Effects of nonpharmacological interventions on sleep improvement and delirium prevention in critically ill patients: A systematic review and meta-analysis.

OBJECTIVE: Sleep disturbance and delirium are common problems experienced by critically ill patients in the intensive care unit (ICU). These interrelated issues increase the length of stay in the ICU but might also negatively affect long-term health outcomes. The objective of this study was to identify the nonpharmacological interventions provided to improve sleep or prevent delirium in ICU patients or both and integrate their effect sizes. REVIEW METHODS: This study was a registered systematic review and meta-analysis. We searched MEDLINE, CINAHL, EMBASE, Web of Science, and Cochrane Library from their inception until December 2021. We included randomised controlled trials and nonrandomised controlled trials-(RCT) that provided nonpharmacological interventions and reported sleep or delirium as outcome variables. Studies not published in English or whose full text was not available were excluded. The quality of the evidence was assessed with version 2 of the Cochrane risk-of-bias tool for RCTs and the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I). RESULTS: The systematic review included 118 studies, and the meta-analysis included 100 studies. Overall nonpharmacological interventions had significant effects on subjective sleep quality (standardised mean difference = 0.30, 95% confidence interval [CI] = 0.05 to 0.56), delirium incidence (odds ratio = 0.62, 95% CI = 0.53 to 0.73), and delirium duration (standardised mean difference = -0.68, 95% CI = -0.93 to -0.43). In individual interventions, aromatherapy, music, and massage effectively improved sleep. Exercise, family participation, information giving, cognitive stimulation, bright light therapy, architectural intervention, and bundles/protocols effectively reduced delirium. Light/noise blocking was the only intervention that ensured both sleep improvement and delirium prevention. CONCLUSIONS: Our results suggest nonpharmacological interventions improve sleep and prevent delirium in ICU patients. We recommend that ICU nurses use nonpharmacological interventions that promote person-environment compatibility in their clinical practice. The results of our review can guide nurses in adopting interventions related to sleep and delirium. PROSPERO REFERENCE NUMBER: CRD42021230815.

Risk Factors for Frailty in Critical Care Survivors: A secondary analysis.

OBJECTIVES: The purpose of this study was to investigate the prevalence of frailty and its risk factors among critical care survivors who were discharged after receiving treatment in an intensive care unit. METHODS: This was a secondary analysis using data from a methodological study conducted between June and August 2018. The sample included 494 adults who had been admitted to the intensive care unit for more than 48 hours within a year. Only post-intensive care frailty was evaluated using the Kihon Checklist. The sociodemographic and intensive care-related risk factors for frailty were analysed using multivariate logistic regression. RESULTS: The prevalence of frailty in the sample was 65.8%. The risk factors for frailty were female sex (adjusted odds ratio [aOR] = 1.68, 95% CI: 1.02-2.78), aged 70 years or older (aOR = 4.16, 95% CI: 2.00-8.65), unemployment (aOR = 2.41, 95% CI: 1.39-4.17) and longer ICU days (aOR = 2.29, 95% CI: 1.35-3.91). Analysis of differences in risk factors according to sex revealed that risk factors for frailty were unemployment and longer ICU length of stay for male and older age for female. CONCLUSION: Health care providers should be aware of frailty risk factors in female and male patients and provide patient-specific interventions for preventing frailty.

The effect of postintensive care syndrome on the quality of life of intensive care unit survivors: A secondary analysis.

BACKGROUND: Despite increasing interest in postintensive care syndrome and the quality of life of intensive care unit survivors, the empirical literature on the relationship between these two variables is limited. OBJECTIVES: This study aimed to examine whether postintensive care syndrome predicts the quality of life of intensive care unit survivors. METHODS: We analysed secondary data, which were collected as part of a larger cross-sectional study. The participants were recruited from six health institutions in Korea. The data of 496 survivors who had been admitted to an intensive care unit for at least 48 h during the past year were analysed. They responded to measures of postintensive care syndrome and quality of life. RESULTS: The participants' mean physical and mental component summary scores (quality of life) were 40.08 ± 8.99 and 40.24 ± 11.19, respectively. Physical impairment (ß = -0.48, p < 0.001), unemployment (ß = -0.19, p < 0.001), low income (ß = -0.11, p = 0.004), older age (ß = -0.08, p = 0.039), and cognitive impairment (ß = -0.11, p = 0.045) predicted lower physical component summary scores. Mental (ß = -0.49, p < 0.001) and cognitive impairment (ß = -0.14, p = 0.005) and low income (ß = -0.09, p = 0.014) predicted mental component summary scores. CONCLUSIONS: The participants reported poor physical and mental health-related quality of life. Postintensive care syndrome, unemployment, low income, and older age were the main predictors of poor quality of life. In addition, postintensive care syndrome was a stronger risk factor for poor quality of life than demographic characteristics and intensive care unit treatment factors.

