Moral distress and psychological status among healthcare workers in a newly established paediatric intensive care unit.

INTRODUCTION: Healthcare workers in intensive care units often experience moral distress, depression, and stress-related symptoms. These conditions can lower staff retention and influence the quality of patient care. This study aimed to evaluate the prevalence of moral distress and psychological status among healthcare workers in a newly established paediatric intensive care unit (PICU) in Hong Kong. METHODS: A cross-sectional questionnaire survey was conducted in the PICU of the Hong Kong Children's Hospital; healthcare workers (doctors, nurses and allied health professionals) were invited to participate. The Revised Moral Distress Scale (MDS-R) Paediatric Version and Depression Anxiety and Stress Scale-21 items were used to assess moral distress and psychological status, respectively. Demographic characteristics were examined in relation to moral distress, depression, anxiety, and stress scores to identify risk factors for poor psychological outcomes. Correlations of moral distress with depression, anxiety, and stress were examined. RESULTS: Forty-six healthcare workers completed the survey. The overall median MDS-R moral distress score was 71. Nurses had a significantly higher median moral distress score, compared with doctors and allied health professionals (102 vs 47 vs 20). Nurses also had the highest median anxiety and stress scores (11 and 20, respectively). Moral distress scores were correlated with depression (r=0.445; P=0.002) and anxiety scores (r=0.417; P<0.05). Healthcare workers intending to quit their jobs had significantly higher moral distress scores (P<0.05). CONCLUSION: Among PICU healthcare workers, nurses had the highest level of moral distress. Moral distress was associated with greater depression, anxiety, and intention to quit. Healthcare workers need support and a sustainable working environment to cope with moral distress.

Monetary reinforcement for self-monitoring of blood glucose among young people with type 1 diabetes: evaluating effects on psychosocial functioning.

AIMS: To explore the auxiliary psychosocial effects of a monetary reinforcement intervention targeting self-monitoring of blood glucose among young people with Type 1 diabetes. METHODS: Sixty young people with Type 1 diabetes, HbA1c concentrations between 58 and 119 mmol/mol (7.5-13.0%), and average self-monitoring of blood glucose <4 times per day were randomized to either enhanced usual care or a 24-week intervention of monetary rewards for self-monitoring of blood glucose and associated behaviours (e.g. uploading glucose meters). Data were collected from the young people and their parents at baseline, during the intervention (6, 12 and 24 weeks) and after the intervention (36 weeks). RESULTS: Linear mixed models were used to evaluate the intervention effects on psychosocial outcomes, adjusting for corresponding baseline levels and potential moderation by baseline level. The intervention reduced diabetes distress at week 6 among young people who had average and high baseline distress. It also reduced diabetes distress at weeks 12 and 24 among those with low baseline distress. The intervention also reduced young person-reported diabetes-related family conflict and diabetes-related interference among those with high baseline scores in these areas; however, the intervention worsened young person-reported diabetes interference among those with low baseline interference. Effects were medium-sized and time-limited. CONCLUSIONS: Findings indicate predominantly positive impacts of monetary reinforcement interventions on psychosocial outcomes, although effects varied by outcome and time point. Whereas early improvements in diabetes distress were observed for all who received the intervention, improvements in other areas varied according to the level of psychosocial challenge at baseline. Incorporating psychosocial interventions may bolster and maintain effects over time.

Reliability and validity of self-reported questionnaires to measure pain and disability in adults with neck pain and its associated disorders: part 3-a systematic review from the CADRE Collaboration.

PURPOSE: To determine the reliability and validity of self-reported questionnaires to measure pain and disability in adults with grades I-IV neck pain and its associated disorders (NAD). METHODS: We updated the systematic review of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and systematically searched databases from 2005 to 2017. Independent reviewers screened and critically appraised studies using standardized tools. Evidence from low-risk-of-bias studies was synthesized according to best evidence synthesis principles. Validity studies were ranked according to the Sackett and Haynes classification. RESULTS: We screened 2823 articles, and 26 were eligible for critical appraisal; 18 were low risk of bias. Preliminary evidence suggests that the Neck Disability Index (original and short versions), Whiplash Disability Questionnaire, Neck Pain Driving Index, and ProFitMap-Neck may be valid and reliable to measure disability in patients with NAD. We found preliminary evidence for the validity and reliability of pain measurements including the Body Pain Diagram, Visual Analogue Scale, the Numeric Rating Scale and the Pain-DETECT Questionnaire. CONCLUSION: The evidence supporting the validity and reliability of instruments used to measure pain and disability is preliminary. Further validity studies are needed to confirm the clinical utility of self-reported questionnaires to assess pain and disability in patients with NAD. These slides can be retrieved under Electronic Supplementary Material.

