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Chest Nov 2021Decannulation from venovenous extracorporeal membrane oxygenation (ECMO) at the earliest and safest possible time may improve outcomes and reduce cost. Yet, no...
BACKGROUND
Decannulation from venovenous extracorporeal membrane oxygenation (ECMO) at the earliest and safest possible time may improve outcomes and reduce cost. Yet, no prospective studies have compared weaning strategies for liberation from ECMO.
RESEARCH QUESTION
Is a protocolized daily assessment of readiness to liberate from venovenous ECMO safe and feasible?
STUDY DESIGN AND METHODS
We conducted a prospective, single-arm safety and feasibility study of a protocol for daily assessment of readiness to liberate from venovenous ECMO among consecutive adult patients receiving venovenous ECMO across four ICUs at a single center between June 20, 2020, and November 24, 2020. The ECMO-free protocol included three phases: (1) the safety screening, (2) non-ECMO Fio titration, and (3) the ECMO-free trial. Enrollment, interventions, and data collection were performed prospectively by trained study staff.
RESULTS
Twenty-six patients received the ECMO-free protocol on 385 patient-days. The safety screening was passed during a total of 59 ECMO-free daily assessments (15.3%) among 20 patients. Every passed safety screening proceeded to an ECMO-free trial. Twenty-eight passed ECMO-free trials (47.5%) occurred among 16 patients (61.5%). No missed safety screenings, protocol deviations, or adverse events occurred. Of the 16 patients who passed an ECMO-free trial, 14 patients (87.5%) were decannulated. Among decannulated patients, 12 patients (85.7%) were decannulated on the same day as a passed ECMO-free trial, 6 patients (42.9%) were decannulated on the first day that they passed an ECMO-free trial, and 6 patients (42.9%) passed an ECMO-free trial at least twice consecutively before decannulation. The median time from first passed ECMO-free trial to decannulation was 2 days (interquartile range, 0-3 days).
INTERPRETATION
The ECMO-free protocol is feasible and may identify patients for decannulation earlier than gradual approaches to weaning.
Topics: Clinical Protocols; Critical Care; Duration of Therapy; Extracorporeal Membrane Oxygenation; Feasibility Studies; Female; Humans; Male; Middle Aged; Outcome and Process Assessment, Health Care; Patient Safety; Pilot Projects; Prospective Studies; Risk Adjustment; Symptom Assessment; Withholding Treatment
PubMed: 34166644
DOI: 10.1016/j.chest.2021.05.066 -
Infection Control and Hospital... Sep 2017OBJECTIVE To evaluate healthcare worker (HCW) risk of self-contamination when donning and doffing personal protective equipment (PPE) using fluorescence and MS2...
OBJECTIVE To evaluate healthcare worker (HCW) risk of self-contamination when donning and doffing personal protective equipment (PPE) using fluorescence and MS2 bacteriophage. DESIGN Prospective pilot study. SETTING Tertiary-care hospital. PARTICIPANTS A total of 36 HCWs were included in this study: 18 donned/doffed contact precaution (CP) PPE and 18 donned/doffed Ebola virus disease (EVD) PPE. INTERVENTIONS HCWs donned PPE according to standard protocols. Fluorescent liquid and MS2 bacteriophage were applied to HCWs. HCWs then doffed their PPE. After doffing, HCWs were scanned for fluorescence and swabbed for MS2. MS2 detection was performed using reverse transcriptase PCR. The donning and doffing processes were videotaped, and protocol deviations were recorded. RESULTS Overall, 27% of EVD PPE HCWs and 50% of CP PPE HCWs made ≥1 protocol deviation while donning, and 100% of EVD PPE HCWs and 67% of CP PPE HCWs made ≥1 protocol deviation while doffing (P=.02). The median number of doffing protocol deviations among EVD PPE HCWs was 4, versus 1 among CP PPE HCWs. Also, 15 EVD PPE protocol deviations were committed by doffing assistants and/or trained observers. Fluorescence was detected on 8 EVD PPE HCWs (44%) and 5 CP PPE HCWs (28%), most commonly on hands. MS2 was recovered from 2 EVD PPE HCWs (11%) and 3 CP PPE HCWs (17%). CONCLUSIONS Protocol deviations were common during both EVD and CP PPE doffing, and some deviations during EVD PPE doffing were committed by the HCW doffing assistant and/or the trained observer. Self-contamination was common. PPE donning/doffing are complex and deserve additional study. Infect Control Hosp Epidemiol 2017;38:1077-1083.
