Overlooked Pain Assessment Records in Patients with Pressure Injuries During the COVID-19 Pandemic: A Retrospective Data Analysis

BACKGROUND

During the COVID-19 pandemic, healthcare professionals focused on identifying the cause of hemodynamic instability in patients and may have neglected to assess pressure injury (PI)-related pain. Although pain is an early indicator of PI development, there has been no systematic evaluation of PI-related pain in patients.

OBJECTIVE

To review nurses' records of PI-related pain in patients who developed PIs during the COVID-19 pandemic.

METHODS

This retrospective, descriptive study included data from 510 patients at one hospital. Collected data included patient demographics (age, sex, diagnosis, and comorbidities), PI classification, and assessment of PI-related pain. Assessment data regarding PI-related pain included the characteristics of the pain, the type of analgesia (pharmacologic/nonpharmacologic) administered before and after PI management (debridement, dressing change, etc), the route of administration, and the frequency of pain assessment before and after analgesia.

RESULTS

The mean age of the patients (60.4% men) was 28.96 (SD, 5.82) years, and the mean length of hospital stay was 26.15 (SD, 16.1) days. Overall, 43.1% of the patients were treated in the ICU, 68.0% were conscious, and 18.6% tested positive for COVID-19. Deep-tissue injuries occurred in 57.5% of patients, with 48.6% developing stage 2 PI. The sacral region was the most common area for PI development (44.8%). The mean duration of repositioning in patients with PI was 23.03 (SD, 5.4) hours. Only 0.40% of patients (n = 2) were evaluated for pain, and only one patient was assessed for pain before and after analgesia was administered.

CONCLUSIONS

The findings suggest a lack of comprehensive evaluation and records concerning PI-related pain in patients with COVID-19.

Pathogens in Pediatric Septic Arthritis: A Multi-Center Study in Turkiye (PEDSART Study)

OBJECTIVES

Septic arthritis (SA) is a serious bacterial infection that must be treated efficiently and timely. The large number of culture-negative cases makes local epidemiological data important. Accordingly, this study aimed to evaluate the etiology, clinical characteristics, and therapeutic approach of SA in children in Turkiye, emphasizing the role of real-time polymerase chain reaction (PCR) techniques in the diagnosis.

METHODS

In this multi-center, prospective study, children hospitalized due to SA between February 2018 and July 2020 in 23 hospitals in 14 cities in Turkiye were included. Clinical, demographic, laboratory, and radiological findings were assessed, and real-time PCR was performed using synovial fluid samples.

RESULTS

Seventy-five children aged between 3 and 204 months diagnosed with acute SA were enrolled. Joint pain was the main complaint at admission, and the most commonly involved joints were the knees in 58 patients (77.4%). The combination of synovial fluid culture and real-time PCR detected causative bacteria in 33 patients (44%). In 14 (18.7%) patients, the etiological agent was demonstrated using only PCR. The most commonly isolated etiologic agent was Staphylococcus aureus, which was detected in 22 (29.3%) patients, while Streptococcus pyogenes was found in 4 (5.3%) patients and Kingella kingae in 3 (4%) patients. Streptococcus pyogenes and Kingella kingae were detected using only PCR. Most patients (81.3%) received combination therapy with multiple agents, and the most commonly used combination was glycopeptides plus third-generation cephalosporin.

CONCLUSIONS

Staphylococcus aureus is the main pathogen in pediatric SA, and with the use of advanced diagnostic approaches, such as real-time PCR, the chance of diagnosis increases, especially in cases due to Kingella kingae and Streptococcus pyogenes.

Predictors for postoperative cranial nerve complications in carotid body tumor resection: a retrospective cohort study

INTRODUCTION

Carotid body tumors (CBTs) are slow-growing benign tumors. Therefore, surgical resection is considered in case of tumor growth. The timing of surgery is of the utmost importance as the risk of iatrogenic surgical complications increases when resecting larger tumors, whereas on the other hand, resections for asymptomatic small CBT should be prevented. The primary aim of this study was to identify which tumor size or dimension is most accurate to predict nerve injury in patients undergoing resection of a CBT.

MATERIAL AND METHODS

This retrospective cohort study included patients who underwent surgical resection of CBT at the university hospital in South-Holland. Baseline patient characteristics and tumor measurements were retrieved from the medical records. The authors assessed how the different methods of measuring the size of the tumor were interrelated using Pearson correlation. Logistic regression was used to assess which variables were independently associated with nerve injury, including age at surgery, Shamblin classification, and those dimensions that captured different aspects of tumor size (rather than measuring the same as shown by high correlations) as possible independent variables.

RESULTS

In 125 patients, 143 CBTs were resected whereof in 35 cases cranial nerve injury occurred, (transient in 16 cases and permanent in 19 cases). The risks for nerve injury increased with larger tumor size and the Shamblin classification. Logistic regression analysis showed that the anterior-posterior (AP) diameter significantly increased the odds of a nerve injury, a doubling for every 1 cm increase in AP diameter [odds ratio (95% CI) 2.12 (1.29-3.48), P =0.003].

CONCLUSION

This study shows that measured tumor size in the AP plane is a strong predictor for postoperative nerve injury of a CBT resection. This predictor can be used in the daily clinic to give insight in operative risks. More research is needed in order to select the most appropriate time window for CBT resection.

Evaluation of 601 children with multisystem inflammatory syndrome (Turk MISC study)

PURPOSE

Due to its link with the 2019 coronavirus, the multisystem inflammatory syndrome in children (MISC) has garnered considerable international interest. The aim of this study, in which MISC patients were evaluated multicenter, and the data of the third period of the Turk-MISC study group, to compare the clinical and laboratory characteristics and outcomes of MISC patients who did and did not require admission to an intensive care unit (ICU).

METHODS

This retrospective multicenter observational study was carried out between June 11, 2021, and January 01, 2022. The demographics, complaints, laboratory results, system involvements, and outcomes of the patients were documented.

