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Current Opinion in Critical Care Aug 2024To examine the evolving landscape of cardiac surgery, focusing on the increasing complexity of patients and the role of mechanical circulatory support (MCS) in managing... (Review)
Review
PURPOSE OF REVIEW
To examine the evolving landscape of cardiac surgery, focusing on the increasing complexity of patients and the role of mechanical circulatory support (MCS) in managing perioperative low cardiac output syndrome (P-LCOS).
RECENT FINDINGS
P-LCOS is a significant predictor of mortality in cardiac surgery patients. Preoperative risk factors, such as cardiogenic shock and elevated lactate levels, can help identify those at higher risk. Proactive use of MCS, rather than reactive implementation after P-LCOS develops, may lead to improved outcomes by preventing severe organ hypoperfusion. The emerging concept of "protected cardiac surgery" emphasizes early identification of these high-risk patients and planned MCS utilization. Additionally, specific MCS strategies are being developed and refined for various cardiac conditions, including AMI-CS, valvular surgeries, and pulmonary thromboendarterectomy.
SUMMARY
This paper explores the shifting demographics and complexities in cardiac surgery patients. It emphasizes the importance of proactive, multidisciplinary approaches to identify high-risk patients and implement early MCS to prevent P-LCOS and improve outcomes. The concept of protected cardiac surgery, involving planned MCS use and shared decision-making, is highlighted. The paper also discusses MCS strategies tailored to specific cardiac procedures and the ethical considerations surrounding MCS implementation.
Topics: Humans; Cardiac Surgical Procedures; Cardiac Output, Low; Postoperative Complications; Heart-Assist Devices; Shock, Cardiogenic; Extracorporeal Membrane Oxygenation; Risk Factors; Risk Assessment
PubMed: 38958182
DOI: 10.1097/MCC.0000000000001179 -
Nursing Open Jul 2024To investigate nursing/midwifery students, Clinical Mentors, Link Teachers and Head Nurses experiences within "Dedicated Education Unit" model in 6 European clinical...
AIM
To investigate nursing/midwifery students, Clinical Mentors, Link Teachers and Head Nurses experiences within "Dedicated Education Unit" model in 6 European clinical placements and analyse the necessary elements for a powerful clinical learning environment.
DESIGN
A multi-country, phenomenological, qualitative study.
METHODS
Focus group interviews were performed to identify the personal and organizational factors of importance for students and nurses/midwives.
RESULTS
Data analysis produced 4 main themes (1) Clinical placement organization, (2) students' clinical knowledge and skill acquisition, (3) students, and nurses/midwives' experiences within the DEU model and (4) factors for creating an effective learning environment.
CONCLUSIONS
A close educational-service collaboration, a realistic clinical placement planning, a focus on student learning process and an investment in professionals' education and development among others, are elements to set up a powerful clinical learning environment.
IMPLICATIONS FOR THE PROFESSION
It is considered advisable and urgent to improve the working conditions of nurses/midwives and the learning environments of students as a strategy to alleviate the global shortage of nurses and respond to the increasingly demanding health needs of the population.
IMPACT
Due to the close relationship between students' learning and features of the clinical environment nurse educators seek innovative models which allow students to manage patient care and their transition to professional practice. To implement new learning strategies, identifying students, nurses and midwives perceptions and suggestions is a powerful information to evaluate implementation process and outcomes.
PUBLIC CONTRIBUTION
Our findings could help academic and clinical managers to meet the human and organizational requirements to create a successful learning environment in every student placement.
Topics: Humans; Qualitative Research; Focus Groups; Students, Nursing; Europe; Midwifery; Female; Clinical Competence; Nurses; Adult; Education, Nursing, Baccalaureate; Nurse Midwives
PubMed: 38958174
DOI: 10.1002/nop2.2210 -
The Cochrane Database of Systematic... Jul 2024Schizophrenia is often a severe and disabling psychiatric disorder. Antipsychotics remain the mainstay of psychotropic treatment for people with psychosis. In limited... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Schizophrenia is often a severe and disabling psychiatric disorder. Antipsychotics remain the mainstay of psychotropic treatment for people with psychosis. In limited resource and humanitarian contexts, it is key to have several options for beneficial, low-cost antipsychotics, which require minimal monitoring. We wanted to compare oral haloperidol, as one of the most available antipsychotics in these settings, with a second-generation antipsychotic, olanzapine.