Giant Mixed Tumor of the Skin Affecting the Hemiface.

Mixed tumor of the skin (MTS) is a rare skin adnexal neoplasm occurring in sweat glands. It is usually benign, measures 0.5 to 3 cm, and presents as a slowly growing, painless, firm nodule commonly in the head and neck regions. Owing to its rarity and lack of distinctive clinical manifestations, confirmative diagnosis is made on the basis of its pathologic features. Malignant MTS also develops de novo or from preexisting benign MTS even though they occur rarely. It should be excised completely to exclude malignant potentials. Herein, we report a 35-year history of a giant MTS of eccrine type measuring approximately 10.5 × 6.5 cm on the right hemiface of a 91-year-old woman, which is the largest facial MTS reported in the literature so far, to the best of our knowledge.

Cut-Off Values of the Post-Intensive Care Syndrome Questionnaire for the Screening of Unplanned Hospital Readmission within One Year.

PURPOSE: This study aimed to assign weights for subscales and items of the Post-Intensive Care Syndrome questionnaire and suggest optimal cut-off values for screening unplanned hospital readmissions of critical care survivors. METHODS: Seventeen experts participated in an analytic hierarchy process for weight assignment. Participants for cut-off analysis were 240 survivors who had been admitted to intensive care units for more than 48 hours in three cities in Korea. We assessed participants using the 18-item Post-Intensive Care Syndrome questionnaire, generated receiver operating characteristic curves, and analysed cut-off values for unplanned readmission based on sensitivity, specificity, and positive likelihood ratios. RESULTS: Cognitive, physical, and mental subscale weights were 1.13, 0.95, and 0.92, respectively. Incidence of unplanned readmission was 25.4%. Optimal cut-off values were 23.00 for raw scores and 23.73 for weighted scores (total score 54.00), with an area of under the curve (AUC) of .933 and .929, respectively. There was no significant difference in accuracy for original and weighted scores. CONCLUSION: The optimal cut-off value accuracy is excellent for screening of unplanned readmissions. We recommend that nurses use the Post-Intensive Care Syndrome Questionnaire to screen for readmission risk or evaluating relevant interventions for critical care survivors.

Risk factors for post-intensive care syndrome: A systematic review and meta-analysis.

OBJECTIVE: The objective of this study was to identify the risk factors for each area of post-intensive care syndrome (PICS) and to determine their effect size. REVIEW METHOD USED: This study used systematic review and meta-analysis. DATA SOURCES: PubMed, CINAHL, EMBASE, PsycINFO, and Cochrane Library were searched. REVIEW METHODS: Eighty-nine studies were selected for the review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PICS areas and risk factors reported in the individual studies were reviewed and categorised. We used the Newcastle-Ottawa Scale to evaluate the quality of studies. The effect size of each risk factor was calculated as odds ratio (OR). RESULTS: There were 33 mental health studies, 15 cognitive impairment studies, 32 physical impairment studies, eight studies on two areas, and one study on all three areas. Sixty risk factors were identified, including 33 personal and 27 intensive care unit (ICU)-related factors. Significant risk factors for mental health included female sex (odds ratio [OR] = 3.37, 95% confidence interval [CI]: 1.12-10.17), previous mental health problems (OR = 9.45, 95% CI: 2.08-42.90), and negative ICU experience (OR = 2.59, 95% CI: 2.04-3.28). The only significant risk factor for cognitive impairment was delirium (OR = 2.85, 95% CI: 1.10-7.38). Significant risk factors for physical impairment included older age (OR = 2.19, 95% CI: 1.11-4.33), female sex (OR = 1.96, 95% CI: 1.32-2.91), and high disease severity (OR = 2.54, 95% CI: 1.76-3.66). CONCLUSIONS: Although PICS is a multidimensional concept, each area has been studied separately. Significant risk factors for PICS included older age, female sex, previous mental health problems, disease severity, negative ICU experience, and delirium. To prevent PICS, the multidisciplinary team should pay attention to modifiable risk factors such as delirium and patients' ICU experience.

