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Purpose Thrombocytopenia is common among critically ill patients and heparin-induced thrombocytopenia (HIT) is often on the differential. Professional guidelines recommend calculating a pre-test probability score before performing HIT testing. The 4Ts score is widely utilized but accuracy has been questioned in critically ill patients. The HIT Expert Probability (HEP) score is available, but complexity limits use. Our objective was to compare a modified intensive care unit (ICU)-4Ts score to available scoring tools. Materials and methods This was a single-center retrospective pilot study. Adult ICU patients that were tested for HIT and had a documented 4Ts score were included. A blinded investigator retrospectively calculated the HEP and ICU-4Ts score. Receiver operating characteristics (ROC) area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were compared. Results In 194 included patients, ROC AUC was significantly higher for the ICU-4Ts compared to the 4Ts score (0.80 versus 0.66, respectively; p = 0.044). The ICU-4Ts score had the highest specificity, PPV, and NPV. The sensitivity was similar between the HEP and ICU-4Ts score. Conclusions The ICU-4Ts score better predicted the diagnosis of HIT compared to the 4Ts score. Prospective validation studies are needed to confirm these results.

Coagulation factor Xa (recombinant), inactivated-zhzo (andexanet alfa) is approved for reversal of life-threatening bleeding with rivaroxaban and apixaban use. Clinical decision-making to initiate reversal is reliant on dose taken and timing of last dose. In practice, timing of last dose may be unknown, and the turnaround time for drug-specific anti-factor Xa levels at some institutions may be prolonged, leaving clinicians balancing a difficult decision with limited tools. This report includes a series of 3 patients who presented to our institution with an intracranial hemorrhage and received andexanet alfa for apixaban reversal. These cases highlight the challenges clinicians are facing when using andexanet alfa for emergent rivaroxaban or apixaban reversal when the timing of last dose is unknown, or patients fall outside of the recommended timeframe for use and clinically relevant drug levels are still suspected. Based on our experiences, we encourage other institutions to evaluate their abilities to rapidly and accurately detect the presence of clinically relevant rivaroxaban and apixaban levels when utilizing andexanet alfa.

Background: Evidence suggests that poor sleep increases risk of delirium. Because delirium is associated with poor outcomes, institutions have developed protocols to improve sleep in critically ill patients. Objective: To assess the impact of implementing a multicomponent sleep protocol. Methods: In this prospective, preimplementation and postimplementation evaluation, adult patients admitted to the medical intensive care unit (ICU) over 42 days were included. Outcomes evaluated included median delirium-free days, median Richards-Campbell Sleep Questionnaire (RCSQ) score, median optimal sleep nights, duration of mechanical ventilation (MV), ICU and hospital length of stay (LOS), and in-hospital mortality. Results: The preimplementation group included 78 patients and postimplementation group, 84 patients. There was no difference in median delirium-free days (1 day [interquartile range, IQR, = 0-2.5] vs 1 day [IQR = 0-2]; P = 0.48), median RCSQ score (59.4 [IQR = 43.2-71.6] vs 61.2 [IQR = 49.9-75.5]; P = 0.20), median optimal sleep nights (1 night [IQR = 0-2] vs 1 night [IQR = 0-2]; P = 0.95), and in-hospital mortality (16.7% vs 17.9%, P = 1.00). Duration of MV (8 days [IQR = 4-10] vs 4 days [IQR = 2-7]; P = 0.03) and hospital LOS (13 days [IQR = 7-22.3] vs 8 days [IQR = 6-17]; P = 0.05) were shorter in the postimplementation group, but both were similar between groups after adjusting for age and severity of illness. Conclusions and Relevance: This report demonstrates that implementation of a multicomponent sleep protocol in everyday ICU care is feasible, but limitations exist when evaluating impact on measurable outcomes. Additional evaluations are needed to identify the most meaningful interventions and best practices for quantifying impact on patient outcomes.

Primary care providers (PCPs) are evaluating increasing numbers of concussions, but it is unknown how often they are documenting concussion-specific history and physical examination findings vital for this process. This study reviews clinical documentation to determine how PCPs are evaluating concussed patients. PCPs often did not document important aspects of concussion history, including dizziness (48%), nausea (48%), vision changes (54%), cognitive complaints (54%), emotional changes (83%), sleep difficulties (84%), and neck pain (87%). Additionally, they often did not document important aspects of a concussion physical examination, including detailed neurologic examination (73%), clinical cognitive assessment (87%), balance testing (59%), and neck evaluation (54%). Omitting these parts of the history and physical examination could result in a premature return to play.

The American Society of Hematology and American College of Chest Physicians heparin-induced thrombocytopenia guidelines recommend calculation of a pretest probability score prior to performing laboratory testing, and the 4Ts score is commonly used. Inter-rater agreement of the 4Ts score has been evaluated, but limited data are available regarding the reliability of the 4Ts score when performed by nonexpert clinicians. The purpose of this study was to Compare 4Ts scores calculated by medical teams to an expert. A single-center observational study was conducted in patients evaluated for heparin-induced thrombocytopenia over 24 months. The primary outcome was difference in mean 4Ts score calculated by the medical team compared with an expert. Secondary outcomes included inter-rater agreement in risk category assignment and the negative predictive value (NPV) of the 4Ts score. The mean total 4Ts score was significantly higher when calculated by the medical team compared with expert (4.16 ± 1.41 versus 3.42 ± 1.53; P < 0.001). There was slight agreement in risk category assignment (Cohen κ coefficient = 0.164; P = 0.005). The NPV of the 4Ts score was 0.949 (95% confidence interval 0.891-1.000) when calculated by the medical team and 0.927 (95% confidence interval 0.869-0.984) when calculated by expert. Total 4Ts scores calculated by the medical team were significantly higher with only slight inter-rater agreement compared with expert. The NPV of the 4Ts score when calculated by nonexperts may be lower than previously reported. The recommendation to forgo laboratory testing for low 4Ts score patients may need to be revisited.

