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Severe acute malnutrition (SAM) remains a major global public health problem. SAM cases are treated using ready‐to‐use therapeutic food (RUTF) at a dosage of ∼200 kcal/kg/day per the standard treatment protocol (STD). Emerging evidence on simplifications to the standard protocol, which among other adaptations, includes reducing the daily RUTF dosage, indicates that it is effective and safe for treating children with SAM. In response to a foreseen stock shortage of RUTF, the government of Afghanistan endorsed the temporary use of a modified treatment protocol in which the daily RUTF dosage was prescribed at 1000 kcal/day (irrespective of body weight) until the child achieved moderate acute malnutrition status (weight‐for‐height z‐score ≥ −3 or mid‐upper arm circumference [MUAC] ≥ 115 mm), at which point 500 kcal/day was prescribed until cured (modified treatment protocol [MTP]). In this paper, we report the results of this nonweight‐based daily RUTF dosage experience. Data of 2042 children with SAM, treated using either the STD protocol (n = 269) or the MTP protocol (n = 1773) from August 2019 to March 2021 in five provinces, were analyzed. The per‐protocol analyses confirmed noninferiority of MTP protocol when compared to STD protocol for recovery rate [93.3% vs. 90.2%; ∆ (95% confidence interval, CI) = 3.1 (−0.9; 7.2) %] and length‐of‐stay [82.6 vs. 75.6 days; ∆ (95% CI) = 6.9 (3.3; 10.5) days], considering the margin of noninferiority of −10% and +14 days, respectively. Weight gain velocity was smaller in the MTP protocol group than in the STD protocol group [3.7 (1.7) vs. 5.2 (2.9) g/kg/day; ∆ (95% CI) = −1.5 (−1.8, −1.2); p < 0.001]. The STD group had a significantly higher mean than the MTP group for absolute MUAC gain [∆ (95% CI) = 1.7 (1.0; 2.3) mm; p < 0.001] and the MUAC velocity [∆ (95% CI) = 0.29 (0.20; 0.37) mm/week; p < 0.001]. Our results confirm the noninferiority of a nonweight‐based daily dosage and support the endorsement of this modification as an alternative to the standard protocol in resource‐constrained contexts. Key messages: More evidence supporting the use of the nonweight‐based daily ready‐to‐use therapeutic food (RUTF) dosage for treating uncomplicated severe acute malnutrition (SAM), in specific contexts, is needed.Our real‐world prospective nonrandomized study showed that the fixed nonweight‐based daily RUTF dosage protocol is as effective as the standard weight‐based protocol for treating uncomplicated SAM in children <5 in the Afghanistan context.Our findings support the reflection of a nonweight‐based daily RUTF dosage in resource‐constrained contexts in national and global policies and guidelines to improve coverage of all children in need of treatment. [ABSTRACT FROM AUTHOR]