Reliability and validity of clinical tests to assess posture, pain location, and cervical spine mobility in adults with neck pain and its associated disorders: Part 4. A systematic review from the cervical assessment and diagnosis research evaluation (CADRE) collaboration.

PURPOSE: To determine the reliability and validity of clinical tests to assess posture, pain location, and cervical spine mobility in adults with grades I-IV neck pain and associated disorders (NAD). METHODS: We systematically searched electronic databases to update the systematic review of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Eligible reliability and validity studies were critically appraised using modified versions of the QAREL and QUADAS-2 instruments, respectively. Evidence from low risk of bias studies were synthesized following best evidence synthesis principles. RESULTS: We screened 14302 articles, critically appraised 46 studies, and found 32 low risk of bias articles (14 reliability and 18 validity studies). We found preliminary evidence of: 1) reliability of visual inspection, aided with devices (CROM and digital caliper) to assess head posture; 2) reliability and validity of soft tissue palpation to locate tender/trigger points in muscles; 3) reliability and validity of joint motion palpation to assess stiffness and pain provocation in combination; and 4) range of motion tests using visual estimation (in cervical extension only) or devices (digital caliper, goniometer, inclinometer) to assess cervical mobility. CONCLUSIONS: We found little evidence to support the reliability and validity of clinical tests to assess head posture, pain location and cervical mobility in adults with NAD grades I-III. More advanced validity studies are needed to inform the clinical utility of tests used to evaluate patients with NAD.

Risk of post-operative surgical site infections after vedolizumab vs anti-tumour necrosis factor therapy: a propensity score matching analysis in inflammatory bowel disease.

BACKGROUND: Perioperative vedolizumab (VDZ) and anti-tumour necrosis factor (TNFi) therapies are implicated in causing post-operative complications in inflammatory bowel disease (IBD). AIM: To compare the risk of surgical site infections (SSIs) between VDZ- and TNFi-treated IBD patients in propensity-matched cohorts. METHODS: The Optum Research Database was used to identify IBD patients who received VDZ or TNFi within 30 days prior to abdominal surgery between January 2015 and December 2016. The date of IBD-related abdominal surgery was defined as the index date. SSIs were determined by ICD-9/10 and CPT codes related to superficial wound infections or deep organ space infections after surgery. Propensity score 1:1 matching established comparable cohorts based on VDZ or TNFi exposure before surgery based on evidence-based risk modifiers. RESULTS: The propensity-matched sample included 186 patients who received pre-operative biologic therapy (VDZ, n = 94; TNFi, n = 92). VDZ and TNFi cohorts were similar based on age, gender, IBD type, concomitant immunomodulator exposure, chronic opioid or corticosteroid therapy, Charlson Comorbidity Index and malnutrition. VDZ patients were more likely to undergo an open bowel resection with ostomy. After propensity score matching, there was no significant difference in post-operative SSIs (TNFi 12.0% vs VDZ 14.9%, P = 0.56). Multivariable analysis indicated that malnutrition was the sole risk factor for developing SSI (OR 3.1, 95% CI 1.11-8.71) regardless of the type of biologic exposure. CONCLUSION: In the largest, risk-adjusted cohort analysis to date, perioperative exposure to VDZ therapy was not associated with a significantly higher risk of developing an SSI compared to TNFi therapy.

Market share and costs of biologic therapies for inflammatory bowel disease in the USA.