RESULTS

A total of 601 patients were enrolled; 157 patients (26.1%) required hospitalization in the intensive care unit (ICU). Median age was 8 years (interquartile range (IQR) 4.5-11.3 years. The proportion of Kawasaki disease-like features in the ICU group was significantly higher than in the non-ICU group (56.1% vs. 43.2% p = 0.006). The ICU group had considerably lower counts of both lymphocytes and platelets (lymphocyte count 900 vs. 1280 cells × μL, platelet count 153 vs. 212 cells × 103/ μL, all for p< 0.001). C-reactive protein, procalcitonin, and ferritin levels were significantly higher in the ICU group (CRP 164 vs. 129 mg/L, procalcitonin 9.2 vs. 2.2 μg/L, ferritin 644 vs. 334 μg/L, all for p< 0.001). Being between ages 5-12 and older than 12 increased the likelihood of hospitalization in the ICU by four [95% confidence intervals (CI)1.971-8.627] and six times (95% CI 2.575-14.654), respectively, compared to being between the ages 0-5. A one-unit increase in log D-dimer (µg/L) and log troponin (ng/L) was also demonstrated to increase the need for intensive care by 1.8 (95% CI 1.079-3.233) and 1.4 times (95% CI 1.133-1.789), respectively.     Conclusion: By comparing this study to our other studies, we found that the median age of MISC patients has been rising. Patients requiring an ICU stay had considerably higher levels of procalcitonin, CRP, and ferritin but significantly lower levels of lymphocyte and thrombocyte. In particular, high levels of procalcitonin in the serum might serve as a valuable laboratory marker for anticipating the need for intensive care.

WHAT IS KNOWN

• Lymphopenia and thrombocytopenia were an independent predictor factors in patients with MISC who needed to stay in intensive care unit. • The possibility of the need to stay in the intensive care unit in patients with MISC who had Kawasaki disease-like findings was controversial compared with those who did not.

WHAT IS NEW

• A one-unit increase log D dimer and log troponin was demonstrated to require for intensive care unit by 1.8 and 1.4 times, respectively. • Serum procalcitonin levels had the best performance to predict stay in the intensive care unit stay.

A prospective long-term evaluation of the ocular findings of children followed with the diagnosis of multisystem inflammatory syndrome (long-term evaluation of ocular findings following MIS-C)

BACKGROUND/OBJECTIVES

The most frequently reported ocular finding in the acute phase of the multisystem inflammatory syndrome in children (MIS-C), is conjunctivitis. More rarely, punctuate epitheliopathy, anterior uveitis and optic disc oedema can be seen. We aimed to investigate the acute and long-term ocular effects of MIS-C.

SUBJECTS/METHODS

Cases aged 1 month to 18 years who were diagnosed with MIS-C between January 2022 and June 2022 in the Department of Pediatric Infectious Diseases in our hospital were included in the study. Ophthalmological examinations were performed immediately after diagnosis, at one month, three months, and six months.

RESULTS

Males consisted of 64.7% of the 34 cases included in the study and the mean age was 8.68 ± 4.32 years (min-max:2-17). In the first examination, conjunctivitis was observed in 6 (17.6%), punctuate epitheliopathy in 4 (11.7%), and subconjunctival haemorrhage in 3 (8.8%) patients. Two patients (5.8%) had optic disc oedema. No pathological anterior or posterior segment findings were observed in the sixth-month examination. The relationship between subconjunctival haemorrhage and intensive care hospitalisation was statistically significant (p = 0.014). Also, all patients with subconjunctival haemorrhage were clinically classified as severe MIS-C (p = 0.002).

CONCLUSION

Although pathological ocular findings were observed in the acute phase of the disease, all of them were found to be improved at the sixth-month follow-up. The most striking finding of our study is that cases with subconjunctival haemorrhage were clinically more severe, and all patients needed intensive care. This study may be informative in establishing ocular follow-up protocols that are expected to be carried out in the acute period and in the follow-up of these patients.

The frequency of thyroid dysfunction in patients with a diagnosis of depressive disorder

Objective

Thyroid dysfunctions are among the most common endocrine disorders in society. An increase or decrease in thyroid hormone levels may present with neurological and/or psychiatric symptoms. In this study, we aimed both to determine the prevalence of this disorder in our region by determining the frequency of thyroid dysfunction in patients diagnosed with major depressive disorder in our outpatient clinic and to raise awareness during the evaluation process of patients.

Material and Method

Thyroid-stimulating hormone (TSH) levels of 1035 patients diagnosed with major depressive disorder in our hospital between January 2020 and January 2022 were retrospectively scanned from the hospital information management system and those outside the reference ranges (0.38-5.33 mIU/L) were determined.

Results

It was observed that TSH was not within the reference ranges in approximately 7% of the patients diagnosed with depressive disorder. 1035 patients were included in the study. When the blood results of 1035 patients included in the study were examined retrospectively, 32 of them had TSH values below 0.38 mIU/L. TSH value was found to be above 5.33 mIU/L in 44 of them.

Conclusion

Obtained data have shown that thyroid dysfunctions can be encountered frequently in patients presenting with depressive complaints. It is thought that the evaluation of patients with depressive complaints in terms of thyroid dysfunction, and the treatment of the underlying thyroid dysfunction will contribute to the regression of psychiatric symptoms.

Parental Attitudes About Lumbar Puncture in Children With Suspected Central Nervous System Infection

OBJECTIVES

This study aimed to evaluate parents' attitudes toward lumbar puncture (LP) for their children with suspected central nervous system infection to determine the reasons for rejection and related factors.

METHODS

The survey was provided to parents of children (1 month to 18 years old) for whom LP was recommended because of a concern for central nervous system infection. Sociodemographic characteristics and other related factors of parents who did and did not approve of LP were compared statistically. The reasons for the disapproval of parents who refused LP were revealed.

RESULTS

A total of 100 parents were included in the study. Eighty-two percent of the participating parents were mothers, and the median age of the mothers was 31 years (min: 17 years; max: 70 years). The median age of the fathers was 37 years (min: 22 years; max: 60 years). Among the parents, 34% did not give consent for LP. The most common reason for the participants to refuse LP was fear of paralysis of their children due to the procedure (82.3%). There was a statistical difference between the approval of the LP procedure and the person who informed the parents about the LP procedure and read the informed consent form ( P = 0.004 and P = 0.038, respectively).As a result of the binary logistic regression analysis, it was seen that the rate of acceptance of the LP procedure by the parents informed by the specialist doctors was 7.1-fold ( P = 0.02; 95% confidence interval, 1.3-37.6) higher than the parents informed by the resident physicians.