Background: Studies suggest swallow intervention programmes that incorporate visual biofeedback and motor programming principles can improve swallowing and quality of life for people with idiopathic Parkinson's disease (IPD) and dysphagia. Few studies have examined outcomes using instrumentation. Aims: Using fibreoptic endoscopic examination of swallowing (FEES), this study examines the effectiveness of a neurorehabilitation intervention involving biofeedback via surface electromyography (sEMG) to improve swallowing in people with IPD, and to explore the feasibility of the intervention approach. Methods & Procedures: We recruited 12 participants with IPD and dysphagia. A total of 10 completed the study. Intervention was delivered for 1 h per day, 5 days per week, for 4 weeks (20 h). Swallowing tasks using sEMG biofeedback incorporated principles of motor learning and neuroplasticity. Instrumental and non‐instrumental assessment, including quality‐of‐life measures carried out at four different time points (two pre‐treatment and two post‐treatment). The final assessment was at 3 months post‐intervention. Outcome & Results: Statistically significant improvement (p < 0.05) in oral intake methods (95% confidence interval (CI) = 4.70–5.50) and in pharyngeal residue from saliva (95% CI = 2.14–3.15) and solids (95% CI = 2.4–3.5) post‐intervention were confirmed using FEES with improvements at 3 months. The intervention protocol was well tolerated. Participants reported positive change in saliva control and duration of mealtimes as well as unanticipated improvements in voice and cognitive attention. Conclusions & Implications: An intensive neurorehabilitation with biofeedback shows positive effects in improving swallow function in IPD. This protocol is feasible with amendments to inform a larger clinical trial. What this paper adds: What is already known on the subject: Biofeedback has positive effects on increasing swallowing function and quality of life in people with IPD and dysphagia. sEMG is the most common method used to deliver swallowing biofeedback in this population. The quality of the evidence on the intervention, based on findings from a recent systematic review, is low. Included studies in this review were heterogeneous in terms of type and frequency of biofeedback, study design and outcome measures. The majority of outcome measures were subjective and higher quality studies to examine the efficacy of biofeedback using sEMG are needed. What this study adds: Recognizing the limitations of earlier studies, this within‐subject feasibility study examined the efficacy and effectiveness of an intensive biofeedback intervention using sEMG in a sample of people with dysphagia and IPD. Valid and reliable outcome measures were used and repeated after a 3‐month period. The feasibility of the methodological approach was also tested and a qualitative component was included in the study. Positive findings were evident. Qualitative information added new perspectives and provided direction for new outcomes to be included in future studies. This study helps to inform further research trials as well as clinical practice. Clinical implications of this study: This intensive intervention using principles of neuroplasticity and motor programming with sEMG biofeedback led not only to positive swallowing outcomes but also to unexpected benefits such as improved voice production and general attention skills. No adverse events were reported. Improvement in function was retained at 3 months post‐intervention. Despite the small sample size, participants described the benefits of the treatment, and enjoyed sEMG biofeedback tasks, especially using an sEMG game mode. This suggests that intensive biofeedback not only improved swallowing but also was acceptable to these participants. This intensive protocol has merit and is worth considering further in clinical practice. [ABSTRACT FROM AUTHOR]

Background: A resuscitation plan is a medically authorised order to use or withhold resuscitation interventions. Absence of appropriate resuscitation orders exposes patients to the risk of invasive medical interventions that may be of questionable benefit depending on individual circumstances. Aims: To describe among junior doctors: (i) self‐reported confidence discussing and completing resuscitation plans; (ii) knowledge of resuscitation policy including whether resuscitation plans are legally enforceable and key triggers for completion; and (iii) the factors associated with higher knowledge of triggers for completing resuscitation plans. Methods: A cross‐sectional survey was conducted at five hospitals. Junior doctors on clinical rotation were approached at scheduled training sessions, before or after ward rounds or at change of rotation orientation days and provided with a pen‐and‐paper survey. Results: A total of 118 junior doctors participated. Most felt confident discussing (79%; n = 92) and documenting (87%; n = 102) resuscitation plans with patients. However, only 45% (n = 52) of doctors correctly identified that resuscitation plans are legally enforceable medical orders. On average, doctors correctly identified 6.8 (standard deviation = 1.8) out of 10 triggers for completing a resuscitation plan. Doctors aged >30 years were four times more likely to have high knowledge of triggers for completing resuscitation plans (odds ratio 4.28 (95% confidence interval 1.54–11.89); P = 0.0053). Conclusion: Most junior doctors feel confident discussing and documenting resuscitation plans. There is a need to improve knowledge about legal obligations to follow completed resuscitation plans, and about when resuscitation plans should be completed to ensure they are completed with patients who are most at risk. [ABSTRACT FROM AUTHOR]