OBJECTIVES
To assess the clinical benefits and harms of haloperidol compared to olanzapine for people with schizophrenia and schizophrenia-spectrum disorders.
SEARCH METHODS
We searched the Cochrane Schizophrenia study-based register of trials, which is based on monthly searches of CENTRAL, CINAHL, ClinicalTrials.gov, Embase, ISRCTN, MEDLINE, PsycINFO, PubMed and WHO ICTRP. We screened the references of all included studies. We contacted relevant authors of trials for additional information where clarification was required or where data were incomplete. The register was last searched on 14 January 2023.
SELECTION CRITERIA
Randomised clinical trials comparing haloperidol with olanzapine for people with schizophrenia and schizophrenia-spectrum disorders. Our main outcomes of interest were clinically important change in global state, relapse, clinically important change in mental state, extrapyramidal side effects, weight increase, clinically important change in quality of life and leaving the study early due to adverse effects.
DATA COLLECTION AND ANALYSIS
We independently evaluated and extracted data. For dichotomous outcomes, we calculated risk ratios (RR) and their 95% confidence intervals (CI) and the number needed to treat for an additional beneficial or harmful outcome (NNTB or NNTH) with 95% CI. For continuous data, we estimated mean differences (MD) or standardised mean differences (SMD) with 95% CIs. For all included studies, we assessed risk of bias (RoB 1) and we used the GRADE approach to create a summary of findings table.
MAIN RESULTS
We included 68 studies randomising 9132 participants. We are very uncertain whether there is a difference between haloperidol and olanzapine in clinically important change in global state (RR 0.84, 95% CI 0.69 to 1.02; 6 studies, 3078 participants; very low-certainty evidence). We are very uncertain whether there is a difference between haloperidol and olanzapine in relapse (RR 1.42, 95% CI 1.00 to 2.02; 7 studies, 1499 participants; very low-certainty evidence). Haloperidol may reduce the incidence of clinically important change in overall mental state compared to olanzapine (RR 0.70, 95% CI 0.60 to 0.81; 13 studies, 1210 participants; low-certainty evidence). For every eight people treated with haloperidol instead of olanzapine, one fewer person would experience this improvement. The evidence suggests that haloperidol may result in a large increase in extrapyramidal side effects compared to olanzapine (RR 3.38, 95% CI 2.28 to 5.02; 14 studies, 3290 participants; low-certainty evidence). For every three people treated with haloperidol instead of olanzapine, one additional person would experience extrapyramidal side effects. For weight gain, the evidence suggests that there may be a large reduction in the risk with haloperidol compared to olanzapine (RR 0.47, 95% CI 0.35 to 0.61; 18 studies, 4302 participants; low-certainty evidence). For every 10 people treated with haloperidol instead of olanzapine, one fewer person would experience weight increase. A single study suggests that haloperidol may reduce the incidence of clinically important change in quality of life compared to olanzapine (RR 0.72, 95% CI 0.57 to 0.91; 828 participants; low-certainty evidence). For every nine people treated with haloperidol instead of olanzapine, one fewer person would experience clinically important improvement in quality of life. Haloperidol may result in an increase in the incidence of leaving the study early due to adverse effects compared to olanzapine (RR 1.99, 95% CI 1.60 to 2.47; 21 studies, 5047 participants; low-certainty evidence). For every 22 people treated with haloperidol instead of olanzapine, one fewer person would experience this outcome. Thirty otherwise relevant studies and several endpoints from 14 included studies could not be evaluated due to inconsistencies and poor transparency of several parameters. Furthermore, even within studies that were included, it was often not possible to use data for the same reasons. Risk of bias differed substantially for different outcomes and the certainty of the evidence ranged from very low to low. The most common risks of bias leading to downgrading of the evidence were blinding (performance bias) and selective reporting (reporting bias).
