel groups comparing the use of CTG and XCM with a minimum follow-up of 3 months. As the primary outcome, the amount of soft tissue thickness gain after soft tissue augmentation with XCM or CTG was assessed. Secondary outcomes were clinical and patient-related outcomes; evaluation of aesthetic outcomes, patient-reported outcomes measures (PROMs) and complications. Eligible studies were selected based on the inclusion criteria. Meta-analysis was applied whenever possible. The quality of the evidence of studies including in meta-analysis was assessed using the GRADE approach. SOURCE: A systematic literature search up to January 2022 was conducted using the following electronic databases: PubMed (MEDLINE), Scopus, Cochrane Library, LILACS, eLIBRARY.RU. Unpublished researches, the gray literature, nonprofit reports, government studies and other materials were reviewed electronically using an EASY search. An additional manual search was carried out in November 2022. STUDY SELECTION: Of the 1376 articles from the initial search, 8 randomized controlled trials (RCTs) (306 patients and 325 implants) were included in this systematic review, and 7 studies were part of the meta-analysis. Meta-analysis revealed that XCM is less effective than the CTG in increasing soft tissue thickness around dental implants. However, XCM also provides soft tissue thickness gain and can be recommended for use in various clinical situations. CLINICAL SIGNIFICANCE: Previous systematic reviews and meta-analyses have shown that autologous grafts are more effective than collagen matrices in increasing soft tissue thickness, however, the latter can be used as an alternative. Studies included in previous systematic reviews varied in design, which could lead to limitations. The present systematic review and meta-analysis includes for the first time only randomized controlled clinical trials with collagen matrix of xenogeneic origin in the test group. Tight eligibility criteria were established, and the main parameter studied was soft tissue thickness. It was found that xenogeneic collagen matrix is effective for increasing soft tissue thickness around dental implants, however, the results obtained using an autogenous connective tissue graft are superior.

Efficacy, safety and cost of emicizumab prophylaxis in haemophilia A patients with inhibitors: A nationwide observational study in Taiwan.

INTRODUCTION: Emicizumab mimicking the cofactor function of activated factor VIII (FVIII) restores haemostasis. METHODS: This nationwide observational study aimed to retrospectively investigate efficacy, safety, and cost in 1 year before and up to 3 years after emicizumab prophylaxis for haemophilia A (HA) patients with FVIII inhibitors. RESULTS AND DISCUSSION: A total of 39 severe HA patients with a median age of 23.0 years were enrolled. The median historical peak FVIII inhibitor titre was 174.2 BU/mL with an interquartile range of 56.5-578.8 BU/mL. The median annualized bleeding rate reduced from 24 to 0 events in the first year after emicizumab prophylaxis (p < .01) and sustained in the second and third years. The median annualized joint bleeding rate reduced to 0 and maintained up to 3 years (p < .01). Twenty-seven patients (69.2%) had target joints before emicizumab prophylaxis and only seven patients (17.9%) of them had target joints after prophylaxis. Medical costs, including cost of haemostatic therapy, frequency of outpatient department visits, emergency room visits and hospital admission, were significantly reduced after emicizumab prophylaxis (p < .01). FVIII inhibitor titre decreased after emicizumab prophylaxis. Overall, three (7.7%) patients experienced 202 grade 1 drug-related adverse events after emicizumab prophylaxis. No serious adverse events were reported during emicizumab prophylaxis period. The adherence to emicizumab prophylaxis was 100% up to 3 years. CONCLUSIONS: HA patients with FVIII inhibitors treated with emicizumab prophylaxis resulted in a significant reduction in treated bleeds and associated costs. No new safety events were observed.

The effect of increased positive end expiratory pressure on brain tissue oxygenation and intracranial pressure in acute brain injury patients.

Cerebral hypoxia is an important cause of secondary brain injury. Improving systemic oxygenation may increase brain tissue oxygenation (PbtO2). The effects of increased positive end-expiratory pressure (PEEP) on PbtO2 and intracranial pressure (ICP) needs to be further elucidated. This is a single center retrospective cohort study (2016-2021) conducted in a 34-bed Department of Intensive Care unit. All patients with acute brain injury under mechanical ventilation who were monitored with intracranial pressure and brain tissue oxygenation (PbtO2) catheters and underwent at least one PEEP increment were included in the study. Primary outcome was the rate of PbtO2 responders (increase in PbtO2 > 20% of baseline) after PEEP increase. ΔPEEP was defined as the difference between PEEP at 1 h and PEEP at baseline; similarly ΔPbtO2 was defined as the difference between PbtO2 at 1 h after PEEP incrementation and PbtO2 at baseline. We included 112 patients who underwent 295 episodes of PEEP increase. Overall, the median PEEP increased form 6 (IQR 5-8) to 10 (IQR 8-12) cmH2O (p = 0.001), the median PbtO2 increased from 21 (IQR 16-29) mmHg to 23 (IQR 18-30) mmHg (p = 0.001), while ICP remained unchanged [from 12 (7-18) mmHg to 12 (7-17) mmHg; p = 0.42]. Of 163 episode of PEEP increments with concomitant PbtO2 monitoring, 34 (21%) were PbtO2 responders. A lower baseline PbtO2 (OR 0.83 [0.73-0.96)]) was associated with the probability of being responder. ICP increased in 142/295 episodes of PEEP increments (58%); no baseline variable was able to identify this response. In PbtO2 responders there was a moderate positive correlation between ΔPbtO2 and ΔPEEP (r = 0.459 [95% CI 0.133-0.696]. The response in PbtO2 and ICP to PEEP elevations in brain injury patients is highly variable. Lower PbtO2 values at baseline could predict a significant increase in brain oxygenation after PEEP increase.