BACKGROUND: Real-world data quantifying the costs of increasing use of biologics in inflammatory bowel disease (IBD) are unknown. AIM: To determine the outpatient IBD drug utilization trends, relative market share, and costs in the USA during a 9-year period. METHODS: The Truven MarketScan® Database was analysed for patients with Crohn's disease (CD) and ulcerative colitis (UC) during 2007-2015. National drug codes were used to identify prescription drugs; Healthcare Common Procedure Coding System J-codes were used to capture biologic out-patient infusions. Proportion of drug usage, relative market share and per-member per-year (PMPY) costs were analysed for biologics, immunomodulators, 5-ASAs and corticosteroids. RESULTS: In 415 405 patients (188 842 CD; 195 183 UC; 31 380 indeterminate colitis; 54.67% female), utilization trends show a consistent rise in the market share of biologics during the 9-year study period. The proportion of patients using biologics increased from 21.8% to 43.8% for CD and 5.1%-16.2% for UC. This contrasts a small decrease in immunomodulator and 5-ASA use for CD and relative constancy of other classes including corticosteroids-only use as primary IBD medication from 2007 to 2015. The average biologic-taking patient accounted for $25 275 PMPY in 2007 and $36 051 PMPY in 2015. The average paediatric biologic-taking patient accounted for $23 616 PMPY in 2007 and $41 109 PMPY in 2015. In all patients, the share of costs for biologics increased from 72.9% in 2007 to 85.7% in 2015 (81.7% in 2007 to 94.9% in 2015 in paediatrics). CONCLUSION: The vast majority of costs allocated to out-patient IBD medications in the USA is attributed to increasing use of biologic therapies despite the relative minority of biologic-taking patients.

Reliability and validity of clinical tests to assess the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders: Part 1-A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration.

OBJECTIVE: To determine the reliability and validity of clinical tests to assess the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders. METHODS: We updated the systematic review of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders. We also searched the literature to identify studies on the reliability and validity of Doppler velocimetry for the evaluation of cervical arteries. Two independent reviewers screened and critically appraised studies. We conducted a best evidence synthesis of low risk of bias studies and ranked the phases of investigations using the classification proposed by Sackett and Haynes. RESULTS: We screened 9022 articles and critically appraised 8 studies; all 8 studies had low risk of bias (three reliability and five validity Phase II-III studies). Preliminary evidence suggests that the extension-rotation test may be reliable and has adequate validity to rule out pain arising from facet joints. The evidence suggests variable reliability and preliminary validity for the evaluation of cervical radiculopathy including neurological examination (manual motor testing, dermatomal sensory testing, deep tendon reflexes, and pathological reflex testing), Spurling's and the upper limb neurodynamic tests. No evidence was found for doppler velocimetry. CONCLUSIONS: Little evidence exists to support the use of clinical tests to evaluate the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders. We found preliminary evidence to support the use of the extension-rotation test, neurological examination, Spurling's and the upper limb neurodynamic tests.

Clinical spectrum of children receiving palliative care in Malaysian Hospitals.

INTRODUCTION: Awareness for paediatric palliative care has resulted in the impetus for paediatrician-led palliative care services across Malaysia. However, there is paucity of local data on patients receiving hospital-based paediatric palliative care. We aim to review the clinical spectrum of patients referred to these services. METHODS: An observational study of children aged between 0-18 years receiving palliative care at 13 hospitals between 1st January and 31st December 2014 was carried out. RESULTS: There were 315 patients analysed, 90 (28.6%) and 46 (14.6%) were neonates and adolescents respectively. The main ICD-10 diagnostic categories for all patients were identified to be 'Congenital malformations, deformations and chromosomal abnormalities' 117 (37.1%), 'Diseases of nervous system' 76 (24.1%) and 'Neoplasms' 60 (19.0%). At referral 156 (50%) patients had holistic needs assessments. Patients with 'Diseases of nervous system' were assessed to have significantly more physical needs than the other two diagnostic categories. Majority of patients who knew of their diagnosis and prognosis were those with malignancy. Over a fifth of referrals were at their terminal admission. Of 144 who died, 111 (77.1%) had advanced care plans. There was bereavement follow-up in 98 (68.1%) patients. CONCLUSION: Patients referred for palliative care have varied diagnoses and needs. To ensure all paediatricians are competent to deliver quality care to all children, further education and training initiatives is imperative.

Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed. Overall, most guidelines target nonspecific LBP and recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments. The recommendation to use paracetamol for acute LBP is challenged by recent evidence and needs to be revisited. SIGNIFICANCE: Most high-quality guidelines recommend education, staying active/exercise, manual therapy and paracetamol/NSAIDs as first-line treatments for LBP. Recommendation of paracetamol for acute LBP is challenged by recent evidence and needs updating.

Oscillatory spin polarization and magneto-optical Kerr effect in Fe3O4 thin films on GaAs(001).