AUTHORS' CONCLUSIONS
Overall, the certainty of the evidence was low to very low for the main outcomes in this review, making it difficult to draw reliable conclusions. We are very uncertain whether there is a difference between haloperidol and olanzapine in terms of clinically important global state and relapse. Olanzapine may result in a slightly greater overall clinically important change in mental state and in a clinically important change in quality of life. Different side effect profiles were noted: haloperidol may result in a large increase in extrapyramidal side effects and olanzapine in a large increase in weight gain. The drug of choice needs to take into account side effect profiles and the preferences of the individual. These findings and the recent inclusion of olanzapine alongside haloperidol in the WHO Model List of Essential Medicines should increase the likelihood of it becoming more easily available in low- and middle- income countries, thereby improving choice and providing a greater ability to respond to side effects for people with lived experience of schizophrenia. There is a need for additional research using appropriate and equivalent dosages of these drugs. Some of this research needs to be done in low- and middle-income settings and should actively seek to account for factors relevant to these. Research on antipsychotics needs to be person-centred and prioritise factors that are of interest to people with lived experience of schizophrenia.
Topics: Humans; Olanzapine; Schizophrenia; Haloperidol; Antipsychotic Agents; Randomized Controlled Trials as Topic; Administration, Oral; Quality of Life; Bias; Recurrence; Weight Gain; Adult
PubMed: 38958149
DOI: 10.1002/14651858.CD013425.pub2 -
Journal of the American Heart... Jul 2024
PubMed: 38958144
DOI: 10.1161/JAHA.124.035849 -
Journal of the American Heart... Jul 2024Reinterventions may influence the outcomes of children with functionally single-ventricle (f-SV) congenital heart disease.
Retrospective Cohort Study of Additional Procedures and Transplant-Free Survival for Patients With Functionally Single Ventricle Disease Undergoing Staged Palliation in England and Wales.
BACKGROUND
Reinterventions may influence the outcomes of children with functionally single-ventricle (f-SV) congenital heart disease.
METHODS AND RESULTS
We undertook a retrospective cohort study of children starting treatment for f-SV between 2000 and 2018 in England, using the national procedure registry. Patients were categorized based on whether they survived free of transplant beyond 1 year of age. Among patients who had transplant-free survival beyond 1 year of age, we explored the relationship between reinterventions in infancy and the outcomes of survival and Fontan completion, adjusting for complexity. Of 3307 patients with f-SV, 909 (27.5%), had no follow-up beyond 1 year of age, among whom 323 (35.3%) had ≥1 reinterventions in infancy. A total of 2398 (72.5%) patients with f-SV had transplant-free survival beyond 1 year of age, among whom 756 (31.5%) had ≥1 reinterventions in infancy. The 5-year transplant-free survival and cumulative incidence of Fontan, among those who survived infancy, were 93.4% (95% CI, 92.4%-94.4%) and 79.3% (95% CI, 77.4%-81.2%), respectively. Both survival and Fontan completion were similar for those with a single reintervention and those who had no reinterventions. Patients who had >1 additional surgery (adjusted hazard ratio, 3.93 [95% CI, 1.87-8.27] <0.001) had higher adjusted risk of mortality. Patients who had >1 additional interventional catheter (adjusted subdistribution hazard ratio, 0.71 [95% CI, 0.52-0.96] =0.03) had a lower likelihood of achieving Fontan.
CONCLUSIONS
Among children with f-SV, the occurrence of >1 reintervention in the first year of life, especially surgical reinterventions, was associated with poorer prognosis later in childhood.
PubMed: 38958142
DOI: 10.1161/JAHA.123.033068 -
Journal of the American Heart... Jul 2024
PubMed: 38958140
DOI: 10.1161/JAHA.123.033964 -
Journal of the American Heart... Jul 2024Iodine-meta-iodobenzylguanidine scintigraphy is useful for assessing cardiac autonomic dysfunction and predict outcomes in heart failure (HF). The relationship of...