Topics: Adult; Female; Gloves, Protective; Guideline Adherence; Health Personnel; Humans; Infection Control; Levivirus; Male; Middle Aged; Missouri; Personal Protective Equipment; Pilot Projects; Protective Clothing; Respiratory Protective Devices; Reverse Transcriptase Polymerase Chain Reaction; Tertiary Care Centers; Ultraviolet Rays; Video Recording
PubMed: 28606192
DOI: 10.1017/ice.2017.121 -
Gait & Posture Sep 2022Objective gait analysis that fully captures the multi-segmental foot movement of a clubfoot may help in early identification of a relapse clubfoot. Unfortunately, this...
BACKGROUND
Objective gait analysis that fully captures the multi-segmental foot movement of a clubfoot may help in early identification of a relapse clubfoot. Unfortunately, this type of objective measure is still lacking in a clinical setting and it is unknown how it relates to clinical assessment.
RESEARCH QUESTION
The aim of this study was to identify differences in total gait and foot deviations between clubfoot patients with and without a relapse clubfoot and to evaluate their relationship with clinical status.
METHODS
In this study, Ponseti-treated idiopathic clubfoot patients were included and divided into clubfoot patients with and without a relapse. Objective gait analysis was done resulting in total gait and foot scores and clinical assessment was performed using the Clubfoot Assessment Protocol (CAP). Additionally, a new clubfoot specific foot score, the clubFoot Deviation Index (cFDI*), was calculated to better capture foot kinematics of clubfoot patients.
RESULTS
Clubfoot patients with a relapse show lower total gait quality (GDI*) and lower clinical status defined by the CAP than clubfoot patients without a relapse. Abnormal cFDI* was found in relapse patients, reflected by differences in corresponding variable scores. Moderate relationships were found for the subdomains of the CAP and total gait and foot quality in all clubfoot patients.
SIGNIFICANCE
A new total foot score was introduced in this study, which was more relevant for the clubfoot population. The use of this new foot score (cFDI*) besides the GDI*, is recommended to identify gait and foot motion deviations. Along with clinical assessment, this will give an overview of the overall status of the complex, multi-segmental aspects of a (relapsed) clubfoot. The relationships found in this study suggest that clinical assessment might be indicative of a deviation in total gait and foot pattern, therefore hinting towards personalised screening for better treatment decision making.
Topics: Casts, Surgical; Clubfoot; Foot; Gait; Gait Analysis; Humans; Recurrence; Treatment Outcome
PubMed: 35995000
DOI: 10.1016/j.gaitpost.2022.07.261 -
International Journal of Radiation... May 2022To evaluate the results of the radiation therapy (RT) quality assurance (QA) program of the phase 3 randomized SAKK 09/10 trial in patients with biochemically recurrent...
PURPOSE
To evaluate the results of the radiation therapy (RT) quality assurance (QA) program of the phase 3 randomized SAKK 09/10 trial in patients with biochemically recurrent prostate cancer after prostatectomy.
METHODS AND MATERIALS
Within the Schweizerische Arbeitsgemeinschaft für Klinische Krebsforschung (SAKK) 09/10 trial testing 64-Gy versus 70-Gy salvage RT, a central collection of treatment plans was performed and thoroughly reviewed by a dedicated medical physicist and radiation oncologist. Adherence to the treatment protocol and specifically to the European Organization for the Research and Treatment of Cancer (EORTC) guidelines for target volume definition (classified as deviation observed yes vs no) and its potential correlation with acute and late toxicity (Common Terminology Criteria for Adverse Events version 4.0) and freedom from biochemical progression (FFBP) were investigated.
RESULTS
The treatment plans for 344 patients treated between February 2011 and April 2014 depicted important deviations from the EORTC guidelines and the recommendations per trial protocol. For example, in up to half of the cases, the delineated structures deviated from the protocol (eg, prostate bed in 48.8%, rectal wall [RW] in 41%). In addition, variations in clinical target volume (CTV) and planning target volume (PTV) occurred frequently (eg, CTV and PTV deviations in up to 42.4% and 25.9%, respectively). The detected deviations showed a significant association with a lower risk of grade ≥2 gastrointestinal acute toxicity when the CTV did not overlap the RW versus when the CTV overlapped the RW (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.22-0.85; P = .014), and a higher rate of grade ≥2 late genitourinary (GU) toxicity when the CTV overlapped the RW (OR, 2.58; 95% CI, 1.17-5.72; P = .019). A marginally significant lower risk of grade ≥2 late GU toxicity was observed when the prostate bed did not overlap versus did overlap the RW (OR, 0.51; 95% CI, 0.25-1.03; P = .06). In addition, a marginally significant decrease in FFBP was observed in patients with PTV not including surgical clips as potential markers of the limits of the prostate bed (hazard ratio, 1.44; 95% CI, 0.96-2.17; P = .07).