BackgroundDuring the first wave of COVID-19 pandemic, hospitals were forced to cancel or postpone non-COVID-19 care. With new outbreaks emerging, hospitals are now figuring out how to balance preparedness for future COVID-19 waves with their elective and regular services. This report discusses how four hospital systems deal with these dual responsibilities in China, Norway and the UK.ReflectionsBased on the experiences and combined reflections of hospital executives, we have formulated five strategic and leadership lessons for hospitals as they manage these dual responsibilities. (1) Redesign organisation to separate COVID-19 and non-COVID-19 services both within and across hospitals. (2) Expand virtual care strategies to improve access. (3) Use data-driven models to allocate resources across COVID-19 and non-COVID-19 units. (4) Invest in programmes to promote frontline staff well-being. (5) Secure financial support to continue to deliver on the dual responsibilities.ConclusionThe COVID-19 pandemic gives rise to leadership challenges that have fuelled organisational change and new approaches to healthcare delivery. Leading hospitals during the pandemic is a balancing act—providing care for both patients with COVID-19 and non-COVID-19, while at the same time preparing for the next waves of the pandemic.

Evaluating acute sport-related concussion (SRC) differs among providers, who apply international consensus and national guidelines variably. Retrospective medical record review was completed for 889 outpatients aged 7 to 18 years, diagnosed with SRC from 2014 to 2017. Associations between board-certified sports medicine fellowship (SMF) training status and assessment of concussion-specific history and physical examination items were tested using nonparametric χ tests. Differential odds (by fellowship training status) of using history and physical examination items were assessed using multivariable logistic regression modeling. Each SRC history and physical examination items were assessed in higher proportions by SMFs, as compared with non-SMFs, statistically significant for all tested items with the exception of headache history. SMFs demonstrated higher odds of detailed neurologic examinations and clinical cognitive testing compared with non-SMFs, after adjusting for patient and physician characteristics. Physicians caring for concussed patients should seek continuing education opportunities aligning them with training provided to sports medicine fellows.

Aims and objectives To explore the determinants of and behaviour change models for seasonal influenza vaccination compliance among healthcare personnel. Background COVID-19 vaccine hesitancy among healthcare personnel may be better understood by exploring determinants of seasonal influenza vaccine hesitancy. Design Integrative literature review. Methods A systematic search was conducted in accordance with PRISMA guidelines. Six thousand and forty-eight articles were screened. Seventy-eight met inclusion criteria. Due to the heterogeneity of included articles, a narrative synthesis was conducted utilising a conceptual matrix to identify thematic categories. Results Six thematic categories were identified as influencing HCP SIV compliance: 'perceived vulnerability', 'trust', 'past behaviour', 'professional duty', 'access and convenience' and 'knowledge and experience'. The Health Belief Model (HBM) was the most commonly utilised health behaviour change model within the seasonal influenza vaccination context. Few studies have examined seasonal influenza vaccine acceptance and uptake within the Australian HCP context, particularly involving community care and aged care. Conclusions Factors that appear to relate to influenza vaccination compliance among HCP can be grouped according to several thematic categories, and they also appear influential in COVID-19 vaccine uptake. In particular, an emerging focus on 'trust' or the more emotive considerations of decision-making around health-protective behaviours requires further exploration in the context of a pandemic. Efforts to influence these domains to increase compliance, however, are likely to be impeded by a lack of a well-developed and tested behaviour change model. Relevance to clinical practice Healthcare personnel (HCP) face high levels of occupational exposure to seasonal influenza every year. An emerging focus on 'trust' and the more emotive considerations of decision-making around health-protective behaviours requires further exploration in the context of a pandemic.

Objectives Cranioplasty is being performed more often due to rising rates of decompressive craniectomy. Hospital length of stay is a quality metric which has not been directly studied after cranioplasty. This study aims to identify factors associated with length of stay after cranioplasty to better understand their outcomes. Patients and methods A retrospective review was conducted at a single academic center from 2007 to 2015 for all patients >18 years of age who received cranioplasty. Baseline data from 148 patients were recorded including demographics, clinical characteristics, and surgeon decision-making factors for cranioplasty. Post-operative complications within 30 days after cranioplasty were recorded in addition to disposition and discharge data. Weibull accelerated failure time models were used to identify significant associations with length of stay after cranioplasty. Results The overall post-operative complication rate was 27.0%, and the most frequent indication for craniectomy was traumatic brain injury. The majority (72.3%) of patients returned home, compared to other disposition, and median length of stay was 2.0 days (interquartile range = 2.0). Average length of stay was 7.7 days in men, as compared with 2.4 days in women, and even upon adjusting for covariate effects, length of stay was longer in men than in women irrespective of post-operative complications. When time-to-cranioplasty fell between 0 and 30 days, average length of stay was 19.2 days, as compared with 10.3 days when time-to-cranioplasty fell between 30 and 90 days, and 2.5 days when time-to-cranioplasty was >90 days. After adjustment for covariate effects, the association between time-to-cranioplasty and length of stay was maintained only in patients without post-operative complications. Conclusions Length of stay can inform our understanding of outcomes after cranioplasty. In our study, length of stay was associated with sex, indication for craniectomy, and surgical decision-making (time-to-cranioplasty and implant material), but time-to-cranioplasty was only associated in patients without post-operative complications. These relationships should be seen not as direct causation, but rather as tools to add to our understanding of this relatively complicated procedure.

Recent studies aim to reduce radiation exposure associated with computed tomography (CT) using rapid-sequence magnetic resonance imaging (MRI). We evaluated imaging modalities used for hydrocephalus and traumatic brain injury (TBI) to identify opportunities for further radiation exposure reduction. Pediatric (≤ 18 years) patients, with either hydrocephalus or TBI receiving a head CT or head MRI from 2009 to 2017, were quantified using ICD9, ICD10, and CPT codes at a large university hospital. The odds ratios of receiving each imaging modality year-to-year and receiving a MRI or CT in a given year with each diagnosis were calculated. Beginning in 2015, hydrocephalus patients were more likely to receive a MRI vs CT (p < 0.0001), with likelihood increasing in the following 2 years. TBI patients were more likely to receive a CT than an MRI from 2009 to 2017. There was a smaller overall decrease in CT scans in TBI patients (p < 0.05) than hydrocephalus patients (p < 0.0001) and a larger increase in MRI use in hydrocephalus patients (p < 0.05) than TBI patients (p < 0.05) from 2009 to 2017. Use of CT to evaluate hydrocephalus significantly decreased over the last 3-year time period. However, CT use for TBI patients was inconsistent and did not decrease proportionally, potentially representing a belief that CT is more effective than MRI for detecting hemorrhage. There was greater use of MRI as an alternate imaging method in hydrocephalus patients than TBI patients. Head injury remains an area of improvement to decrease pediatric radiation exposure at our institution and may be an area in need of attention more broadly.