The spin dependent properties of epitaxial Fe3O4 thin films on GaAs(001) are studied by the ferromagnetic proximity polarization (FPP) effect and magneto-optical Kerr effect (MOKE). Both FPP and MOKE show oscillations with respect to Fe3O4 film thickness, and the oscillations are large enough to induce repeated sign reversals. We attribute the oscillatory behavior to spin-polarized quantum well states forming in the Fe3O4 film. Quantum confinement of the t(2g) states near the Fermi level provides an explanation for the similar thickness dependences of the FPP and MOKE oscillations.

Coronin promotes the rapid assembly and cross-linking of actin filaments and may link the actin and microtubule cytoskeletons in yeast.

Coronin is a highly conserved actin-associated protein that until now has had unknown biochemical activities. Using microtubule affinity chromatography, we coisolated actin and a homologue of coronin, Crn1p, from Saccharomyces cerevisiae cell extracts. Crn1p is an abundant component of the cortical actin cytoskeleton and binds to F-actin with high affinity (Kd 6 x 10(-9) M). Crn1p promotes the rapid barbed-end assembly of actin filaments and cross-links filaments into bundles and more complex networks, but does not stabilize them. Genetic analyses with a crn1Delta deletion mutation also are consistent with Crn1p regulating filament assembly rather than stability. Filament cross-linking depends on the coiled coil domain of Crn1p, suggesting a requirement for Crn1p dimerization. Assembly-promoting activity is independent of cross-linking and could be due to nucleation and/or accelerated polymerization. Crn1p also binds to microtubules in vitro, and microtubule binding is enhanced by the presence of actin filaments. Microtubule binding is mediated by a region of Crn1p that contains sequences (not found in other coronins) homologous to the microtubule binding region of MAP1B. These activities, considered with microtubule defects observed in crn1Delta cells and in cells overexpressing Crn1p, suggest that Crn1p may provide a functional link between the actin and microtubule cytoskeletons in yeast.

Cytoablative therapy with combined resection and cryosurgery for limited bilobar hepatic colorectal metastases.

BACKGROUND: Cryosurgery can be employed in patients with unresectable hepatic metastases when the tumor size and the number of metastases are limited. However, local recurrence can result from incomplete ablation. We proposed a trial of complete cytoablation with a combined approach of cryosurgery and hepatic resection for patients with bilobar hepatic metastases. METHODS: Seven patients underwent cryosurgery alone (CRYO). Seven additional patients underwent combined resection and cryosurgery (CRYO+RES) for bilobar metastases. RESULTS: In the CRYO group, 5 of 7 patients had at least one centrally located tumor. All 5 of these patients had early recurrence at the site of ablation. In the CRYO+RES group complete ablation was achieved in 7 of 7. Two (28.6%) of these patients developed local recurrence. CONCLUSION: Cytoablation of hepatic metastases can be safely achieved with combined hepatic resection and cryosurgery in selected patients. Long-term survival data are necessary before advocating widespread application of this approach.

Quality assurance for abdominal CT: a rapid, computer-assisted technique.

OBJECTIVE: Maintaining high standards in a large CT imaging department with multiple scanners, a large technical and clerical staff, and a rotating staff of radiologists is an ongoing challenge. We undertook a project to design and implement a simple, rapidly performed computer-assisted system of quality assurance (QA) for use in abdominal CT. In our project, we also analyzed the results of that QA system. MATERIALS AND METHODS: We graded 1810 abdominal CT studies done in a 50-week period, using a three-point scale to indicate the quality of the following five parameters of technical quality: IV contrast enhancement, oral contrast opacification, window settings and artifacts, conformity to radiologists' protocol, and completeness and accuracy of header and scout data. In addition, a parameter reflecting performance of the film library and clerical staff was similarly graded. To provide a measure of peer review for radiologists, any disagreements with prior CT study reports were recorded when comparison studies were reviewed in the process of CT interpretation. A commercially available spreadsheet and database software program was tailored to allow rapid, easily performed data entry and analysis. Tables and graphs showing performance of technologists and film library and clerical staff were generated. This customized program was made available on the radiology department computer network. Results generated by the program were further analyzed with linear regression models. RESULTS: Our QA system was successfully integrated into the routine operation of the abdominal CT division. During the first 11.5 months of operation, the system reflected improvement in each of the technical parameters with a statistically significant improvement in the combined average technical score (from 1.15 to 1.68 on a scale of 0-2; p < .0001). The "Throughout Speed/Old Exams" parameter for performance of the film library and clerical staff, which was analyzed separately from the technical parameters, also improved significantly (from 1.3 to 1.8; p < .02). Improvements were statistically significant, even when we controlled for potential variations in quality among different CT scanners and variations among the radiologists who rated the quality of the examination. Thirty-eight disagreements with previous scan interpretations (5% of all scan comparisons) were recorded for evaluation at peer review conferences. CONCLUSION: The ability to monitor performance continuously using a rapid, computer-assisted system has effected measurable improvement in our CT service. Technologist and film library and clerical staff performance improved for all parameters studied. Deficiencies were revealed and trends demonstrated. The QA system allowed us to identify disagreements in interpretation of CT examinations for subsequent peer review by radiologists. Our QA software program has been made available on the Internet as freeware to licensed Excel users via anonymous file transfer protocol at Internet Protocol 134.192.6.110.