CONCLUSION

The informed consent process mainly influenced parents' attitudes toward LP. To increase the acceptance rates of LP, we should standardize the informed consent process so that it is not affected by factors such as seniority of the physician.

Diagnostic Accuracy of SARS-CoV-2 Rapid Antigen Testing in a Pediatric Population: Children are Not Little Adults

BACKGROUND

Information on the use of antigen-based SARS-CoV-2 rapid antigen tests (RAT) in children is limited. RATs have been used more frequently, because they are easily applicable, inexpensive, and can be easily performed at home without the need for special equipment. This study was designed to assign the diagnostic test accuracy of the SARS-CoV-2 RAT in daily clinical practice in children.

METHODS

One thousand forty-two pediatric patients (aged 1 month - 18 years) who presented to the pediatric COVID-19 outpatient clinic of our hospital between January 2021 and June 2022 and met the inclusion criteria were included in this study. Nasopharyngeal samples were taken from the patients at the same visit, first for reverse transcription polymerase chain reaction (RT-PCR) and then for RAT.

RESULTS

The data of all patients with RT-PCR positivity (n = 314) and additionally 14 patients with RAT positivity were analyzed in depth. The overall sensitivity and specificity were 62.1% (95% CI: 56.4 - 67.4) and 98% (95% CI: 96.7 - 98.9), respectively. The positive predictive value (PPV) and the negative predictive value (NPV) in this pediatric study were 93.3% and 85.7% (95% CI: 88.7 - 96.1 and 83.1 - 87.9), respectively. Considering the Ct values, which are indirect indicators of viral load, it was observed that the sensitivity of the rapid antigen test increased at low Ct values. The sensitivity increased to 75.1% (95% CI: 67.9 - 81.1) in patients with a Ct value of < 25. The specificity was 92.7% (95% CI: 90.7 - 94.3), PPV was 67.8% (95% CI: 60.7 - 67.8) and the NPV was 94.7% (95% CI: 93.0 - 96.1) in patients with a Ct value < 25. When the patients were evaluated according to their symptomatic/asymptomatic status, the difference between the diagnostic performance of the RAT test was found to be statistically significant (p = 0.006).

CONCLUSIONS

In our study, it was found that the sensitivity of RATs in pediatric patients was lower than in adults. Our results also showed that children are not small adults, and the sensitivity of the test was higher, especially in symptomatic patients and patients with high viral load. To obtain more accurate results, we believe that performing the test in the first 3 days of symptoms will give more accurate results.

HSV-1 Encephalitis Presenting with Diplopia: Effects of Infection or Autoimmunity?

This report describes a case in which diplopia was developed as a finding of postinfectious anti- N -methyl- d -aspartate receptor encephalitis. Infectious encephalitis, especially herpes simplex virus, is essential as it is one of the triggers of autoimmune encephalitis. Even if the cases present unexpected clinical findings, we should be vigilant in terms of autoimmune processes, such as diplopia seen in our case.

Characteristics of maxillary sinus ostia and their correlation with anatomic variations of the osteomeatal complex: Indications for sinus floor elevation

Background

Knowledge of the anatomy and variations of the maxillary sinus is essential for reducing oral surgery complications, such as sinus floor elevation, and increasing surgery success. The CBCT images of 385 patients were examined.

Materials and Methods

The prevalence, localization, and height of PMO (Primer Maxillary Ostium) and AMO (Accessory Maxillary Ostium) were evaluated with respect to sex, dentition, dental treatment, Schneiderian membrane (SM) thickness, concha bullosa, Haller Cells, and septal deviation.

Results

The PMO was present in 87.3% of all patients. Further analysis showed that the mean PMO diameter was 1.42 ± 0.62 mm. Although 11.6% of the PMO was in the inferior region, 60.4% was in the middle and 28% in the superior region. The effect of age and SM on the height and diameter of the PMO was found to be statistically significant. An AMO was present in 20% of the CBCT images. The mean AMO diameter was 2.55 ± 1.25 mm. Although 45.4% of the AMO was in the inferior region, 48% was in the middle and 6.6% was in the superior region. Moreover, SM thickness seemed to influence the height. A significant positive relationship was found between the PMO and AMO height. Also, a significant relationship was observed between the presence of the AMO and septum deviation.

Conclusion

The presence of the AMO, PMO diameter, and height should be added to the preoperative evaluation criteria for the success of sinus floor evaluation. Specifically, sinonasal and demographic conditions should be carefully examined preoperatively for the long-term success of the surgery.

Association between mannose binding lectin gene polymorphisms and clinical severity of COVID-19 in children

BACKGROUND

Mannose-binding lectin (MBL) is a member of innate immunity and acts with MASP (MBL-associated serine protease) to activate the lectin pathway of the complement system. MBL gene polymorphisms are associated with susceptibility to infectious diseases. This study investigated whether MBL2 genotype, serum MBL levels, and serum MASP-2 levels affect the course of SARS-CoV-2 infection.

METHODS AND RESULTS

Pediatric patients diagnosed with COVID-19 by positive real-time polymerase chain reaction (PCR) were included in the study. Single nucleotide polymorphisms in the promoter and exon 1 in the MBL2 gene (rs11003125, rs7096206, rs1800450, rs1800451, rs5030737) were identified by a PCR and restriction fragment length polymorphisms analysis. Serum MBL and MASP-2 levels were measured by ELISA. COVID-19 patients were divided into asymptomatic and symptomatic. Variables were compared between these two groups. A total of 100 children were included in the study. The mean age of the patients was 130 ± 67.2 months. Of the patients, 68 (68%) were symptomatic, and 32 (32%) were asymptomatic. The polymorphisms in the - 221nt and - 550nt promoter regions did not differ between groups (p > 0.05). All codon 52 and codon 57 genotypes were determined as wild-type AA. AB genotypes were found 45.6% in symptomatic patients while 23.5% in asymptomatics. Moreover, BB genotype was detected 9.4% in symptomatic and 6.3% in asymptomatic patients (p < 0.001). B allele was more frequent in symptomatic patients (46.3%) compared to asymptomatic patients (10.9%). (p < 0.001). Serum MBL and MASP-2 levels did not differ statistically between the groups (p = 0.295, p = 0.073).