OBJECTIVESkull fractures represent a common source of morbidity in the pediatric trauma population. This study characterizes the type of follow-up that these patients receive and discusses predictive factors for follow-up.METHODSThe authors reviewed cases of nonoperative pediatric skull fractures at a single academic hospital between 2007 and 2017. Clinical patient and radiological fractures were recorded. Recommended neurosurgical follow-up, follow-up appointments, imaging studies, and fracture-related complications were recorded. Statistical analyses were performed to identify predictors for outpatient follow-up and imaging.RESULTSThe study included 414 patients, whose mean age was 5.2 years; 37.2% were female, and the median length of stay was 1 day (IQR 0.9–4 days). During 438 clinic visits and a median follow-up period of 8 weeks (IQR 4–12, range 1–144 weeks), 231 imaging studies were obtained, mostly head CT scans (55%). A total of 283 patients were given recommendations to attend follow-up in the clinic, and 86% were seen. Only 12 complications were detected, including 7 growing skull fractures, 2 traumatic encephaloceles, and 3 cases of hearing loss. Primary care physician (PCP) status and insurance status were associated with a recommendation of follow-up, actual follow-up compliance, and the decision to order outpatient imaging in patients both with and without intracranial hemorrhage. PCP status remained an independent predictor in each of these analyses. Follow-up compliance was not associated with a patient’s distance from home. Among patients without intracranial hemorrhage, a follow-up recommendation and actual follow-up compliance were associated with pneumocephalus and other polytraumatic injuries, and outpatient imaging was associated with a bilateral fracture. No complications were found in patients with linear fractures above the skull base in those without an intracranial hemorrhage.CONCLUSIONSPediatric nonoperative skull fractures drive a large expenditure of clinic and imaging resources to detect a relatively small profile of complications. Understanding the factors underlying the decision for clinic follow-up and additional imaging can decrease future costs, resource utilization, and radiation exposure. Factors related to injury severity and socioeconomic indicators were associated with outpatient imaging, the decision to follow up patients in the clinic, and patients’ subsequent attendance. Socioeconomic status (PCP and insurance) may affect access to appropriate neurosurgical follow-up and deserves future research attention. Patients with no intracranial hemorrhage and with a linear fracture above the skull base do not appear to be at risk for delayed complications and could be candidates for reduced follow-up and imaging.

The effect of type 1 diabetes on the developing brain is a topic of primary research interest. A variety of potential dysglycaemic insults to the brain can cause cellular and structural injury and lead to altered neuropsychological outcomes. These outcomes might be subtle in terms of cognition but appear to persist into adult life. Age and circumstance at diagnosis appear to play a substantial role in potential CNS injury. A history of diabetic ketoacidosis and chronic hyperglycaemia appear to be more injurious than previously suspected, whereas a history of severe hypoglycaemia is perhaps less injurious. Neurocognitive deficits manifest across multiple cognitive domains, including executive function and speed of information processing. Some evidence suggests that subtle brain injury might directly contribute to psychological and mental health outcomes. Impaired executive function and mental health, in turn, could affect patients' adherence and the ability to make adaptive lifestyle choices. Impaired executive functioning creates a potential feedback loop of diabetic dysglycaemia leading to brain injury, further impaired executive function and mental health, which results in suboptimal adherence, and further dysglycaemia. Clinicians dealing with patients with suboptimal glycaemic outcomes should be aware of these potential issues.

Introduction Management of patients with suspected heparin-induced thrombocytopenia (HIT) can lead to significant costs. Reported cost-saving initiatives have focused on minimizing inappropriate testing in low-risk patients and optimizing alternative anticoagulant selection. We sought to further investigate how utilizing various HIT laboratory testing models would impact total cost of testing and alternative anticoagulant use. Methods Utilizing a retrospective cohort of adult patients tested for HIT over three years within our institution, we evaluated how utilization of four distinct laboratory models impacted total number of HIT test combinations completed, time to HIT testing finalization, percentage of patients discharged from the hospital prior to HIT testing finalization, total alternative anticoagulant days, and total anticipated major bleed events. Additionally, we calculated cost of laboratory testing and alternative anticoagulant associated with each model. Results A total of 482 patients were included in our cohort. A laboratory testing model that utilized an in-house platelet factor 4 (PF4)-heparin enzyme-linked immunosorbent assay (ELISA) completed three days weekly, and reflex serotonin release assay (SRA) with a five-day turnaround resulted in the shortest mean time to HIT testing finalization, lowest percentage of patients discharged prior to HIT testing finalization, and lowest total alternative anticoagulant days. Conclusions Institutions should evaluate current HIT laboratory testing practices and assess for opportunities for optimization. Testing models utilizing a PF4-heparin antibody ELISA with a reflex SRA for positive results may improve testing metrics and lead to lower utilization of alternative anticoagulants.