CONCLUSIONS
Despite a thorough QA program, the central review of a phase 3 trial showed limited adherence to treatment protocol recommendations, which was associated with a higher risk of toxicity by means of acute or late gastrointestinal or GU toxicity and showed a trend toward worse FFBP. Data from this QA review might help to refine future QA programs and prostate bed delineation guidelines.
Topics: Gastrointestinal Diseases; Humans; Male; Prostatectomy; Prostatic Neoplasms; Radiotherapy, Intensity-Modulated; Rectum; Salvage Therapy
PubMed: 34990777
DOI: 10.1016/j.ijrobp.2021.12.174 -
Medicina Oral, Patologia Oral Y Cirugia... Jul 2023The insertion torque of dental implants will depend on a combination of different factors such as bone density, the design of the implant and the drilling protocol used....
BACKGROUND
The insertion torque of dental implants will depend on a combination of different factors such as bone density, the design of the implant and the drilling protocol used. However, it is not clear how the interaction of these factors affects the final insertion torque and which drilling protocol should be used in each clinical situation. The aim of this work is to analyse the influence of bone density, implant diameter and implant length on the insertion torque using different drilling protocols.
MATERIAL AND METHODS
An experimental study was carried out in which the maximum insertion torque was measured, in standardised polyurethane blocks (Sawbones Europe AB) of four densities, for M12 Oxtein dental implants (Oxtein, Spain) with diameters of 3.5, 4.0, 4.5 and 5mm, and lengths of 8.5mm, 11.5mm and 14.5mm. All these measurements were carried out following four drilling protocols, a standard protocol, adding a bone tap, cortical drill or conical drill. In this way, a total of 576 samples were obtained. For the statistical analysis, the table of confidence intervals, mean, standard deviation and covariance was carried out, in total and grouped by the parameters used.
RESULTS
The insertion torque for D1 bone obtained very high levels, reaching 77 6.95 N/cm, these values improved with the use of conical drills. In D2 bone, the mean torque obtained was 37.89± 13.70N/cm, with values within the standard. In D3 and D4 bone significantly low torques were obtained with values of 14.97± 4.40N/cm and 9.88± 4.16N/cm (p>0.001) respectively.
CONCLUSIONS
In D1 bone, conical drills must be incorporated in drilling to avoid excessive torque, while in D3 and D4 bone, these would be contraindicated, as they drastically decrease the insertion torque, which may compromise the treatment.
Topics: Humans; Dental Implants; Dental Implantation, Endosseous; Bone Density; Torque; Bone and Bones
PubMed: 37330951
DOI: 10.4317/medoral.25804 -
The Journal of Prosthetic Dentistry Sep 2015Even though high-precision technologies have been used in computer-guided implant surgery, studies have shown that linear and angular deviations between the planned and...
STATEMENT OF PROBLEM
Even though high-precision technologies have been used in computer-guided implant surgery, studies have shown that linear and angular deviations between the planned and placed implants can be expected.
PURPOSE
The purpose of this study was to evaluate the effect of operator experience on the accuracy of implant placement with a computer-guided surgery protocol.
MATERIAL AND METHODS
Ten surgically experienced and 10 surgically inexperienced operators participated in this study. Each operator placed 1 dental implant (Replace Select) on the partially edentulous mandibular model that had been planned with software by following a computer-guided surgery (NobelGuide) protocol. Three-dimensional information of the planned and placed implants were then superimposed. The horizontal and vertical linear deviations at both the apex and platform levels and the angular deviation were measured and compared between the experienced and inexperienced groups with the independent t test with Bonferroni adjustment (α=.01). The magnitude and direction of the horizontal deviations were also measured and recorded.
RESULTS
No significant differences were found in the angular and linear deviations between the 2 groups (P>.01). Although not statistically significant (P>.01), the amount of vertical deviation in the coronal direction of the implants placed by the inexperienced operators was about twice that placed by the experienced operators. Overall, buccal apical deviations were most frequent and of the highest magnitude.