CONCLUSION

These findings suggest that codon 54 polymorphism in the MBL2 gene exon-1 region can be associated with the symptomatic course of COVID-19.

Clinical nurses' knowledge and practices on routine care related to the prevention of complications of peripheral intravenous therapy: A cross-sectional study

AIM

The aim of this descriptive and cross-sectional study was to determine the knowledge and practices of nurses related to the prevention of peripheral intravenous therapy (PIT) complications, and to identify the influencing factors.

METHODS

The study adopted a cross-sectional and descriptive design and was conducted between April and August of 2018 with a total of 214 clinical nurses. The data collection tools employed were a 12-item sociodemographic questionnaire and a 16-item questionnaire on knowledge and practices related to the prevention of peripheral intravenous therapy complications.

RESULTS

The mean knowledge scores of the nurses were found to be 81.54 ± 12.06 (min: 50, max: 100). No statistically significant difference was found to exist between the scores, and the variables of the nurses' gender, length of employment in the health profession, type of work, training received related to PIT complications, and self-competence level in PIT complications.

CONCLUSION

The nurses were found to have high knowledge levels; however, their practices for preventing PIT complications differed. Standardized practice procedures and workplace training are needed in order to transform nurses' knowledge into practice with regard to the prevention of PIT complications.

The diversity in the clinical features of children hospitalized with COVID-19 during the nonvariant, Alpha (B.1.1.7), Delta (B.1.617.2), and Omicron (B.1.1.529) variant periods of SARS CoV-2: Caution for neurological symptoms in Omicron variant

BACKGROUND

Since the COVID-19 pandemic began, various SARS-CoV-2 variants have been identified with different characteristics than the nonvariant strain.

METHODS

We retrospectively evaluated the demographic and clinical differences in the cohort of hospitalized COVID-19 children (1 month-18 years old) between March 11, 2020, and September 31, 2022, by the time the variants identified in our country predominate. Bonferroni post hoc analysis was performed to compare the differences between the periods.

RESULTS

Of the 283 children in this study, 142 (50.2%) were females. The median age was 36 (IQR: 7-132) months. Sixty-three (22.2%) patients were hospitalized in the nonvariant period, 24 (8.5%) in the Alpha period, 93 (32.9%) in the Delta period, and 103 (36.4%) in the Omicron period. Fever was the most common symptom in all groups, with no statistically significant differences (p=0.25). In the Omicron period, respiratory and gastrointestinal symptoms decreased, and neurological symptoms increased significantly compared to other periods: [respiratory symptoms; nonvariant (65.1%) vs. Omicron (41.7%), (p=0.024)], [gastrointestinal symptoms; Delta (41.9%) vs. Omicron (22.3%), (p=0.018), [neurological symptoms; Delta (14.5%) vs. Omicron (31.1%), (p=0.03]. Altered mental status and seizures were more common during the Omicron period compared to the pre-Omicron (nonvariant, Alpha, and Delta) period (p=0.017 and p=0.005, respectively).

CONCLUSION

Although the main symptoms in children with COVID-19 were fever and respiratory symptoms, an increase in severe neurological manifestations was seen throughout the Omicron variant period. This article is protected by copyright. All rights reserved.

Can Serum 25 hydroxy Vitamin D Levels Predict the Severity of Multisystem Inflammatory Syndrome in Children and COVID-19?

OBJECTIVE

To determine the clinical significance of serum 25 hydroxy (OH) vitamin D levels in pediatric patients with multisystem inflammatory syndrome (MIS-C) and compare the vitamin D levels of these patients with those patients with COVID-19 and healthy controls.

METHODS

This study was designed for pediatric patients who were aged 1 month to 18 years between July 14 and December 25, 2021. Fifty-one patients with MIS-C, 57 who were hospitalized with COVID-19, and 60 controls were enrolled in the study. Vitamin D insufficiency was defined as a serum 25 OH vitamin D level of less than 20 ng/mL.

RESULTS

The median serum 25 (OH) vitamin D was 14.6 ng/mL in patients with MIS-C, 16 ng/mL in patients with COVID-19, and 21.1 ng/mL in the control group (p<0.001). Vitamin D insufficiency was present in 74.5% (n=38) of patients with MIS-C, 66.7% (n=38) of patients with COVID-19, and 41.7% (n=25) of the controls (p=0.001). The percentage of four or more affected organ systems was 39.2% in patients with MIS-C. The correlation between the number of affected organ systems and serum 25 (OH) vitamin D levels was evaluated in patients with MIS-C and there was a moderate negative correlation (r= -0.310; p=0.027). A weak negative correlation was found between the severity of COVID-19 and serum 25 (OH) vitamin D (r= -0.320, p=0.015).

CONCLUSION

It was found that vitamin D levels were insufficient in both groups and correlated with the number of affected organ systems of MIS-C and the severity of COVID-19.

The development of a decision aid for shared decision making in the Dutch implantable cardioverter defibrillator patient population: A novel approach to patient education

Background

Counseling of Implantable Cardioverter-defibrillator (ICD) patients with regard to individual risks and benefits is challenging. An evidence-based decision aid tailored to the needs of Dutch ICD patients is not yet available. The objective of this pilot project was to structurally evaluate the current clinical practice in The Netherlands and the ICD patient experience, in order to develop an online decision aid to facilitate shared decision making in ICD procedures.