Nonbiliary laparoscopic gastrointestinal surgery: role of CT in diagnosis and management of complication.

OBJECTIVE: Laparoscopic techniques are evolving for a wide range of surgical procedures outside the biliary tree. We describe the CT findings of important complications detected after nonbiliary laparoscopic gastrointestinal surgery and the role of CT in their management. MATERIALS AND METHODS: Over a 3-year period, 209 patients had nonbiliary gastrointestinal laparoscopic procedures (partial or total colectomy, splenectomy, Nissen fundoplication, lymph-node dissection, herniorrhaphy, appendectomy, and exploratory laparoscopy). Thirty-seven abdominopelvic CT studies were performed on 18 (9%) of these patients for complications after surgery. In all cases CT findings were reviewed and correlated with follow-up surgical, clinical, or interventional radiologic findings. RESULTS: Fourteen major complications were detected on CT in 12 of 18 (67%) patients who had undergone partial or total colectomy (6/25, 24%), splenectomy (4/41, 10%), appendectomy (1/15, 7%), or lymph-node dissection (1/43, 2%). These complications included seven abscesses (three of the splenic bed, two of the pelvis, one of the liver, and one of the abdominal wall). The remaining complications were four hematomas (two in the abdominal wall caused by trocar site bleeding, one intraperitoneal, and one retroperitoneal), one case of colon perforation, one case of pancreatitis, and one case of splenic infarction. Percutaneous abscess drainage was performed successfully in seven patients, using CT guidance in six. Six patients had negative CT studies. CONCLUSION: Major complications may occur after complex nonbiliary laparoscopic procedures and are probably related to lack of experience with new surgical techniques. In this study, such complications occurred most often after laparoscopic colectomy and splenectomy. CT valuable in their diagnosis and in the management of abscess collections.

Sonographic evaluation of acute pancreatic transplant rejection: morphology-Doppler analysis versus guided percutaneous biopsy.

OBJECTIVE: Despite the increasing success of pancreatic transplantation for diabetes, rejection remains the most common cause of graft loss. The purpose of this study was to correlate gray-scale sonographic morphology and Doppler resistive index (RI) with acute pancreatic transplant rejection as determined by percutaneous, sonographically guided biopsy of the pancreas. SUBJECTS AND METHODS: Fifty-one sonograms of 36 patients were correlated with sonographically guided biopsies performed for clinically suspected acute rejection. Sonographic studies consisted of gray-scale morphologic assessment of gland size, texture, marginal definition, peripancreatic fluid, and duct dilatation as well as measurement of the average Doppler RI. Biopsies were performed within 48 hr of sonography. After localization by sonography, we performed percutaneous biopsy with an 18-gauge automated biopsy device. RESULTS: Biopsy findings were acute rejection (n = 40, 78%), chronic rejection (n = 2, 4%), and no evidence of rejection (n = 9, 18%). Procedure-related hemorrhage occurred in one patient and resolved spontaneously. Gray-scale sonographic abnormalities were present in 37 studies (73%). The most common abnormality was pancreatic enlargement (n = 23) with a sensitivity and specificity of 58% and 100%, respectively, for acute rejection. Loss of marginal definition occurred in nine studies with a sensitivity and specificity of 15% and 73%, respectively, for acute rejection. An RI > or = 0.7 was found in 11 studies (22%) with a sensitivity of 20% and a specificity of 73% for acute rejection. CONCLUSION: For the diagnosis of acute pancreatic rejection, sonographically guided percutaneous biopsy is superior to gray-scale and spectral Doppler sonography. Sonographically guided percutaneous biopsy is a safe technique with a high success rate. Gray-scale and spectral Doppler sonography lack sensitivity, and a normal RI should not delay biopsy.