CONCLUSIONS
When a computer-guided protocol was used, the accuracy of the vertical dimension (depth of implant placement) was most influenced by the operator's level of experience.
Topics: Computer-Aided Design; Cone-Beam Computed Tomography; Dental Implantation; Dental Implants; Humans; Image Processing, Computer-Assisted; Jaw, Edentulous, Partially; Mandible; Mouth, Edentulous; Software; Surgery, Computer-Assisted; User-Computer Interface
PubMed: 26119019
DOI: 10.1016/j.prosdent.2015.04.004 -
BMC Emergency Medicine May 2022The number of ambulance assignments and the influx of patients to the emergency departments (EDs) in Sweden have increased in recent years. This is one reason the...
BACKGROUND
The number of ambulance assignments and the influx of patients to the emergency departments (EDs) in Sweden have increased in recent years. This is one reason the protocol for prehospital emergency care was developed around referring patients for non-conveyance, either through the see-and-convey elsewhere approach or through the see-and-treat approach. However, this protocol has led to challenges in patient assessments. This study aimed to investigate the underlying causes of patient harm among those referred for the see-and-treat approach by the emergency medical services.
METHODS
This three-phase study involved a mixed-methods design. Cases of injuries, internal investigations and incident analyses of referrals for the see-and-treat approach in two regions in south eastern Sweden from 2015 to 2020 were examined using qualitative content analysis. This qualitative analysis was the basis for the quantitative analysis of the ambulance records. After the qualitative analysis was completed, a review protocol was developed; 34 variables were used to review 240 randomly selected ambulance records logged in 2020, wherein patients were referred for the see-and-treat approach. Finally, the review results were synthesised.
RESULTS
The qualitative analysis revealed three common themes: 'assessment of patients', 'guidelines' and 'environment and organisation'. These results were confirmed by a medical journal review. Shortcomings were found in the anamnesis and in the number of targeted examinations performed. The checklist for referring patients for the see-and-treat approach and the information sheet to be provided to the patients were not used. In 34% of the ambulance records examined, the EMS clinicians deviated from the current guidelines for a see-and-treat referral.
CONCLUSIONS
The results indicated that the low adherence to guidelines and the patient assessment deviating from the protocol put patients at risk of being harmed during a see-and-treat referral. Measures are needed to guarantee a safe assessment of an increasing number of patients who are referred for the see-and-treat approach, especially the multi-sick elderly patients.
Topics: Aged; Ambulances; Emergency Medical Services; Emergency Service, Hospital; Humans; Referral and Consultation; Sweden
PubMed: 35524195
DOI: 10.1186/s12873-022-00630-8 -
Epidemiology (Cambridge, Mass.) Jul 2021Important questions exist regarding the comparative effectiveness of alternative childhood vaccine schedules; however, optimal approaches to studying this complex issue...
BACKGROUND
Important questions exist regarding the comparative effectiveness of alternative childhood vaccine schedules; however, optimal approaches to studying this complex issue are unclear.
METHODS
We applied methods for studying dynamic treatment regimens to estimate the comparative effectiveness of different rotavirus vaccine (RV) schedules for preventing acute gastroenteritis-related emergency department (ED) visits or hospitalization. We studied the effectiveness of six separate protocols: one- and two-dose monovalent rotavirus vaccine (RV1); one-, two-, and three-dose pentavalent rotavirus vaccine (RV5); and no RV vaccine. We used data on all infants to estimate the counterfactual cumulative risk for each protocol. Infants were censored when vaccine receipt deviated from the protocol. Inverse probability of censoring-weighted estimation addressed potentially informative censoring by protocol deviations. A nonparametric group-based bootstrap procedure provided statistical inference.
RESULTS
The method yielded similar 2-year effectiveness estimates for the full-series protocols; weighted risk difference estimates comparing unvaccinated children to those adherent to either full-series (two-dose RV1, three-dose RV5) corresponded to four fewer hospitalizations and 12 fewer ED visits over the 2-year period per 1,000 children. We observed dose-response relationships, such that additional doses further reduced risk of acute gastroenteritis. Under a theoretical intervention to fully vaccinate all children, the 2-year risk differences comparing full to observed adherence were 0.04% (95% CI = 0.03%, 0.05%) for hospitalizations and 0.17% (95% CI = 0.14%, 0.19%) for ED visits.