Methods

Between June 2016 and December 2017, a Dutch web-based decision aid was developed according to the Patient Decision Aid Standards (IPDAS) using the RAND-UCLA/multi-stepped Delphi model. Development process consisted of 5 stages in which the Dutch clinical practice was reviewed (stage 1), patients’ needs and their history of decision making was structurally assessed (stages 2A and B) and a modified Delphi consensus process was performed with an expert panel consisting of representatives from different medical fields (stage 3). Results from stages 1–3 were used to design and structure the content of an online-based decision aid (stage 4) which was finally evaluated in a usability testing by patients in stage 5.

Results and conclusion

This study describes the evidence-based approach to the development of the Dutch ICD decision aid. In our population, levels of shared decision-making experience were low. The ICD decision aid was structurally developed for the Dutch ICD patient population. Our upcoming multicenter stepped wedge clustered randomized trial will further evaluate the ICD decision aid in clinical practice.

Langerhans Cell Histiocytosis with an Undetected Ileal Polyp

Null.

Implantable cardioverter-defibrillators and the older patient: the Dutch clinical practice

Background and objective

Balance between benefit and burden of implantable cardioverter-defibrillator (ICD) therapy is more debatable in older patients, compared to younger patients. Of around 6000 yearly implanted ICDs in the Netherlands, 1:4 is received by patients ≥75 years. We aimed to evaluate the current clinical practice in the Netherlands for ICD implants and generator replacements, with a special focus on the older ICD patients.

Research design and methods

Cardiologists from all Dutch ICD implanting centres (n = 28) were interviewed. Questions aimed to evaluate outpatient care, pre-operative patient assessment, end-of-life-care counselling, evaluation of social and cognitive wellbeing, clinical evaluation of all patients prior to ICD replacement, and the consideration of the option to downgrade or not replace a device.

Results

Implanting cardiologists from all 28 implanting centres were approached for an interview. Response rate was 86%. Management appeared diverse. An age ≥80 years was consistently reported as incentive for more extensive patient evaluation. Patients were invited for counselling prior to device replacements in only the minority (46%) of hospitals. Downgrade or non-replacement was performed in rare cases. End-of-life care discussions were not standard procedure in 67% of the hospitals. Evaluation of social and cognitive wellbeing of patients was based solely on the general clinical impression of the physician in 83%, or not at all assessed in 8% of the centres.

Discussion and implication

A structured framework for care and evaluation of cognitive and/or physical limitations is currently absent in most hospitals. At time of ICD (re-)evaluation, several factors may be considered before deciding on (continuation of) ICD therapy: patient preferences and comorbidity, the need for pacemaker therapy, primary vs. secondary prevention, procedural risks, and patient preferences.

Modulation of cigarette smoke extract-induced human bronchial epithelial damage by eucalyptol and curcumin

Smoking is one of the most important leading death cause worldwide. From a toxicological perspective, cigarette smoke serves hazards especially for the human being exposed to passive smoke. Over the last decades, the effects of natural compounds on smoking-mediated respiratory diseases such as COPD, asthma, and lung cancer have been under investigation, as well as the mechanistic aspects of disease progression. In the present study, the protective mechanism of eucalyptol (EUC), curcumin (CUR), and their combination on BEAS-2B cells were investigated in vitro to understand their impact on cell death, oxidative cell injury, and inflammatory response induced by 3R4F reference cigarette extract (CSE). According to the present findings, EUC, CUR, and their combination improved cell viability, attenuated CSE-induced apoptosis, and LC3B expression. Further, CSE-induced oxidative damage and inflammatory response in human bronchial epithelial cells were remarkably reduced by the combination treatment through modification of enzymatic antioxidant activity, GSH, MDA, and intracellular ROS levels as well as nitrite and IL-6 levels. In addition, nuclear translocation of Nrf2, a regulatory protein involved in the indirect antioxidant response, was remarkably up-regulated with the combination pre-treatment. In conclusion, EUC and CUR in combination might be a potential therapeutic against smoking-induced lung diseases through antioxidant and inflammatory pathways and results represent valuable background for future in vivo pulmonary toxicity studies.

A Phenomenological Analysis of Experiences and Practices of Nurses Providing Palliative and End of Life Care

The aim of this study was to describe the experiences and practices of nurses providing palliative and end of life care. The study was conducted in the palliative care unit of a territory hospital in Turkey. The sample consisted of 11 nurses who had been working as palliative care nurses for at least one year. The face to face interview method was used to collect data, with a semi-structured in-depth individual interview. 5 main themes and 24 sub-themes were emerged in relation to the experiences and practices of the nurses. The majority of participant nurses pointed that inadequacy in the number of nurses, secondary nursing care activities, refusal of treatment, cultural and ethical problems were barriers in the provision of nursing care. They frequently experienced ethical issues when caring for end of life patients, and for this reason they felt the need for ethics counselling which they could consult.

Effect of reflexology on ankle brachial index, diabetic peripheral neuropathy, and glycemic control in older adults with diabetes: A randomized controlled trial

OBJECTIVE

The purpose of this study was to determine the effect of foot reflexology on ankle brachial index, diabetic peripheral neuropathy and glycemic control in older adults with diabetes.

METHODS

A randomized controlled, parallel-group trial study was conducted at the outpatient elderly health center in Bolu, Turkey. 48 adults aged 65 and over enrolled in the elderly health center were randomized into two groups in a ratio of 1:1 (experimental, n = 24; control, n = 24). Foot reflexology was performed for 12-week in the experimental group, whereas the control group continued their routine treatment and follow-up. The outcome measures included: (1) ankle brachial index, (2) diabetic peripheral neuropathy measured by a comprehensive foot exam, and (3) glycemic control by a glycated hemoglobin A blood test at baseline and after 12 weeks.

RESULTS

Post-test diabetic peripheral neuropathy scores (p < 0.001) and glycated hemoglobin A levels (p = 0.002) decreased in the experimental group and increased in the control group. There was no significant between-group difference regarding post-test ankle brachial index scores (p = 0.726). Foot reflexology had a medium effect size on diabetic peripheral neuropathy (95% confidence interval 0.003-2.24; d = 0.51; p < 0.001) and glycated hemoglobin A (95% confidence interval 0.72-1.22; d = 0.52; p = 0.002).

CONCLUSIONS

A foot reflexology practice can be a useful for improving the glycemic control and diabetic peripheral neuropathy in the older adults with diabetes.