Background: Anticoagulation monitoring practices vary during extracorporeal membrane oxygenation (ECMO). The Extracorporeal Life Support Organization describes that a multimodal approach is needed to overcome assay limitations and minimize complications. Objective: Compare activated clotting time (ACT) versus multimodal approach (activated partial thromboplastin time (aPTT)/anti-factor Xa) for unfractionated heparin (UFH) monitoring in adult ECMO patients. Methods: We conducted a single-center retrospective pre- (ACT) versus post-implementation (multimodal approach) study. The incidence of major bleeding and thrombosis, blood product and antithrombin III (ATIII) administration, and UFH infusion rates were compared. Results: Incidence of major bleeding (69.2% versus 62.2%, p = 0.345) and thrombosis (23% versus 14.9%, p = 0.369) was similar between groups. Median number of ATIII doses was reduced in the multimodal group (1.0 [IQR 0.0-2.0] versus 0.0 [0.0 -1.0], p = 0.007). The median UFH infusion rate was higher in the ACT group, but not significant (16.9 [IQR 9.6-22.4] versus 13 [IQR 9.6-15.4] units/kg/hr, p = 0.063). Fewer UFH infusion rate changes occurred prior to steady state in the multimodal group (0.9 [IQR 0.3 -1.7] versus 0.1 [IQR 0.0-0.2], p < 0.001). Conclusion: The incidence of major bleeding and thrombosis was similar between groups. Our multimodal monitoring protocol standardized UFH infusion administration and reduced ATIII administration.

Purpose Obtaining an accurate medication history from patients on hospital admission is a priority in pharmacy practice. Timely and accurate histories are imperative as they may help determine the etiology of illness and prevent medication errors. We conducted a quality improvement project to assess the accuracy of alternate-source medication histories obtained for critically ill patients who were delirious or mechanically ventilated at the time of intensive care unit admission. Methods Included patients were 18 years of age or older, admitted to the medical intensive care unit from August 2017 through January 2018, and had a medication history obtained from a family member or outpatient pharmacy due to active delirium or mechanical ventilation. Patients were directly interviewed after resolution of delirium or extubation. Discrepancies between the initial and follow-up histories were documented and categorized using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Medication Errors. Results Forty patients were included. One hundred four discrepancies were documented, with a median of 2 discrepancies per patient. The most common types of discrepancies were addition (51.9%), followed by omission (24.0%). NCC MERP index category A (51%) was the most common error classification identified. Conclusion Discrepancies between initial and follow-up medication histories occurred at a frequent rate in delirious or mechanically ventilated patients; however, these discrepancies tended to be of low risk severity.

Background: Severe obesity in adolescence and young adulthood is undertreated which leads to obesity-related chronic diseases that progress into adulthood. Many organizations including the American Academy of Pediatrics (AAP) support early consideration of metabolic and bariatric surgery (MBS) in the pediatric population to reduce morbidity and mortality. Methods: Five diverse patients who underwent metabolic and bariatric surgery (MBS) in the form of a Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) contributed patient narratives that captured their life, with a focus on health related quality of life, before and after MBS. Results: MBS leads to significant improvement in health status via decreased mortality and improved health related quality of life. Conclusion: The perspectives of those patients who have undergone surgery in adolescence and young adulthood are not adequately captured in the medical literature. While the featured voices are not representative of all, their narratives may increase awareness and utilization of MBS in the treatment of severe obesity in the pediatric population.

Purpose Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin administration. Management strategies are complex and include discontinuing heparin products, initiating alternative anticoagulants, interpreting laboratory test results, documenting heparin allergies, and providing patient education. Medication error reports and a retrospective review conducted at an academic medical center revealed an opportunity for a quality improvement initiative and led to the creation of a multidisciplinary workflow for the management of HIT. In a pre-post study, the impact of the multidisciplinary workflow on the safety and management of HIT was evaluated. Methods The preimplementation group consisted of adult patients tested for suspected HIT from April 4, 2014, through May 31, 2016; the postimplementation group consisted of adult patients tested from November 1, 2016, through October 31, 2018. The primary outcome was the incidence of heparin product administration while HIT testing was ongoing. The secondary outcome was the rate of appropriate heparin allergy documentation. Results The incidence of heparin product administration while HIT testing results were pending was significantly reduced, from 54.2% to 20.0% (P < 0.001), after workflow implementation. The rate of appropriate heparin allergy documentation significantly increased, from 95.0% to 100% (P < 0.001). Conclusion Implementation of a multidisciplinary workflow for the management of HIT significantly reduced the incidence of heparin administration while testing was ongoing and improved the rate of appropriate heparin allergy documentation.

Background There is limited evidence of Aboriginal and Torres Strait Islander people attending cardiac rehabilitation (CR) programs despite high levels of heart disease. One key enabler for CR attendance is a culturally safe program. This study evaluates improving access for Aboriginal and Torres Strait Islander women to attend a CR program in a non-Indigenous health service, alongside improving health workforce cultural safety. Methods An 18-week mixed-methods feasibility study was conducted, with weekly flexible CR sessions delivered by a multidisciplinary team and an Aboriginal and/or Torres Strait Islander Health Worker (AHW) at a university health centre. Aboriginal and Torres Strait Islander women who were at risk of, or had experienced, a cardiac event were recruited. Data was collected from participants at baseline, and at every sixth-session attended, including measures of disease risk, quality-of-life, exercise capacity and anxiety and depression. Cultural awareness training was provided for health professionals before the program commenced. Assessment of health professionals’ cultural awareness pre- and post-program was evaluated using a questionnaire (n = 18). Qualitative data from participants (n = 3), the AHW, health professionals (n = 4) and referrers (n = 4) was collected at the end of the program using yarning methodology and analysed thematically using Charmaz’s constant comparative approach. Results Eight referrals were received for the CR program and four Aboriginal women attended the program, aged from 24 to 68 years. Adherence to the weekly sessions ranged from 65 to 100%. At the program’s conclusion, there was a significant change in health professionals’ perception of social policies implemented to ‘improve’ Aboriginal people, and self-reported changes in health professionals’ behaviours and skills. Themes were identified for recruitment, participants, health professionals and program delivery, with cultural safety enveloping all areas. Trust was a major theme for recruitment and adherence of participants. The AHW was a key enabler of cultural authenticity, and the flexibility of the program contributed greatly to participant perceptions of cultural safety. Barriers for attendance were not unique to this population. Conclusion The flexible CR program in a non-Indigenous service provided a culturally safe environment for Aboriginal women but referrals were low. Importantly, the combination of cultural awareness training and participation in the program delivery improved health professionals’ confidence in working with Aboriginal people. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR) 12618000581268, http://www.ANZCTR.org.au/ACTRN12618000581268.aspx, registered 16 April 2018.