Objective The purpose of this review was to systematically evaluate the effects of an alcohol vehicle solution ( V- Sol) compared with an essential-oils mouthwash ( EOMW) and if available with a water-based control ( WC) on plaque, gingival inflammation parameters and extrinsic tooth staining. Materials and Methods The Pub Med- MEDLINE, Cochrane- CENTRAL and EMBASE databases were searched. Where appropriate, a meta-analysis was performed, and difference of means ( DIFFM) as calculated. Results In total, 971 unique papers were found of which five met the eligibility criteria. The DIFFM of the meta-analysis of four 6-month studies showed that the EOMW provided significantly better plaque control ( DIFFM = 0.39, P < 0.00001) and gingival inflammation reduction as measured by the Löe and Silness Index ( DIFFM = 0.36, P = 0.00001) as compared to the V- Sol. Regarding extrinsic tooth staining, a small but significant difference ( DIFFM = −0.08, P = 0.03) was observed. Conclusion Limited data, but with a low risk of bias, were available to assess the potential benefit of the alcohol-containing V- Sol. 'High'- and 'moderate'-quality data were available for the analysis of plaque and gingivitis, respectively. Within these limitations, EOMW appears to provide a significant oral health benefit during the 6 months of use. The data retrieved for this review suggest that the essential oils produce an effect on plaque and gingivitis that extends beyond the V- Sol. Furthermore, the V- Sol proved to be no different from a WC. [ABSTRACT FROM AUTHOR]

Aim: To determine the efficacy of manual tooth brushing with respect to toothbrush design and brushing duration. Material and Methods: The PubMed--MEDLINE and Cochrane CENTRAL were searched through October 2010 to identify appropriate studies. The outcome measurement was dental plaque removal following subject brushing. Results: The search yielded 2119 titles and abstracts. Ultimately, 59 papers with 212 brushing exercises as separate legs of the experiments and meeting the eligibility criteria were selected. Overall, a brushing exercise provides a 42% (21) plaque score reduction (95% CI: 41.23; 42.03). Of the brushing studies providing data as assessed according to the Quigley and Hein plaque index, the weighted mean reduction from baseline in plaque scores was 30% (95% CI: 26.79; 33.21). A weighted mean plaque score reduction of 53% (95% CI: 49.51; 56.49) was observed in the experiments using the Navy plaque index. Subanalysis between the different bristle tuft configurations illustrated variation in plaque removal ability (24-61%). The angled bristle design numerically showed the highest mean plaque reduction with either index. A subanalysis of brushing duration revealed after 1 min, a mean reduction of 27% and after 2 min, 41%. Conclusion: The efficacy in plaque removal following a brushing exercise is a reduction from baseline plaque scores of 42% on average, with a variation of 30-53% dependent on the plaque index used. The available evidence indicates that bristle tuft arrangement (flat trim, multilevel, angled) and brushing duration are factors that contribute to the variation in observed efficacy. [ABSTRACT FROM AUTHOR]

Current policy in UK health services emphasizes that, where possible, people with intellectual disabilities should access the same services as people without intellectual disabilities. One of the barriers to this is the confidence of clinicians and therapists. In this paper, we report on the development of a scale to describe the confidence of therapists in working with people with intellectual disabilities (the Therapy Confidence Scale-Intellectual Disabilities [TCS-ID]). One-hundred and eighty-one therapists who provided talking therapies but who did not work primarily with people with intellectual disabilities completed the scale; 43 people completed the scale twice for test-retest reliability purposes. One-hundred and seven people also completed a scale of general therapy self-efficacy. The TCS-ID has a single factor structure accounting for 62% of the variance, Cronbach's alpha for the scale is 0.93 and test-retest reliability is 0.83. There are significant differences in confidence based upon participants experience in working with people with intellectual disabilities and their therapeutic orientation, and there is a significant association between the TCS-ID and the General Therapy Self-efficacy Scale. Sixty clinicians working in mainstream mental health services received training on adapting their therapeutic approaches to meet the needs of people with intellectual disabilities. The TCS-ID was used pre-training and post-training and demonstrated a significant increase in confidence for all group. We suggest that the scale has good psychometric properties and can be used to develop an understanding of the impact of training for mainstream therapist in working with people with intellectual disabilities. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message There is increasing emphasis on people with intellectual disabilities receiving services from mainstream mental health services., There is no research describing the experiences and outcomes of people with intellectual disabilities receiving mainstream talking therapy services., The confidence that clinicians have in working with people with intellectual disabilities may be a barrier to them receiving mainstream services., The Therapy Confidence Scale-Intellectual Disabilities is a psychometrically sound scale for measuring the confidence of therapists in working with people with intellectual disabilities and is a useful outcome measure for training clinicians to work with people with intellectual disabilities. [ABSTRACT FROM AUTHOR]