TRIAL REGISTRATION NUMBER

NCT04416503.

The relationship between neutrophil/lymphocyte ratio and uric acid levels in multiple sclerosis patients

BACKGROUND

In this study, we aimed to determine whether neutrophil / lymphocyte ratio (NLR), obtained by dividing the number of neutrophils by the number of lymphocytes, and uric acid (UA) levels in multiple sclerosis (MS) patients vary compared with healthy controls and to establish correlations among these changes themselves as well as between such changes and MS subtypes, immunomodulatory drug use, the duration of the disease and prognosis.

METHODS

150 patients who presented to our hospital and were diagnosed with MS and 150 healthy volunteers were retrospectively included in our study. EDSS score (Expanded Disability Status Scale) was used to assess the disability of the patients.

RESULTS

Compared to healthy volunteers, MS patients had lower UA levels (p < 0.001) and higher NLR values (p = 0.02). In addition, UA levels were higher in patients with a low EDSS score or those on immunomodulating drugs (p < 0.001, p = 0.04, respectively). NLR value was lower in patients with a low EDSS score (p < 0.001). There was a negative correlation between NLR value and UA (r = ‒0.23, p = 0.003). Similarly, UA level decreased with increasing EDSS score and duration of disease (r = ‒0.38, p < 0.001; r = ‒0.17, p = 0.02, respectively).

CONCLUSION

Evaluating the NLR value, recognized as a new marker for inflammation in MS, together with the UA value, thought to be protective in MS, might be more effective than evaluating these parameters alone in demonstrating disability in patients (Tab. 4, Ref. 28). Text in PDF www.elis.sk Keywords: neutrophil/lymphocyte ratio, uric acid, multiple sclerosis, inflammation, Expanded Disability Status Scale.

Shared decision making in implantable cardioverter-defibrillator patients

Background

Implantable cardioverter-defibrillators (ICD) are effective in the prevention of sudden cardiac death and treating life-threatening arrhythmias. As the number of older patients increases, the number of implanted devices does as well. Evidence for current guidelines is mostly derived from trials conducted decades ago, in selected patient groups. Communicating the risks and benefits of an ICD to patients can be challenging. Shared decision making with the use of a decision aid has proven to result in more active patient participation and improved outcomes in several fields.

Purpose

The aim of our study is to evaluate the effect of an ICD specific decision aid in clinical practice.

Methods

We developed an evidence based decision aid according to the Delphi method. The decision aid was tested in 6 Dutch centres within a stepped wedge clustered randomized trial. We compared pre-procedural counselling with and without the use of a decision aid. Level of shared decision making was measured with the SDM-Q-9 in patients and SDM-Q-doc in caregivers. Additionally, we measured decisional conflict in patients with the decisional conflict scale questionnaire (DCS). This includes a subscore on how informed patients deemed to be. We included a set of 4 knowledge questions in our questionnaire. Differences between scoresbetween groups were analysed using the Mann-Whitney U test or One-way ANOVA. For categorical variables, we used the Chi-square test or Fishers Exact test accordingly.

Results

In total, we retrieved questionnaires from 234 caregivers and 150 patients. The majority of the patients were male (75%) and the mean age was 70±9 years. Levels of shared decision making were marked high in all groups. With the use of a decision aid, caregivers experienced significantly more shared decision making (median 78 (IQR 62–84) versus 81 (IQR 71–87) in the decision aid group (p=0.002)). Patients reported low levels of decisional conflict in both groups. There were also no differences for the subscales of the DCS (median 17 (IQR 6–25) in the control group vs 14 (IQR 5–23) in the decision aid group (p&gt;0.05)). Patients reported to be very well informed (DCS subscale score of 0 in the control group vs 8 with a decision aid, p&lt;0.05), although they answered the knowledge quiz poorly in both settings, with only 1 patient (0.067%) answering all the four question correctly (p&lt;0.05).

Conclusions

Patients and caregivers report high levels of shared decision making. This is likely due to a bias associated with the study design, in which all participating centres were required to conduct elaborate pre-implantation counselling with patients as standard care, which is different from current clinical practice. Despite the implications of an ICD procedure, there was no decisional conflict and patients report to be well informed. This is in spite of low scores on the knowledge quiz. This illustrates the phenomenon of the unconsciously uninformed patient.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Federation of Medical Specialists (SKMS), Utrecht, The Netherlands

Mechanical extraction of cardiac implantable electronic devices leads with long dwell time: Efficacy and safety of the step up approach

The aim of this study was to evaluate the efficacy and safety of the stepwise mechanical transvenous lead extraction approach in a patient population with chronically implanted transvenous leads with a long dwell time. From January 2014 till December 2018, all lead extractions with lead dwell time ≥5 years performed at our tertiary centre were retrospectively analysed. A total of 173 leads, from 78 patients (median age 68 years; 81% male) with a median dwell time of 9 years (interquartile range [IQR] 5) were extracted, with three or more leads in 42% of the patients. Right atrial leads: 41%; right ventricular pacing leads: 16%; implantable cardioverter-defibrillator (ICD) leads: 31% (72% dual coil); coronary sinus leads: 12%. The majority (75%) of the leads had an active fixation. Most frequent indication for extraction was pocket infection/erosion (76%). Overall clinical success was 97%, and complete procedural success was 93%. Venous patency, assessed with venous angiography, was well preserved in 93% of the cases. The overall procedural complication rate was 3.8% (2.6% major and 1.3% minor). Despite the complexity of the population and a very long dwell time (median 9 years), a clinical success rate of 97% was achieved with the stepwise mechanical approach. Analysis of impeding progression of pectoral extraction suggests that dense fibrosis and sharp lead curvature in the transvenous trajectory pose a challenge. Complication rate was low, and acute venous patency was generally well preserved.

Identifying Factors Influencing Decision Making in Patients Diagnosed with Carotid Body Tumors: An Exploratory Study

BACKGROUND

Carotid body tumors (CBTs) are rare highly vascularized and slow enlarging tumors arising from the paraganglionic tissue at the carotid bifurcation. Main treatment options for CBTs are surgical resection or "wait and scan" strategy. The choice for either strategy may be equally good medically in many patients. A structured "shared decision making" (SDM) might be helpful for guiding patients.