IntroductionManagement of newly diagnosed type 1 diabetes (T1D) in children and adolescents is challenging for patients, families and healthcare professionals. The objective of this study is to determine whether continued intensive metabolic control using hybrid closed-loop (CL) insulin delivery following diagnosis of T1D can preserve C-peptide secretion, a marker of residual beta-cell function, compared with standard multiple daily injections (MDI) therapy.Methods and analysisThe study adopts an open-label, multicentre, randomised, parallel design, and aims to randomise 96 participants aged 10–16.9 years, recruited within 21 days of diagnosis with T1D. Following a baseline mixed meal tolerance test (MMTT), participants will be randomised to receive 24 months treatment with conventional MDI therapy or with CL insulin delivery. A further 24-month optional extension phase will be offered to all participants to continue with the allocated treatment. The primary outcome is the between group difference in area under the stimulated C-peptide curve (AUC) of the MMTT at 12 months post diagnosis. Analyses will be conducted on an intention-to-treat basis. Key secondary outcomes are between group differences in time spent in target glucose range (3.9–10 mmol/L), glycated haemoglobin (HbA1c) and time spent in hypoglycaemia (Ethics and disseminationEthics approval has been obtained from Cambridge East Research Ethics Committee. The results will be disseminated by peer-reviewed publications and conference presentations.Trial registration numberNCT02871089; Pre-results.

Objective In contrast to adult cohorts, neocortical changes in epileptic children with hippocampal damage are not well characterized. Here, we mapped multimodal neocortical markers of epilepsy‐related structural compromise in a pediatric cohort of temporal lobe epilepsy and explored how they relate to clinical factors. Methods We measured cortical thickness, gray–white matter intensity contrast and intracortical FLAIR intensity in 22 patients with hippocampal sclerosis (HS) and 30 controls. Surface‐based linear models assessed between‐group differences in morphological and MR signal intensity markers. Structural integrity of the hippocampus was measured by quantifying atrophy and FLAIR patterns. Linear models were used to evaluate the relationships between hippocampal and neocortical MRI markers and clinical factors. Results In the hippocampus, patients demonstrated ipsilateral atrophy and bilateral FLAIR hyperintensity. In the neocortex, patients showed FLAIR signal hyperintensities and gray–white matter boundary blurring in the ipsilesional mesial and lateral temporal neocortex. In contrast, cortical thinning was minimal and restricted to a small area of the ipsilesional temporal pole. Furthermore, patients with a history of febrile convulsions demonstrated more pronounced FLAIR hyperintensity in the ipsilesional temporal neocortex. Interpretation Pediatric HS patients do not yet demonstrate the widespread cortical thinning present in adult cohorts, which may reflect consequences of a protracted disease process. However, pronounced temporal neocortical FLAIR hyperintensity and blurring of the gray–white matter boundary are already detectable, suggesting that alterations in MR signal intensities may reflect a different underlying pathophysiology that is detectable earlier in the disease and more pervasive in patients with a history of febrile convulsions.

Background Patient enablement is a patient-centred concept reflecting a patient's ability to cope, understand and manage their own health. It can be used as a measure of the quality of care and has been linked with improved patient outcomes. While there have been studies into patient enablement following consultations with General Practitioners (GPs) and practice nurses, Nurse Practitioners' (NPs) role in enabling patients remains unexplored. Aim To use the lens of enablement to explore patients' lived experience of NP care in a Primary Health Care (PHC) setting in Australia. Methods Using a qualitative approach, 12 patients who had consulted an NP in PHC participated in unstructured interviews. An interpretative phenomenological approach was used to inform the study. A secondary analysis was conducted to explore possible synergies and resonance between the data and the constructs of the Patient Enablement Instrument (PEI). Findings This small qualitative study found that, following consultations with NPs in PHC, patients reported personal approaches and behaviours consistent with enablement. Three key existential themes appeared to contribute to patient enablement: the way NPs used consultation time (temporality), the building of partnerships between NPs and patients (relationality) and through NPs' holistic and hands-on consultation approach (corporality). The effective use of time in the consultation was seen as particularly important. Conclusion The findings from this study suggest consultations with NPs do enable patients. This is a previously undocumented strength of NP care. Further research, using a variety of settings, methods and patient and health care provider populations, is recommended.

OBJECTIVE: Impairment of speech repetition following injury to the dorsal language stream is feature of conduction aphasia - a well-described 'disconnection syndrome' in adults. The impact of similar lesions sustained in infancy has not been established. METHODS: We compared language outcomes in term-born individuals with confirmed neonatal stroke (n=30; age: 7-18 years, left-sided lesions in 21 cases) to matched controls (n=40). Injury to the dorsal and/or ventral language streams was assessed using T1- and T2-weighted MRI and diffusion tractography. Language lateralization was determined using functional MRI. RESULTS: At the group level, left dorsal language stream injury was associated with selective speech repetition impairment for non-words (p=0.021) and sentences (p

Research conducted in primary health care (PHC) shows the value of patient enablement. Although nurse practitioners (NPs) are increasingly playing a role in PHC, limited research exploring their contribution to enabling patients exists. This article describes a qualitative descriptive study in which enablement was used to explore PHC NPs' perceptions of the care they provide to patients. Analysis of the focus group data identified 3 primary themes: patient centeredness and bespoke care; reciprocity, trust, and acceptance; and knowledge transference. Relating these themes to the constructs of the Patient Enablement Instrument demonstrated a clear link between NP care and patient enablement.

Patient enablement after consultations has not yet been adequately investigated among patients of nurse practitioners (NP) in primary health care. The lens of enablement and a qualitative parallel multistrand approach were used to explore patients' experiences and NPs' perspectives of consultations. Metainferences made from this study suggest NPs enable patients by creating opportunities for education and knowledge transference and building on patients' strengths and promoting self-efficacy. Three existential components of the experience of consultations (ie, relationality, temporality, and corporality) also played a role. These findings were used to develop a conceptual framework of how patient enablement is experienced within an NP consultation.