Summary: Objective: The aim of the systematic review was to analyse the available evidence in order to assess the efficacy of dextrose prolotherapy in improving outcomes in temporomandibular joint (TMJ) hypermobility patients as compared to placebo. Methods: An electronic search of PubMed, Scopus, CENTRAL and Google scholar databases was performed for English language papers published up to February 2018. Randomised clinical trials (RCTs) and controlled clinical trials (CCTs) comparing dextrose prolotherapy with placebo for TMJ hypermobility were included. Results: Three RCTs were included in the review. Frequency of subluxation/dislocation was reported by two trials which found no difference between dextrose and placebo. A statistical significant difference in reduction of MMO with the use of dextrose prolotherapy was seen on pooling of data (random: MD = −3.32, 95% CI −5.26 to −1.28; P = 0.0008; I2 = 0%). A statistical significant difference in pain reduction was also seen with dextrose as compared to placebo (random: MD = −1, 95% CI −1.58 to −0.42; P = 0.0007; I2 = 0%). Conclusion: Within the limitations of the study, dextrose prolotherapy may cause significant reduction in mouth opening and pain associated with TMJ hypermobility. Conclusions with regard to reduction of episodes of subluxation/dislocation cannot be drawn. There is a need of more high‐quality RCTs with larger sample size and homogenous prolotherapy protocol to draw stronger conclusions on the effect of dextrose prolotherapy in patients with TMJ hypermobility. [ABSTRACT FROM AUTHOR]

Aim To report the evidence on the effect of mechanical and/or chemical plaque control in the simultaneous management of gingivitis and caries. Material and Methods A protocol was designed to identify randomized ( RCTs) and controlled ( CCTs) clinical trials, cohort studies and prospective case series ( PCS), with at least 6 months of follow-up, reporting on plaque, gingivitis and caries. Relevant information was extracted from full papers, including quality and risk of bias. Meta-analyses were performed whenever possible. Results After the screening of 1,373 titles, 15 RCTs, 10 CCTs and 2 PCS were included. Low to moderate evidence support that combined professional and self-performed mechanical plaque control significantly reduces standardized plaque index [ n = 4; weighted mean difference ( WMD) = 1.294; 95% CI (0.445; 2.144); p = 0.003] and gingivitis scores [ n = 4; WMD = 1.728; 95% CI (0.631; 2.825); p = 0.002]. The addition of fluoride to mechanical plaque control is relevant for caries management [ n = 5; WMD = 1.159; 95% CI (0.145; 2.172); p = 0.025] while chlorhexidine rinses are relevant for gingivitis. Conclusion Mechanical plaque control procedures are effective in reducing plaque and gingivitis. The addition of fluoride to mechanical plaque control is significant for caries management. Chlorhexidine rinse has a positive effect on gingivitis and inconclusive role in caries. [ABSTRACT FROM AUTHOR]

Background: Evidence shows that online interventions could prevent depression. However, to improve the effectiveness of preventive online interventions in individuals with subthreshold depression, it is worthwhile to study factors influencing intervention outcomes. Outcome expectancy has been shown to predict treatment outcomes in psychotherapy for depression. However, little is known about whether this also applies to depression prevention. The aim of this study was to investigate the role of participants' outcome expectancy in an online depression prevention intervention. Methods: A secondary data analysis was conducted using data from two randomised‐controlled trials (N = 304). Multilevel modelling was used to explore the effect of outcome expectancy on depressive symptoms and close‐to‐symptom‐free status postintervention (6–7 weeks) and at follow‐up (3–6 months). In a subsample (n = 102), Cox regression was applied to assess the effect on depression onset within 12 months. Explorative analyses included baseline characteristics as possible moderators. Outcome expectancy did not predict posttreatment outcomes or the onset of depression. Results: Small effects were observed at follow‐up for depressive symptoms (β = −.39, 95% confidence interval [CI]: [−0.75, −0.03], p =.032, padjusted =.130) and close‐to‐symptom‐free status (relative risk = 1.06, 95% CI: [1.01, 1.11], p =.013, padjusted = 0.064), but statistical significance was not maintained when controlling for multiple testing. Moderator analyses indicated that expectancy could be more influential for females and individuals with higher initial symptom severity. Conclusion: More thoroughly designed, predictive studies targeting outcome expectancy are necessary to assess the full impact of the construct for effective depression prevention. Patient or Public Contribution: This secondary analysis did not involve patients, service users, care‐givers, people with lived experience or members of the public. However, the findings incorporate the expectations of participants using the preventive online intervention, and these exploratory findings may inform the future involvement of participants in the design of indicated depression prevention interventions for adults. Clinical Trial Registration: Original studies: DRKS00004709, DRKS00005973; secondary analysis: osf.io/9xj6a. [ABSTRACT FROM AUTHOR]