OBJECTIVES

To develop an SDM strategy for the surgical treatment, we aim to (1) identify considerations and factors involved in the decision making of patients with CBTs and (2) evaluate the current practice in our clinic and explore the opinions of patients on their treatment.

METHODS

This exploratory study was conducted in patients of the Leiden University Medical Centre (LUMC), The Netherlands. Patients who met the inclusion criteria were invited for a semi-structured interview. All conversations were fully audiotaped and transcripted.

RESULTS

Fifteen patients were included and interviewed. Ten of these patients underwent previously surgical resection of at least one tumor. Five patients underwent the wait and scan policy. The most important factors influencing decision making in CBT treatment are family, fears, co-consultants, and doctor-patient relationship.

CONCLUSIONS

This study has identified the factors influencing decision making in CBT and should be considered during consultations. The decision for surgery or not was mainly influenced by physician preferences and family members' prior experiences.

Pain acceptance levels of patients with chronic pain

This study was conducted with the aim of determining pain acceptance levels in patients with chronic pain attending an algology outpatients' department.The research was conducted as a descriptive and cross-sectional study. The population of the study consisted of 97 patients with chronic pain who attended the Algology Outpatients' Department of the Health Implementation and Research Center of Bursa Uludağ University. A Patient Description Form and a Chronic Pain Acceptance Questionnaire (CPAQ) were used to collect research data.The participants' mean sub-score for accomplishing activities by patients with chronic pain was found to be 31.10 ± 11.84, their mean sub-score for pain willingness was 36.65 ± 10.37, and their mean score for the total scale was 67.76 ± 18.30. A statistically significant difference was found between the participants' total score means and their sub-score means according to their education level and frequency of experiencing pain (P < .05), but no statistically significant difference was found according to such factors as age, profession, marital status, or medications used (P > .05).It was found that female sex was generally exposed to chronic pain, and factors such as age, marital status, and drug treatment did not differ in the rate of acceptance of chronic pain, and the rate of acceptance of pain in workers was higher, those with lower education level were lower. There is a need that new studies with larger sample groups regarding the factors affecting the acceptance of chronic pain.

Relationship Between Ethical Leadership Behavior and Work Motivation in Intensive Care Nurses: A Cross-sectional Study

Aim: Affecting the attitudes and the behaviors of the employees, leaders’ ethical focused behavior is one of the most important factors affecting employee work motivation. The study was conducted with the aim of examining the relationship between ethical leadership behavior and the work motivation of Intensive Care Nurses (ICNs). Material and Methods: The study adopted a cross-sectional and descriptive design and was performed between August and October 2018 with 98 ICNs at a university hospital in Turkey. A Nurses’ Description Form, the Ethical Leadership Scale, and the Nurses’ Work Motivation Scale were used to collect data. Since the data were found to be normally distributed, to compare the total scores of ethical leadership scale and nurses’ work motivation scale for demographic information of the nurses independent t-test and analysis of variance (ANOVA) test were used. Pearson correlation analysis was used to determine the relationship between ethical leadership and work satisfaction. Results: A statistically significant positive correlation was found between the mean total score of the Ethical Leadership Scale and the mean total score of the Nurses’ Work Motivation Scale (p < 0.001). A statistically significant difference was found between the mean total score of the ELS and the number of patients for whom daily nursing care was provided (p < 0.05). Conclusions: It was concluded from this study that the perceptions of ICNs concerning ethical leadership behavior and their work motivation were at a medium level. In addition, it was found that the nurses’ ethical leadership behavior had a positive effect on their work motivation. Nursing leaders should therefore endeavor to maintain their ethical behavioral integrity in order to promote nurses’ work motivation.

Abstract P3-03-10: Pre-operative lymphoscintigraphy for sentinel lymph node localisation: Is it necessary?

Introduction

Sentinel lymph node biopsy (SLNB) has replaced lymph node clearance for staging of the axilla in patients with early invasive breast cancer and no evidence of lymph node involvement on ultrasound or needle biopsy. It is recommended that a dual technique, using isotope and blue dye, is used to locate the sentinel lymph node (SLN) intra-operatively. Often, at the time of radioisotope injection, a lymphoscintigram (nuclear medicine scan) is obtained to demonstrate the 'hot' sentinel lymph node with or without skin marking of its anatomical position.

Performing a lymphoscintigram adds time and cost to the localisation process. In our centre, this investigation costs £899-999 (˜US $1180-1300).

Aims

The aim of this study is to find out whether obtaining a pre-operative lymphoscintigram aids the surgeon in the localisation of the SLN or affects the number of sentinel lymph nodes biopsied in the axillary staging of patients with early invasive breast cancer.

Methods

We carried out a retrospective study of patients who underwent SLNB for breast cancer in our hospital Trust between March 2012 and November 2017. We identified those patients who had a lymphoscintigram performed pre-operatively for SLN localisation. We recorded the number of SLNs identified on imaging and compared this with the number of SLNs biopsied during the operation.

Results

349 patients underwent 354 SLNBs during the study period. One patient was male, the remainders were female. The mean age of patients was 57.2 years (range 25 to 98 years).

In 295 (83.3%) cases, a lymphoscintigram was obtained prior to SLNB for node localisation, and 268 (90.8%) of these scans were able to identify one or more SLNs. In 173 (58.6%) scans, a single SLN was identified. In 27 (9.1%) scans it was either unclear how many SLNs were demonstrated or no SLNs were seen (16/295 no SLN identified, 11/295 unclear how many SLNs).

In 102 (34.6%) cases, the number of SLNs biopsied matched the number of SLNs identified on imaging. Of those that did not match, 76.2% had more and 15.0% fewer SLNs excised than shown on imaging. In 8.8% it was unknown if the number of SLNs matched that seen on imaging due to lack of histopathology results.

Conclusion

Lymphoscintigraphy for SLN localisation is costly and time consuming. In a high proportion of cases, number of SLNs identified on imaging does not match the number biopsied and thus, we suggest, that it is not required prior to SLNB and should be removed from practice.