Reduction in use of computed tomography (CT) in favor of rapid-sequence magnetic resonance imaging (MRI) to decrease pediatric radiation exposure has varied across institutions in the United States. The aims of this study were to understand national trends in CT and rapid-sequence MRI usage and identify variables affecting imaging practices and obstacles to CT reduction.This was a retrospective review of deidentified discharge data for children with hydrocephalus and traumatic brain injury (TBI) in the Healthcare Cost and Utilization Project Kids' Inpatient Database in 2000, 2003, 2006, 2009, 2012, and 2016. Utilization of MRI without contrast and CT was extracted using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision, codes. Hospital region and age cohorts were extracted and used to categorize data. χ2 tests and logistic regression were used for analysis.Hospitalizations utilizing CT decreased (P0.05) and hospitalizations utilizing MRI increased (P0.05) overall in both diagnosis groups throughout the years analyzed. However, there was significant regional variation in imaging. The Northeast had higher CT rates (P0.05) and the South had lower CT rates in patients with hydrocephalus and TBI (P0.05). No regional variation was found for rates of MRI use in patients with TBI.Nationwide, the average number of discharges after hospitalizations utilizing CT in patients with hydrocephalus and TBI has decreased, while discharges after hospitalizations utilizing MRI as an alternative imaging modality have increased. Despite successful overall CT reduction, significant regional variation exists within this trend showing inconsistent reduction of CT use.

Motivated by social, economic and health factors, food product manufacturers are increasingly attracted towards the incorporation of potato into snack foods. However, the lack of gluten degrades the mechanical properties of potato dough, posing a challenge in ensuring optimal manufacturing processes. An important process of industrial dough production is the sheeting or rolling process. This study developed a computational design tool to ensure smooth sheeting processes for potato doughs. A visco-hyperelastic constitutive model was calibrated using uniaxial compression data, providing the required material parameters for the rolling simulation. The model output was validated through tests on a laboratory small-scale instrumented rolling rig, where the roller speed and roll gap were varied to determine the effect on the rolling force and sheet exit thickness. A good agreement between the experimental and numerical results for the roll force and sheet exit thickness was found for smaller reduction ratios. At larger reductions, the numerical rolling force and exit thickness values were higher than the experimental values, and this was attributed to the dough being damaged while being fed through small roll gaps. A critical tensile strain-based failure criterion was proven to be accurate in predicting conditions for sheet tearing. The combination of the newly developed numerical model and tensile strain failure criterion can serve as a simple and powerful design tool for predicting the roll forces, the rolled sheet height as well as the process conditions which may lead to damage in the potato dough. As a result, interruptions in the continuous sheeting process associated with sheet damage or tearing may be avoided. Since the present study focuses on rolling parameters in a laboratory scale setup, future work will provide greater insight in scaling up the results to industrial rolling processes.

A 49-year-old female with history of daily inhaled corticosteroid use for asthma presented to a concussion clinic 7 wk after sport-related head injury with headache, visual blurring, dizziness, nausea, fatigue, polydipsia, and polyuria. Examination revealed difficulty with vestibuloocculomotor testing due to nausea and visual straining. Cranial computed tomography/magnetic resonance imaging was unremarkable. Laboratory testing revealed critically low serum cortisol, hypernatremia, and urine studies suggesting diabetes insipidus. The patient was referred to the emergency department. Intravenous fluid resuscitation, corticosteroids, and desmopressin led to significant symptomatic relief. She was maintained on oral hydrocortisone after cosyntropin test revealed adrenal insufficiency. Her clinical picture suggested chronic subclinical adrenal suppression from inhaled corticosteroids which was exacerbated by hypopituitarism from concussion combined with diabetes insipidus. Adrenal insufficiency should be considered in athletes with history of corticosteroid use and endocrine-related symptoms after concussion, because this can create significant morbidity and can mimic traditional symptoms of concussion.

A coherent model of brain-behaviour relationships specific to type 1 diabetes in children remains a work in progress, but there is consensus that the brain is one of the organ systems impacted by the disease. This chapter reviews current evidence for morphologic changes, altered cerebral growth trajectories and reduced functional interconnectivity in the central nervous system in children and adolescents with diabetes, especially following early onset disease. Effects of diabetes on cognition and functional outcomes such as academic achievement, mental health, work participation and quality of life are discussed, and persisting challenges in understanding precise causal mechanisms that may facilitate preventive interventions are noted.

Supplemental Digital Content is available in the text., The organ donation process is complex and stressful for the family of the potential donor and members of the multidisciplinary team who may experience grief, ethical dilemmas, vicarious trauma, or compassion fatigue. Several studies each explore the role of a specific healthcare group and the impact of inhospital processes on group members. We conducted a systematic literature search to identify such studies and a qualitative synthesis to consolidate findings and highlight features of the interaction and relationships between role players. Our results suggest that, while healthcare professionals have different roles, attitudes, and views, the experience of stressors and interdisciplinary tension is common. Nevertheless, staff are united by the goal of caring for the patient and family. We therefore propose that, while focusing on bereavement care and other aspects of the family’s experience, staff can find other shared goals and develop understanding, trust, empathy, and respect for each other’s positions, thereby improving functioning in the complex adaptive system that forms at this time. Education and training can equip staff to facilitate anticipatory mourning, family-led activities, and a meaningful parting from their relative, assisting families with their grief and increasing staff members’ efficacy, confidence, and interdisciplinary teamwork. Knowledge of systems thinking and opportunities to share ideas and experiences will enable staff to appreciate each other’s roles, while supportive mentors, self-care strategies, and meaningful feedback between role players will foster healthy adjustment and shared learning. A focus on psychosocial outcomes such as family satisfaction with the process, collaboration within the multidisciplinary team, and reduction in the role stress of healthcare professionals will contribute to family well-being as well as personal and professional growth for staff.