Background Despite harmful drinking causing a significant burden on global health, there is a large treatment gap, especially in low- and middle-income countries. A major barrier to care is the lack of adequately skilled human resources to deliver contextually appropriate treatments. This paper describes the systematic process used to develop Counselling for Alcohol Problems ( CAP), a brief psychological treatment (PT) for delivery by lay counselors in routine primary care settings to men with harmful drinking in India. Methods CAP was developed using a methodology involving 3 sequential steps: (i) identifying potential treatment strategies; (ii) developing a theoretical framework for the treatment; and (iii) evaluating the acceptability and feasibility of the treatment. Results CAP is a 3-phase treatment delivered over 1 to 4 sessions based on a motivational interviewing ( MI) stance and involves the following strategies: assessment and personalized feedback, family engagement, drink refusal skills, skills to address drinking urges, problem-solving skills and handling difficult emotions, and relapse prevention and management. Data from a case series were used to inform several adaptations to enhance the acceptability of CAP to the recipients and feasibility of delivery by lay counselors of the treatment, for example expansion of the target group to include alcohol-dependent patients and the extension of the delivery settings to include home-based delivery. There was preliminary evidence of the effectiveness of CAP. Conclusions CAP is an acceptable brief PT for harmful drinking delivered by lay counselors in primary care whose effectiveness is currently being tested in a randomized controlled trial based in primary care in Goa, India. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims There is a growing interest in very low rate [fewer than one cigarette per day (CPD)] and light (one to nine CPD) smokers and in some parts of the world their numbers appear to be increasing. This paper examined changes in prevalence over the past 5 years, cessation patterns, and smoking and demographic characteristics of very low rate, light and moderate-to-heavy (10+ CPD) smokers in England. Design Cross-sectional and longitudinal data from aggregated monthly waves of a household survey: the Smoking Toolkit Study. Setting England. Participants A total of 23 245 smokers interviewed between November 2006 and May 2011 and 4147 who provided data at 6-month follow-up. Measurements We compared the demographic and smoking characteristics between the three groups of smokers at baseline, and the rate of attempts to quit, use of aids to cessation and success of quit attempts at follow-up. Findings Very low rate smoking remained extremely rare (1.9% of smokers in 2006 to 2.8% in 2011), but light smoking became increasingly common (23.9-32.8%). Compared with moderate-to-heavy smokers, very low rate and light smokers were younger, more often female and from a higher socio-economic background. They were more motivated to quit and enjoyed smoking less. During the 6-month follow-up period, light smokers, but not very low rate smokers, were more likely to attempt to quit than moderate-to-heavy smokers. When they tried to quit, very low rate and light smokers used aids to cessation less than moderate-to-heavy smokers but still used them to a substantial degree: 18%, 31% and 44% used over-the-counter nicotine replacement therapy in their most recent quit attempt for the three types of smoker, respectively. Even very low rate smokers had a substantial failure rate: 65% failed in their most recent quit attempt within 6 months. Conclusions Very low rate (fewer than one cigarette per day) and light (one to nine cigarettes per day) smokers in England are at least as motivated to quit as heavier smokers. Although they use cessation medication less than heavier smokers and are more likely to succeed, they still use such medication and fail in quit attempts to a substantial degree. [ABSTRACT FROM AUTHOR]