Post-intensive care unit depression among critical care survivors: A nationwide population-based study.

AIM: To investigate the incidence of post-intensive care unit (ICU) depression and its risk factors among critical care survivors. METHODS: The study data were extracted from the database of the National Health Insurance Service of Korea. We retrospectively analyzed data from 161,977 adult patients who were admitted to the ICU for more than 24 hr from January 1, 2012 to December 31, 2014 and survived for more than 1 year after discharge. Risk factors for newly diagnosed depression (Code F32) were analyzed using multiple logistic regression analysis. RESULTS: The incidence of post-ICU depression was 18.5%. The major risk factors were enteral nutrition (odds ratio [OR] = 2.28, 95% confidence interval [CI] = 2.19-2.36), cerebrovascular disease (OR = 1.59, 95% CI = 1.54-1.64), and hemi/paraplegia (OR = 1.48, 95% CI = 1.41-1.56). It was observed that cardiopulmonary resuscitation (OR = 0.55, 95% CI = 0.50-0.61) and myocardial infarction (OR = 0.75, 95% CI = 0.71-0.79) lowered depression. CONCLUSIONS: The incidence of post-ICU depression was high and influenced by ICU treatment and physical impairments. Healthcare providers must pay attention to the psychological changes in survivors with major risk factors in the recovery process.

Effects of a smartphone application for cognitive rehearsal intervention on workplace bullying and turnover intention among nurses.

BACKGROUND: Bullying in nursing workplaces has been considered a serious problem that increases nurse turnover. AIM: To develop a cognitive rehearsal intervention for workplace bullying and examine its effects on nurses' bullying experiences and turnover intentions. METHODS: We developed a smartphone application to cognitively train nurses to handle bullying situations in the workplace. This application included common bullying situations and appropriate non-violent communication scenarios. A cluster quasi-randomized trial was performed with 72 hospital nurses working in a university hospital in South Korea from November 2016 to January 2017. We measured workplace bullying experiences and turnover intention before intervention and 4 and 8 weeks after intervention in both intervention and control groups. RESULTS: The cognitive rehearsal intervention developed in this study was effective for decreasing nurses' person-related bullying, work-related bullying experiences, and turnover intention. However, it had no effects on intimidation-related bullying experiences. CONCLUSIONS: The smartphone application-based cognitive rehearsal intervention can serve as a personal coping measure for person-related and work-related bullying among nurses. It is recommended that the intervention developed in this study be applied as a strategy to reduce nurse turnover.

Development and validation of a questionnaire to measure post-intensive care syndrome.

OBJECTIVE: This study aimed to develop a Post-Intensive Care Syndrome Questionnaire (PICSQ) and assess the psychometric properties of PICSQ in intensive care unit survivors. METHODS: PICSQ items were generated through relevant literature reviews, qualitative interviews among survivors, and multiple rounds of content validity evaluations by experts. Data were collected from 536 survivors at seven health care facilities in three cities of Korea from June to August 2018. The validity and reliability of PICSQ were assessed using exploratory factor analysis, confirmatory factor analysis, internal consistency and correlation coefficients. RESULTS: The final PICSQ consisted of 18 items. Through exploratory factor analysis, three factors (mental, cognitive and physical) were derived. The reliability of PICSQ was represented by a Cronbach's α of 0.93, while the internal consistency of each factor was good (Cronbach's α = 0.84 to 0.90). The model fit of PICSQ was satisfactory and confirmatory factor analysis demonstrated good convergent and discriminant validity of the questionnaire. CONCLUSION: Because PICSQ is valid and reliable, it is recommended for use in clinical practice and research to assess post-intensive care syndrome in intensive care survivors.

Delayed contralateral traumatic carotid cavernous fistula after craniomaxillofacial fractures.

A carotid-cavernous sinus fistula is a rare condition in which an abnormal communication exists between the internal or external carotid artery and the cavernous sinus. It typically occurs within a few weeks after craniomaxillofacial trauma. In most cases, the carotid-cavernous sinus fistula occurs on the same side as the craniomaxillofacial fracture. We report a case of delayed carotidcavernous sinus fistula that developed symptoms 7 months after the craniomaxillofacial fracture. The fistula developed on the side opposite to that of the craniomaxillofacial fracture. Based on our experience with this case, we recommend a long follow-up period of 7-8 months after the occurrence of a craniomaxillofacial fracture. We also recommend that the follow-up should include consideration of the side contralateral to the injury.