Background Venous thromboembolism is a cause of morbidity and mortality in hospitalized patients, and morbid obesity increases this risk. Various prophylaxis dosing strategies have been investigated. However, it is unclear if high-fixed dose enoxaparin or high-fixed dose unfractionated heparin thromboprophylaxis is optimal for minimizing the incidence of major bleeding and reducing hospital-acquired venous thromboembolism. Methods A single-center retrospective observational study was conducted in hospitalized patients who were morbidly obese (body mass index ≥40 kg/m2) and who received either high-fixed dose enoxaparin (40 mg every 12 hours) or unfractionated heparin (7500 units every 8 hours) for venous thromboembolism prophylaxis. Co-primary outcomes included incidence of major bleeding and venous thromboembolism diagnosed during hospitalization. Predictors of major bleeding were evaluated by multivariable regression. Results In the 305 patients included (n = 190 unfractionated heparin, n = 115 enoxaparin), the incidence of major bleeding was significantly higher in the unfractionated heparin group (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.07-3.13; P = 0.025), with no significant difference in the incidence of venous thromboembolism diagnosed during hospitalization. The only independent predictors of major bleeding were intensive care acuity (OR 3.32, 95% CI 1.91-5.78; P Conclusion High-fixed dose unfractionated heparin for venous thromboembolism prophylaxis may lead to a higher risk of major bleeding events compared with high-fixed dose enoxaparin in patients who are morbidly obese.

OBJECTIVEHospital readmission is an important quality metric that has not been evaluated in prenatal versus postnatal myelomeningocele (MMC) repair. This study compares hospital readmission outcomes between these two groups as well as their etiologies.METHODSThe medical records of patients who had undergone MMC repair in the period from 2011 to 2017 at a single academic medical center were retrospectively reviewed. Collected clinical data included surgery and defect details, neonatal intensive care unit (NICU) stay, and any readmissions or surgical procedures up to 1 year after surgery. Patient and defect characteristics, readmission outcomes at 30 and 60 days and 1 year after discharge from the NICU, and cerebrospinal fluid (CSF) diversion surgery rates were analyzed with the two-tailed t-test and/or k-sample test on the equality of medians.RESULTSA total of 24 prenatal and 34 postnatal MMC repairs were completed during the study period. Prenatally repaired patients were born more prematurely (p < 0.001) and with lower birth weights (p < 0.001), although the NICU stay was similar between the two groups (p = 0.59). Fewer prenatally repaired patients were readmitted at 30 days (p = 0.005), 90 days (p = 0.004), and 1 year (p = 0.007) than the postnatal repair group. Hydrocephalus was the most common readmission etiology, and 29% of prenatal repair patients required CSF diversion at 1 year versus 81% of the postnatal repair group (p < 0.01). Prenatal patients who required CSF diversion had a higher body weight (p = 0.02) and an older age (p = 0.01) at the time of CSF diversion surgery than the postnatal group.CONCLUSIONSPatients with prenatal MMC repair had fewer hospital readmissions at 30 days, 60 days, and 1 year than the postnatal repair group, despite similar NICU lengths of stay. The prenatal repair group had lower requirements for CSF diversion at 1 year and was older with greater body weights at the time of CSF diversion surgery, compared to those of the postnatal repair group. Future study of hospital quality metrics such as readmissions should be performed to better understand outcomes of these two procedures.

Background: Preterm birth is associated with increased risk of neuromotor impairment. Rates of major neuromotor impairment (cerebral palsy) have decreased; however, in a large proportion of those who do not develop cerebral palsy impaired neuromotor function is observed and this often has implications for everyday life. The aim of this study was to investigate motor performance in preterm born adolescents without cerebral palsy, and to examine associations with alterations of motor system pathway structure. Design/Methods: Thirty-two adolescents (12 males) without cerebral palsy, born before 33 weeks of gestation (mean 27.4 weeks, SD 2.4; birth weight mean 1084.5 g; SD 387.2), treated at a single tertiary unit, were assessed (median age 16 years; min 14, max 18). Timed performance and quality of movements were assessed with the Zürich Neuromotor Assessment. Neuroimaging included Diffusion Magnetic Resonance Imaging for tractography of the major motor tracts and measurement of fractional anisotropy as a measure of microstructure of the tracts along the major motor pathways. Separate analyses were conducted for areas with predominantly single and predominantly crossing fibre regions. Results: Motor performance in both tasks assessing timed performance and quality of movements, was poorer than expected in the preterm group in relation to norm population. The strongest significant correlations were seen between performance in tasks assessing movement quality and fractional anisotropy in corpus callosum fibres connecting primary motor, primary somatosensory and premotor areas. In addition, timed motor performance was significantly related to fractional anisotropy in the cortico-spinal and thalamo-cortical to premotor area fibres, and the corpus callosum. Conclusions: Impairments in motor abilities are present in preterm born adolescents without major neuromotor impairment and in the absence of focal brain injury. Altered microstructure of the corpus callosum microstructure appears a crucial factor, in particular for movement quality.

Over the past 20 years, cancer patient advocacy groups have demonstrated that patient engagement in cancer care is essential to improving patient quality of life and outcomes. Bladder cancer patient advocacy only began 10 years ago in the United States, but is now expanding around the globe with non-profit organizations established in Canada, the United Kingdom and Italy, and efforts underway in Australia. These organizations, at different levels of maturity, are raising awareness of bladder cancer and providing essential information and resources to bladder cancer patients and their families. The patient advocacy organizations are also helping to advance research efforts by funding research proposals and facilitating research collaborations. Strong partnerships between these patient advocates and the bladder cancer medical community are essential to ensuringsustainability for these advocacy organizations, increasing funding to support advances in bladder cancer treatment, and improving patient outcomes.