Risk for Permanent Pacemaker After Transcatheter Aortic Valve Implantation. Background: Permanent pacemaker (PM) requirement is a known complication after transcatheter aortic valve implantation (TAVI). There are, however, no systematic data concerning this complication. Objective: To determine the incidence and potential predictors of permanent PM requirement after TAVI based on published literature. Methods: We conducted a MEDLINE search to identify potentially relevant literature dealing with PM requirement after TAVI. Data were collected on paper extraction forms by 2 independent investigators. Results: There were 32 relevant published studies comprising data of 5,258 patients without an implanted PM before TAVI. An Edwards-Sapiens® prosthesis (ESP) was implanted in 2,887 patients, whereas 2,371 patients received a CoreValve® prosthesis (CVP). The crude incidence of PM implantation after TAVI was 15%. Six hundred and fourteen of 2,371 (25.8%) CVP patients and 189 of the 2,887 (6.5%) ESP patients had to receive a permanent PM (odds ratio [OR] 4.91, 95% confidence interval [CI] 4.12-5.86, P < 0.001). Presence of right bundle branch block (RBBB) before TAVI was a significant predictor for development of complete atrioventricular (AV) block and subsequent PM need (OR 1.358, 95% CI 1.001-1.841, P = 0.02). More than 90% of all AV-block requiring PM implantation occurred immediately or within 7 days after TAVI. Conclusion: Patients undergoing TAVI with implantation of CVP are at significantly higher risk for development of AV block and subsequent need for permanent PM, particularly if RBBB preexists. Since AV block occurs in >90% within the first week after the procedure, careful monitoring should be performed for at least 7 days after TAVI. [ABSTRACT FROM AUTHOR]

Background: The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID‐19 pneumonitis in those admitted to Australian and New Zealand ICUs. Methods: This registry‐based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID‐19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations. Results: 884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID‐19. There were more male patients in COVID‐19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE‐III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%‐CI 1.39–2.14), age (OR = 1.05; 95%‐CI 1.04–1.06), and presence of chronic respiratory condition (OR = 1.58; 95%‐CI 1.10–2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID‐19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%‐CI 0.98–1.96). Conclusions: The proportion of treatment limitations was similar in patients with frailty with or without COVID‐19 pneumonitis at ICU admission. [ABSTRACT FROM AUTHOR]

Background: Haemodialysis plastic cannulae have been limited to incident arterio‐venous fistulae cannulation or in those who require a more flexible in situ access device. The feasibility of plastic cannulae in prevalent patients on haemodialysis has not been reported. Objective: To determine the feasibility of plastic cannulae in prevalent haemodialysis patients. Design: Prospective feasibility crossover randomised control trial. Participants: Adults diagnosed with chronic kidney disease G5 requiring haemodialysis three or more times per week via a native arteriovenous fistula previously cannulated for at least 6 weeks. Measurements: Cannulation success rate, cannulation manipulation type, arterial and venous needle pressure. Patient needle‐related anxiety as measured by the 4‐item Patient Health Questionnaire and Meditation in Dialysis Questionnaire and nurse satisfaction. Results: Eight patients completed 12 weeks plastic canulae and metal needles. Plastic cannulae were less likely to be successful in cannulation compared to metal needles (odds ratio = 0.15; 95% confidence interval [CI]: 0.05–0.48; p = 0.001). There was no effect of type of needle on the change in arterial needle pressure or change in venous needle pressure and no effect of plastic needle on repositioning (relative risk [RR] = 1.09; 95% CI: 0.385, 3.089; p =.871) or gauze pillow application (RR = 0.936; 95% CI: 0.467, 1.874; p =.851) than metal needles, relative to no manipulation. There were low rates of psychological distress or needle‐related anxiety towards plastic or metal needles. Conclusions: Plastic cannulae are feasible in prevalent haemodialysis patients, however, metal needles are still preferred in a haemodialysis center that has historically used metal needles. [ABSTRACT FROM AUTHOR]