Embracing the new vulnerable self: A grounded theory approach on critical care survivors' post-intensive care syndrome.

OBJECTIVES: This study explored critical care survivors' experience of post-intensive care syndrome. RESEARCH DESIGN AND SETTING: This qualitative study employed a classic grounded theory approach with 13 survivors after intensive care unit treatment. MAIN OUTCOME MEASURES: Data were collected through one-to-one in-depth interviews. Open, axial and selective coding were performed based on interview transcripts, field notes, and memos. FINDINGS: The analysis of survivors' experience with post-intensive care syndrome led to the 'embracing the new vulnerable self' theory. After discharge from the intensive care, survivors became physically, psychologically, cognitively and socially vulnerable. The survivors were struggling for recovery; they faced new crises and some were devastated. However, their internal and external resources helped them recover. Through coping processes, survivors gained a new perspective on normality. CONCLUSION: These results contribute to understanding the post-intensive care syndrome phenomenon and coping process of critical care survivors. This syndromes is a multidimensional phenomenon and the recovery process is a continuum. An integrated rehabilitation program that extends beyond utilising family support requires development.

[Development and Validation of a Measurement to Assess Person-centered Critical Care Nursing].

PURPOSE: The purpose of this study was to develop a scale to measure person-centered critical care nursing and verify its reliability and validity. METHODS: A total of 38 preliminary items on person-centered critical care nursing were selected using content validity analysis of and expert opinion on 72 candidate items derived through literature review and qualitative interviews. We conducted a questionnaire survey with 477 nurses who worked in intensive care units. The collected data were analyzed using exploratory factor analysis (EFA) and confirmative factor analysis (CFA) with SPSS and AMOS 24.0 program. RESULTS: EFA was performed with principal axis factor analysis and Varimax rotation. The 15 items in 4 factors that accounted for 50.8% of the total variance were identified by deleting the items that were not meet the condition that the commonality should be .30 or more and the factor loading over .40. We named the factors as compassion, individuality, respect, and comfort, respectively. The correlation coefficient between this scale and the Caring Perception Scale was r=.57 (p<.001), which determined concurrent validity. The item-total correlation values ranged from .39 to .63, and the internal consistency for the scale was Cronbach's α=.84. CONCLUSION: The reliability and validity of the 15 item person-centered critical care nursing scale were verified. It is expected that the use of this scale would expand person-centered care in critical care nursing.

[Threats to Identity: A Grounded Theory Approach on Student Nurses' Experience of Incivility during Clinical Placement].

PURPOSE: This qualitative study aimed to explore the experience of incivility among nursing students. METHODS: Sixteen nursing students who had experienced incivility during their clinical placement were invited for one-on-one interviews until the point of theoretical saturation. The grounded theory approach of Corbin and Strauss was adopted to analyze transcribed interview contents. RESULTS: Incivility occurred in the context of a hierarchical organizational culture, due to nursing students' position as outsiders, non-systematic clinical education, and poor nursing work environment. The experience of incivility was identified as "being mistreated as a marginal person," and nursing students responded to this phenomenon in the following three steps: reality shock, passive action, and submissive acceptance. This process caused students to lose self-esteem and undergo role conflict. Furthermore, nursing students' experience of incivility could eventually lead to workplace bullying in nurses. CONCLUSION: The results of this study suggest that nursing students' experience of incivility can be a process that threatens their identity. It is necessary to develop educational programs and provide appropriate counseling services so that nursing students can actively cope with the incivility. In addition, institutional plans are needed to ensure safe and supportive clinical learning environments.

Differential Diagnosis of Intramuscular Schwannoma of the Craniocervical Region.

Schwannomas in the head and neck are a relatively common condition. However, intramuscular schwannomas in the craniocervical region are extremely rare. The preoperative consideration of schwannomas is very important to preserve adjacent circulation and nerve function during the surgery in this area. Moreover, the treatment and preoperative evaluation of this condition is not firmly established in the past literatures. The authors successfully managed the intramuscular schwannoma in the craniocervical region, and provide the differential diagnoses with appropriate treatments.

Cervicofacial Primary Cutaneous Actinomycosis: Surgical Treatment for Complete Remission of the Disease.

Actinomycosis, an infectious bacterial disease caused by Actinomyces species, is very rare and is characterized by contiguous spreading, subacute to chronic granulomatous inflammation and the formation of multiple abscesses and sinus tracts that may discharge sulfur granules. Actinomycosis that presents on the skin without endogenous origin is called primary cutaneous actinomycosis, and the occurrence and treatment of primary cutaneous actinomycosis is rarely reported. This report describes the treatment of primary cervicofacial actinomycosis with a literature review, and emphasizes the importance of surgical option for complete remission of the disease.