BACKGROUND
Iodine-meta-iodobenzylguanidine scintigraphy is useful for assessing cardiac autonomic dysfunction and predict outcomes in heart failure (HF). The relationship of cardiac sympathetic function with myocardial remodeling and diffuse fibrosis remains largely unknown. We aimed to evaluate the cardiac sympathetic function of patients with HF and its relation with myocardial remodeling and exercise capacity.
METHODS AND RESULTS
Prospectively enrolled patients with HF (New York Heart Association class II-III) were stratified into HF with preserved left ventricular ejection fraction [LVEF] ≥45%) and reduced LVEF. Ventricular morphology/function and myocardial extracellular volume (ECV) fraction were quantified by cardiovascular magnetic resonance, global longitudinal strain by echocardiography, cardiac sympathetic function by heart-to-mediastinum ratio from iodine-meta-iodobenzylguanidine scintigraphy. All participants underwent cardiopulmonary exercise testing. The cohort included 33 patients with HF with preserved LVEF (LVEF, 60±10%; NT-proBNP [N-terminal pro-B-type natriuretic peptide], 248 [interquartile range, 79-574] pg/dL), 28 with HF with reduced LVEF (LVEF, 30±9%; NT-proBNP, 743 [interquartile range, 250-2054] pg/dL) and 20 controls (LVEF, 65±5%; NT-proBNP, 40 [interquartile range, 19-50] pg/dL). Delayed (4 hours) iodine-meta-iodobenzylguanidine heart-to-mediastinum ratio was lower in HF with preserved LVEF (1.59±0.25) and HF with reduced LVEF (1.45±0.16) versus controls (1.92±0.24; <0.001), and correlated negatively with diffuse fibrosis assessed by ECV (=-0.34, <0.01). ECV in segments without LGE was increased in HF with preserved ejection fraction (0.32±0.05%) and HF with reduced left ventricular ejection fraction (0.31±0.04%) versus controls (0.28±0.04, <0.05) and was associated with the age- and sex-adjusted maximum oxygen consumption (peak oxygen consumption); (=-0.41, <0.01). Preliminary analysis indicates that cardiac sympathetic function might potentially act as a mediator in the association between ECV and NT-proBNP levels.
CONCLUSIONS
Abnormally low cardiac sympathetic function in patients with HF with reduced and preserved LVEF is associated with extracellular volume expansion and decreased cardiopulmonary functional capacity.
PubMed: 38958130
DOI: 10.1161/JAHA.124.035264 -
Journal of the American Heart... Jul 2024Stroke survivors believe neighborhood resources such as community centers are beneficial; however, little is known about the influence of these resources on stroke...
BACKGROUND
Stroke survivors believe neighborhood resources such as community centers are beneficial; however, little is known about the influence of these resources on stroke outcomes. We evaluated whether residing in neighborhoods with greater resource density is associated with favorable post-stroke outcomes.
METHODS AND RESULTS
We included Mexican American and non-Hispanic White stroke survivors from the Brain Attack Surveillance in Corpus Christi project (2009-2019). The exposure was density of neighborhood resources (eg, community centers, restaurants, stores) within a residential census tract at stroke onset. Outcomes included time to death and recurrence, and at 3 months following stroke: disability (activities of daily living/instrumental activities of daily living), cognition (Modified Mini-Mental State Exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life scale). We fit multivariable Cox regression and mixed linear models. We considered interactions with stroke severity, ethnicity, and sex. Among 1786 stroke survivors, median age was 64 years (interquartile range, 56-73), 55% men, and 62% Mexican American. Resource density was not associated with death, recurrence, or depression. Greater resource density (75th versus 25th percentile) was associated with more favorable cognition (Modified Mini-Mental State Exam mean difference=0.838, 95% CI=0.092, 1.584) and among moderate-severe stroke survivors, with more favorable functioning (activities of daily living/instrumental activities of daily living=-0.156 [95% CI, -0.284 to 0.027]) and quality of life (abbreviated Stroke-Specific Quality of Life scale=0.194 [95% CI, 0.029-0.359]).