Citation Format: Clark SL, Yilmaz D, Arun K, Javadzadeh S, Saeed S, Ullah MZ. Pre-operative lymphoscintigraphy for sentinel lymph node localisation: Is it necessary? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-10.

Evaluation of the Impact of a Chronic Total Coronary Occlusion on Ventricular Arrhythmias and Long-Term Mortality in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter-Defibrillator (the eCTOpy-in-ICD Study)

Background

Previous studies report conflicting results about a higher incidence of ventricular arrhythmias in patients with a chronic total coronary occlusion (CTO). We aimed to investigate this association in a large cohort of implantable cardioverter defibrillator patients with long‐term follow‐up.

Methods and Results

All consecutive patients from 1992 onwards who underwent implantable cardioverter defibrillator implantation for ischemic cardiomyopathy at the Leiden University Medical Center were evaluated. Coronary angiograms were reviewed for the presence of a CTO. The occurrence of ventricular arrhythmias and survival status at follow‐up were compared between patients with and patients without a CTO. A total of 722 patients constitute the study cohort (age 66±11 years; 84% males; 74% primary prevention, median left ventricular ejection fraction 30% [first–third quartile: 25–37], 44% received a cardiac resynchronization therapy defibrillator). At baseline, 240 patients (33%) had a CTO, and the CTOs were present for at least 44 (2–127) months. The median follow‐up duration was 4 (2–6) years. On long‐term follow‐up, CTO patients had a higher crude appropriate device therapy rate (37% versus 27%, P=0.010) and a lower crude survival rate (51% versus 67%, P<0.001) compared with patients without a CTO. Corrected for baseline characteristics including left ventricular ejection fraction, the presence of a CTO was an independent predictor for appropriate device therapy.

Conclusions

The presence of a CTO in implantable cardioverter defibrillator patients was associated with more appropriate device therapy and worse prognosis at long‐term follow‐up. Further investigation is warranted regarding a potential beneficial effect of CTO revascularization on the incidence of ventricular arrhythmias.

Prognostic value of global longitudinal strain in heart failure patients treated with cardiac resynchronization therapy

BACKGROUND

Myocardial fibrosis (macroscopic scar or diffuse reactive fibrosis) is one of the determinants of impaired left ventricular (LV) global longitudinal strain (GLS) in heart failure (HF) patients.

OBJECTIVE

The purpose of this study was to evaluate the prognostic value of LV GLS in HF patients treated with cardiac resynchronization therapy (CRT).

METHODS

The study included 829 HF patients (mean age 64.6 ± 10.4 years; 72% men) treated with CRT. Before CRT implantation, LV GLS was assessed using 2-dimensional speckle tracking echocardiography. The primary endpoint was the combination of all-cause mortality, heart transplantation, and LV assist device implantation. The secondary endpoint was the occurrence of ventricular arrhythmias or appropriate implantable defibrillator device therapies.

RESULTS

During follow-up, 332 patients reached the primary endpoint, and 233 presented with the secondary endpoint. Patients were divided according to LV GLS quartiles. Patients with the most impaired LV GLS quartile had a 2-fold higher risk of reaching the combined endpoint compared with patients in the best LV GLS quartile (hazard ratio [HR] 2.088; 95% confidence interval [CI] 1.555-2.804; P <.001). LV GLS was significantly associated with the combined endpoint (HR 1.075; 95% CI 1.020-1.133; P = .007) after adjusting for clinical, electrocardiographic, and echocardiographic characteristics. Although patients in the most impaired LV GLS quartile showed higher event rates for the secondary endpoint compared with the other groups, LV GLS was not independently associated with the secondary endpoint (HR 1.047; 95% CI 0.989-1.107; P = .115).

CONCLUSION

In this large cohort of CRT patients, baseline LV GLS was independently associated with the combined endpoint.

Outpatient Treatment of Pulmonary Embolism: sPESI Score and Highly Sensitive Troponin may Prove Helpful

Introduction

Despite advances in therapeutic and diagnostic options, acute pulmonary embolism (PE) is associated with high morbidity and mortality. Risk classification is important in deciding how and where to treat patients This study aimed to investigate simplified pulmonary embolism severity index (sPESI) scores and highly sensitive troponin levels to predict 30-day clinical outcomes.

Methods

Patients with the symptoms of dyspnoea, chest pain, and haemoptysis were included in the study. Multiple detector computed tomography (CT) examinations were performed. If the patients' glomerular filtration rate levels were less than 60 ml/min/1.73 m2, then the ventilation/perfusion (V/Q) scan was the preferred imaging modality. Venous blood samples were collected to test for highly sensitive troponin T levels (Elecsys troponin T high sensitive, Roche diagnostics). All patients were examined by two-dimensional bedside echocardiography for detection of right ventricular dilatation. Patients' baseline characteristics (sex, ages, etc.) were recorded along with co-morbidities, symptoms, haemodynamic conditions, all-cause mortality rates during hospitalisation, the duration of hospital stay, radiographic test results, and laboratory findings, and electrocardiography were also obtained during emergency department admission. Primary outcome measure was defined as death in a month. Logistic regression model was created to reveal the associated parameters related to mortality within a month of the emergency department visit.

Results

One hundred and seventy patients suspected of PE underwent either a CT angiogram or pulmonary V/Q scan. In total 70 patients were diagnosed with PE and included in the study. The logistic regression model was created in order to assess poor prognosis markers. In addition to the troponin levels and sPESI scores commonly used for pulmonary embolism prognosis, right ventricular dilatation, heart rate, systolic blood pressure and oxygen saturation using logistic regression models were created. Positive troponin level (odds ratio: 5.23 and 95% confidence interval [CI] 1.03 to 26.51) and negative sPESI score (odds ratio 2.14 and 95% CI 1.00 to 4.60) were found to be significant.

Conclusions

Some scoring systems, including PESI and sPESI score, can be used for predicting mortality in patients with pulmonary embolism. If sPESI score is zero, and troponin levels are negative, the patient can be discharged safely.