Progressive fingertip necrosis after nail avulsion injury in a patient with ulnar artery hypoplasia: A case report.

RATIONALE: Slowly progressive hand ischemia is mostly associated with medical illness such as vasculitis, and in patients with smoking history, Buerger disease is often considered first. However, despite the very low incidence of vascular anatomical anomalies, they can lead to hand ischemia. And if there is no consideration for them, proper treatment cannot be selected. PATIENT CONCERNS: A 42-year-old male smoker presented with a slowly progressing 5th fingertip necrosis following blunt trauma. DIAGNOSES: Angiography revealed congenital hypoplasia of ulnar artery, and excluded Buerger disease or hypothenar hammer syndrome. INTERVENTIONS AND OUTCOMES: We reconstructed the necrotic fingertip using a 2nd toe pulp free flap to reflect the patient's need. LESSONS: In this case report, the authors emphasize that the possibility of anatomical anomaly should be considered as a cause of the ischemia. Vascular imaging should be undertaken to investigate the cause of ischemia of the hand.

The Role of Resorbable Plate and Artificial Bone Substitute in Reconstruction of Large Orbital Floor Defect.

It is essential to reduce and reconstruct bony defects adequately in large orbital floor fracture and defect. Among many reconstructive methods, alloplastic materials have attracted attention because of their safety and ease of use. We have used resorbable plates combined with artificial bone substitutes in large orbital floor defect reconstructions and have evaluated their long-term reliability compared with porous polyethylene plate. A total of 147 patients with traumatic orbital floor fracture were included in the study. Surgical results were evaluated by clinical evaluations, exophthalmometry, and computed tomography at least 12 months postoperatively. Both orbital floor height discrepancy and orbital volume change were calculated and compared with preoperative CT findings. The average volume discrepancy and vertical height discrepancies were not different between two groups. Also, exophthalmometric measurements were not significantly different between the two groups. No significant postoperative complication including permanent diplopia, proptosis, and enophthalmos was noted. Use of a resorbable plate with an artificial bone substitute to repair orbital floor defects larger than 2.5 cm(2) in size yielded long-lasting, effective reconstruction without significant complications. We therefore propose our approach as an effective alternative method for large orbital floor reconstructions.

The Use of Topical Lidocaine Gel During Intermaxillary Fixation Procedure.

This study aimed to validate the usefulness of lidocaine gel during intermaxillary fixation using arch bars in patients with mandible fracture by comparing 2 patient groups: one group using lidocaine gel in intermaxillary fixation and the other group undergoing traditional local infiltration.Subjects were patients with mandible fracture undergoing intermaxillary fixation using arch bars from March 2003 to February 2007. Twenty-three patients were anesthetized in the upper and lower gingiva by 2% local lidocaine solution injection; another 23 underwent topical anesthesia with 2% lidocaine hydrochloride gel applied to the upper and lower gingiva. The convenience of fixation was measured in terms of operation time and degree of pain according to the visual analog scale; arch bar loosening rate was assessed postoperatively.The mean operation times were 63 and 47 minutes in the groups undergoing local infiltration and using topical lidocaine gel, respectively. For pain degree according to the visual analog scale, the mean scores were 6.4 and 3.2 in the groups using local infiltration and topical lidocaine gel, respectively. When the arch bar loosening rate was measured postoperatively, the 2 groups differed significantly, with a rate of 26% in the group using local infiltration and 13% in the group using topical lidocaine gel.Application of topical lidocaine gel during intermaxillary fixation using arch bars in patients with mandible fracture relieves pain and offers convenience in performing the procedure. It can be a useful alternative method for patients who are sensitive to pain or have needle phobia.

Polyurethane Foam-Filled Skull Replica of Craniosynostosis for Surgical Training.

Craniosynostosis has a relatively low incidence in the general population and its treatment requires cautious approaches. For these reasons, patients are usually referred to several specialists or a medical center. Therefore, most trainees and young surgeons do not have any chances to experience patients of craniosynostosis, but learn about it only from textbooks. And for a surgeon who tries to operate on a craniosynostosis patient, it is hard to make a proper preoperative plan.The authors suggest a polyurethane foam-filled skull replica of craniosynostosis for trainees that can also be used in planning a craniosynostosis operation.