CONCLUSIONS
We observed associations between greater resource density and cognition overall and with functioning and quality of life among moderate-severe stroke survivors. Further research is needed to confirm these findings and determine if neighborhood resources may be a tool for recovery.
PubMed: 38958125
DOI: 10.1161/JAHA.124.034308 -
Disability and Rehabilitation Jul 2024To analyze immediate effects of TECAR therapy (TT) to reduce lower limb hypertonia and improve functionality in chronic post-stroke.
PURPOSE
To analyze immediate effects of TECAR therapy (TT) to reduce lower limb hypertonia and improve functionality in chronic post-stroke.
MATERIALS AND METHODS
It is a single-blind randomized controlled clinical trial. A total of 36 chronic stroke survivors were divided into two groups. The experimental group received a single 30-minute session of TT with functional massage (FM) on lower limb. The control group received a single 30-minute session sham treatment of TT plus FM. The primary outcome measure was hypertonia (Modified Ashworth Scale, MAS). Secondary outcomes were gait speed (4-Meter Walk-Test), standing knee-flexion (Fugl-Meyer Assessment Scale IV-item), change in weight bearing ankle dorsiflexion (Ankle Lunge Test, ALT), and functional lower limb strength (5-Times Sit-to-Stand Test). All measurements were performed at baseline, immediately and 30-minutes after treatment.
RESULTS
There was a group-time interaction in MAS-knee ( = 0.044), MAS-ankle ( = 0.018) and ALT ( = 0.016) between 1 and 0 (<.0001) and 2 and 0 (<.0001) for the experimental group. There was a significant increase in ALT between 1 and 0 ( = 0.003) in the control group.
CONCLUSIONS
A single session of TT performed at the same time as FM immediately reduces plantar-flexors and knee-extensor muscle hypertonia and increases change in weight bearing ankle dorsiflexion in chronic stroke survivors.
PubMed: 38958103
DOI: 10.1080/09638288.2024.2365992 -
Journal of Extracellular Vesicles Jul 2024Nowadays, it has become clear that extracellular vesicles (EVs) are not a cellular waste disposal vesicle but are an essential part of an intercellular communication... (Meta-Analysis)
Meta-Analysis
Nowadays, it has become clear that extracellular vesicles (EVs) are not a cellular waste disposal vesicle but are an essential part of an intercellular communication system. Besides the use of EVs in biomarker studies and diagnostics, the potential of EV-therapeutics has been seen by many. They provide unique properties for disease therapy, including strong immune-modulatory actions, the possibility of engineering, low immunogenicity, and the capability of crossing biological barriers. Proof-of-concept of EV-therapeutics for various pathologies has been achieved in preclinical studies. However, clinical trials with EVs have only been emerging slowly. Here, we aim to provide a comprehensive overview of the current state-of-the-art concerning clinical studies using EVs in human therapy. By approaching the current knowledge in a systematic manner, we were able to include 21 reports for meta-analysis of safety and evaluation of efficacy outcomes. Overall, we have shown that EV-based therapy is safe with a low incidence of serious adverse events (SAE; 0.7% (95%-CI: 0.1-5.2%), and adverse events (AE; 4.4% (95%-CI: 0.7-22.2%). Subgroup analysis showed no significant difference in SAE when comparing autologous versus allogeneic administration, as well as engineered versus non-engineered EV products. A significantly higher number of AE was seen in autologous versus allogeneic administration. However, the clinical relevance remains questionable. Evaluation of the clinical outcomes of immunostimulatory, immunosuppressive or regenerative EV-therapies indicated improvement in the majority of treated patients. Despite these promising results, data need to be approached with caution due to a high heterogeneity in the EVs manufacturing methods, study design, and reporting of (S)AE. Overall, we conclude that EV-based therapy is safe and presents a promising opportunity in therapy. More efforts are needed in the standardization and harmonization of reporting of EV isolation and characterization data as well as in the reporting of (S)AE to allow inter-study comparison.
Topics: Humans; Extracellular Vesicles; Clinical Trials as Topic
PubMed: 38958077
DOI: 10.1002/jev2.12458