As the point of entry into healthcare for many patients, the emergency department (ED) is an ideal setting in which to assess penicillin (PCN) allergies. An estimated 10% of the United States population has a reported PCN allergy; however, few studies have evaluated the prevalence and impact of PCN allergies on antibiotic selection within the ED. Patients with a documented PCN allergy are more likely to be exposed to costly alternative broad-spectrum antibiotics that have higher rates of adverse events, including C. difficile infections. We sought to determine the prevalence of PCN allergies within the UNC Medical Center ED. Key secondary outcomes included the percentage of patients with a documented PCN allergy who (1) received alternative antibiotics (carbapenems, aztreonam, fluoroquinolones, clindamycin, vancomycin), (2) received β-lactam antibiotics and experienced an allergic reaction during their ED visit, and/or (3) had received a β-lactam antibiotic during a past hospitalization or ED visit without their chart being appropriately updated. A retrospective evaluation included patients aged >18 years with a documented PCN allergy who were discharged from the ED between January 1, 2017, and December 31, 2019. Over the study period, there were 14,635 patient encounters with a documented PCN allergy that comprised 8,573 unique patients. The prevalence of PCN allergies was 14.3% for all ED encounters. PCN allergy–labeled patients received alternative antibiotics in 59.4% of ED encounters in which antibiotics were prescribed. Of the 454 β-lactam antibiotics (62 penicillins, 380 cephalosporins, 12 carbapenems) administered to PCN allergy-labeled patients within the ED, there were zero allergic reactions. Also, 18.6% of PCN allergy-labeled patients had received and tolerated a β-lactam antibiotic during prior hospitalizations or ED visits (1.7% penicillins, 14.4% cephalosporins, 2.6% carbapenems) without appropriate updated documentation to reflect β-lactam antibiotic tolerance. These findings confirm the utilization of non–β-lactam antibiotics in PCN allergy-labeled patients, highlighting the importance of accurate and updated allergy documentation in the electronic medical record. These findings also demonstrate the need for improved allergy documentation and protocols to proactively assess penicillin allergy labels while in the ED.Funding: NoDisclosures: None

Cerebral aspergillosis carries a high mortality. Rapid diagnosis and treatment can increase survival, but symptoms and imaging findings are nonspecific. The literature on cerebral aspergillosis consists mostly of case reports and case series and lacks large-scale review of data.We performed a review of the literature using PubMed in March 2019. We recorded the year of publication, age and sex of patients, neurosurgical involvement, the antifungals administered, use of intrathecal antifungals, and the outcome of patients. The relationships among variables were tested using bivariant statics and linear regression.A total of 324 studies met the eligibility criteria, and 198 studies including 248 patients were included. Surgical resection (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.25-0.80; P0.01) and administration of voriconazole (OR, 0.32; 95% CI, 0.18-0.55; P0.001) or itraconazole (OR, 0.36; 95% CI, 0.16-0.72; P0.001) were shown to be significantly associated with survival.Given the significant survival benefits for patients who received voriconazole and surgical intervention, we suggest early antifungal medical treatment and resection.

Purpose The purpose of this paper is to provide an overview of the adolescent therapeutic community (ATC) literature – drawing on studies primarily from the USA with consideration made to the Australian context. Design/methodology/approach A review of the efficacy research for ATCs is considered, and the characteristics of Australians accessing ATC treatment are discussed in the context of developmental needs. Findings Similarities are found in what precipitates and perpetuates adolescent substance use in the USA and Australia, and therefore, what appears to facilitate effective treatment utilising the therapeutic community model. Originality/value The paper provides a valuable perspective for Australian services, and explores the application of the ATC model within the Australian treatment context.

Purpose The purpose of this paper is to explore the applicability of the Australasian Therapeutic Communities Association (ATCA) Standard to Australian youth-specific modified therapeutic communities (MTCs). An Interpretive Guide for Youth MTCs and Residential Rehabilitation (RR) Services was developed and a pilot trial conducted with three Australian youth MTC services. Design/methodology/approach Using a mixed-methods design, this study included three components: a consultation process with residential youth MTCs (N=15), which informed the development of the ATCA Standard Interpretive Guide for Youth MTCs and RR Services; a pilot trial of the materials with three Australian youth MTCs (N=53); and an evaluation of the interpretive guide and assessment of applicability of the ATCA standard to youth MTCs through pre- (N=32) and post- (N=19) pilot trial administrations of the Survey of Essential Elements Questionnaires (SEEQ), and post-pilot trial focus groups (N=21). Findings Results indicate that the ATCA Standard is applicable to youth MTC settings when applied with the Interpretive Guide, although no significant differences were found between the pre- and post-pilot trial administrations of the SEEQ. Practical implications Future research is recommended to explore active mechanisms of youth-specific MTCs, differences between adults and youth MTCs, and the development of TC-specific training. Originality/value To date, no standard for youth residential substance use services in Australia has been developed, and this is the first study of its kind internationally to explore the efficacy of standards in a youth MTC.

Purpose: The purpose of this Delphi study was to obtain consensus among an international, multidisciplinary panel of child sex-trafficking experts and child sex-trafficking survivors on the most important elements needed in a comprehensive, interdisciplinary health-care-provider education program on the recognition, intervention, and referral of child sex-trafficking victims and survivors.Methods: A two-round Delphi method was utilized to identify the most important elements of a child sex-trafficking health-care-provider education program. A content validity index score was utilized to determine consensus and order importance of each element.Results: Eight content areas including 63 subcontent areas were identified by an international panel of 23 subject-matter experts representing clinical professions, law enforcement, academia, and community support organizations as important for inclusion in comprehensive health-care-provider education programs. Three content areas and 19 subcontent areas were...

Covid-19 and the States — A Conversation with Ralph Northam In this audio interview conducted on February 3, 2021, the editors are joined by Dr. Ralph Northam, the governor of Virginia, to discuss ...

Global health research can transform clinical and surgical practice worldwide. Partnerships between US academic centers and hospitals in low- and middle-income counties can improve clinical care at the host institution hospital and give the visiting institution access to a large volume of valuable research data. Recognizing the value of these partnerships, the University of North Carolina (UNC) formed a partnership with Kamuzu Central Hospital (KCH) in Lilongwe, Malawi.The Department of Neurosurgery joined the partnership with KCH and designed a Head Trauma Surveillance Registry. The success of this registry depended on the development of methods to accurately collect head injury data at KCH. Since medical record documentation is often unreliable in this setting, data collection teams were implemented to capture data from head trauma patients on a 24-hours-a-day, 7-days-a-week basis. As data collection improved, pilot groups tested methods to collect new variables and the registry expanded. UNC provided onsite and remote oversight to strengthen the accuracy of the data.Data accuracy still remains a hurdle in global research. Data collection teams, oversight from UNC, pilot group testing, and meaningful collaboration with local physicians improved the accuracy of the head trauma registry. Overall, these methods helped create a more accurate epidemiological and outcomes-centered analysis of brain injury patients at KCH to date.