CONCLUSIONS
The proposed approach can generate important evidence about the consequences of delaying or skipping vaccine doses, and the impact of interventions to improve vaccine schedule adherence.
Topics: Child; Gastroenteritis; Hospitalization; Humans; Infant; Rotavirus; Rotavirus Infections; Rotavirus Vaccines; Vaccines, Attenuated
PubMed: 33927157
DOI: 10.1097/EDE.0000000000001363 -
Intensive & Critical Care Nursing Dec 2023Potassium replacement protocols are used to standardise practice, reduce risk, and ensure timely potassium replacement, but there is considerable variability in their... (Review)
Review
BACKGROUND
Potassium replacement protocols are used to standardise practice, reduce risk, and ensure timely potassium replacement, but there is considerable variability in their development and use, particularly as part of critical care nursing practice.
AIM
To synthesise the research evidence on how potassium replacement protocols are used in adult critical care; and how critical care nurses' role and practice is influenced by a potassium replacement protocol. The research question was 'How are protocols used by intensive care clinicians to guide potassium replacement in adult critical care?'
DESIGN
A structured integrative review was undertaken. A combination of keywords, synonyms, and Medical Subject Headings were used across the Ovid Medline and Embase databases. Records were independently assessed against inclusion and exclusion criteria. All papers were assessed for quality. A narrative synthesis was used to analyse and present the findings.
RESULTS
Ten studies were included in this review from 4076 records identified. Narrative synthesis revealed five categories: (i) protocol design demonstrating variation in protocol mechanisms, (ii) protocol rationale eliciting reasonings for protocol implementation, (iii) protocol use describing how protocols were nurse-driven enabling nursing autonomy (iv) protocol adherence highlighting variability in protocol compliance and (v) critical care nurse acceptability and feasibility coupling greater shared responsibility for patient care and improved clinician satisfaction.
CONCLUSION
Safe, high-quality care, supported by evidence continues to be a priority. Protocolised potassium replacement can improve patient outcomes and promote nurses' autonomy, efficiency, and job satisfaction.
IMPLICATIONS FOR CLINICAL PRACTICE
Recognising and promoting critical care nurses' expert assessment skills and clinical decision-making is essential for optimising efficient, safe, and high-quality patient care. Although protocol deviations are accommodated in protocol development, comprehensive documentation to justify protocol deviations is key to justifying practice. Understanding protocol deviations are crucial to inform future protocol development, improvements, and evaluation to further enhance critical care nursing practice.
Topics: Adult; Humans; Critical Care; Clinical Decision-Making; Critical Care Nursing; Job Satisfaction; Potassium
PubMed: 37598503
DOI: 10.1016/j.iccn.2023.103524 -
EJNMMI Physics Nov 2019Performance standards for quantitative F-FDG PET/CT studies are provided by the EANM Research Ltd. (EARL) to enable comparability of quantitative PET in multicentre...
PURPOSE
Performance standards for quantitative F-FDG PET/CT studies are provided by the EANM Research Ltd. (EARL) to enable comparability of quantitative PET in multicentre studies. Yet, such specifications are not available for Ga. Therefore, our aim was to evaluate Ga-PET/CT quantification variability in a multicentre setting.
METHODS
A survey across Dutch hospitals was performed to evaluate differences in clinical Ga PET/CT study protocols. Ga and F phantom acquisitions were performed by 8 centres with 13 different PET/CT systems according to EARL protocol. The cylindrical phantom and NEMA image quality (IQ) phantom were used to assess image noise and to identify recovery coefficients (RCs) for quantitative analysis. Both phantoms were used to evaluate cross-calibration between the PET/CT system and local dose calibrator.
RESULTS
The survey across Dutch hospitals showed a large variation in clinical Ga PET/CT acquisition and reconstruction protocols. Ga PET/CT image noise was below 10%. Cross-calibration was within 10% deviation, except for one system to overestimate F and two systems to underestimate the Ga activity concentration. RC-curves for F and Ga were within and on the lower limit of current EARL standards, respectively. After correction for local Ga/F cross-calibration, mean Ga performance was 5% below mean EARL performance specifications.
CONCLUSIONS
Ga PET/CT quantification performs on the lower limits of the current EARL RC standards for F. Correction for local Ga/F cross-calibration mismatch is advised, while maintaining the EARL reconstruction protocol thereby avoiding multiple EARL protocols.
PubMed: 31705215
DOI: 10.1186/s40658-019-0253-z