Background: Enteral immunomodulatory nutrition is recommended as an adjuvant therapy for patients in intensive care units (ICU), but its effectiveness is incompletely understood. Aim: The aim of this review was to examine the effect of a commonly used immunomodulatory formula—omega‐3 fatty acids, γ‐linolenic acid, and antioxidants—on clinical outcomes and mortality risk in critically ill patients. Design: Systematic review and meta‐analysis of randomized controlled trials (RCTs). Method: PubMed, Scopus, and Institute for Scientific Information (ISI) Web of Knowledge databases were searched until 18 February 2021. RCTs that used the immunomodulatory formula in the ICU were included. Results: Ten RCTs (1166 participants) were included in the meta‐analysis. The immunomodulatory formula reduced the duration of ICU stay weighted mean difference [(WMD): −2.97 days; 95%CI: −5.59, −0.35)], mechanical ventilation (WMD = −2.20 days, 95%CI: −4.29, −0.10), sequential organ failure assessment and multiple organ dysfunction scores (Hedge's g: −0.42 U/L; 95% CI: −0.74, −0.11), decreased 8‐day overall mortality risk (RR = 0.74, 95% CI: 0.58, 0.91), and extended the ICU‐free days (WMD: 4.06 days, 95% CI: 0.02, 8.09). The improvement in respiratory function and reduction in mortality risk was more in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Furthermore, the reduction in mechanical ventilation and mortality risk was more evident in older (>60 years) vs young adults. Conclusion and Relevance to Clinical Practice: Taken together, the immunomodulatory formula may enhance clinical practice for critical care nurses, such that the prevalence and/or susceptibility to secondary conditions commonly encountered in the ICU (ie, ALI and ARDS) could be attenuated, ultimately allowing critical care nurses to focus their care on the primary reason for which a patient is in the ICU. The study protocol was registered in PROSPERO. [ABSTRACT FROM AUTHOR]

Background: Fluid treatment in sepsis is a challenge and clinical equipoise exists regarding intravenous (IV) volumes. We aimed to determine whether a 24‐h protocol restricting IV fluid was feasible in adult patients with sepsis without shock presenting to the emergency department (ED). Methods: The REFACED Sepsis trial is an investigator‐initiated, multicenter, randomized, open‐label, feasibility trial, assigning sepsis patients without shock to 24 h of restrictive, crystal IV fluid administration or standard care. In the IV fluid restriction group fluid boluses were only permitted if predefined criteria for hypoperfusion occurred. Standard care was at the discretion of the treating team. The primary outcome was total IV crystalloid fluid volumes at 24 h after randomization. Secondary outcomes included total fluid volumes, feasibility measures, and patient‐centered outcomes. Results: We included 123 patients (restrictive 61 patients and standard care 62 patients) in the primary analysis. A total of 32% (95% confidence interval [CI] 28%–37%) of eligible patients meeting all inclusion criteria and no exclusion criteria were included. At 24 h, the mean (±SD) IV crystalloid fluid volumes were 562 (±1076) ml versus 1370 (±1438) ml in the restrictive versus standard care group (mean difference –801 ml, 95% CI −1257 to −345 ml, p = 0.001). Protocol violations occurred in 21 (34%) patients in the fluid‐restrictive group. There were no differences between groups in adverse events, use of mechanical ventilation or vasopressors, acute kidney failure, length of stay, or mortality. Conclusions: A protocol restricting IV crystalloid fluids in ED patients with sepsis reduced 24‐h fluid volumes compared to standard care. A future trial powered toward patient‐centered outcomes appears feasible. [ABSTRACT FROM AUTHOR]

Background: In managing older adults with atrial fibrillation (AF), their symptomatology impacts their well‐being and may inform treatment decision‐making. We examined AF symptom perception, its impact on quality of life (QoL), and its relation to treatment strategies in older adults with AF. Methods: Data were obtained from older adults with AF enrolled in a multicenter study conducted at clinic sites in Massachusetts and Georgia between 2016 and 2018. Participants were stratified into three age groups: 65–74 (youngest–old), 75–84 (middle–old), and ≥85 (oldest). Perception of AF symptoms was assessed by participant self‐report during their clinic visit and at study enrollment by the Atrial Fibrillation Effect on Quality‐of‐Life Questionnaire which assessed cardiac‐specific and non‐specific, non‐cardiac AF symptoms and their impact on QoL. Treatment strategies (rate or rhythm control) utilized were ascertained from electronic medical records. Results: Among the 1184 participants (mean age 75 years, 48% women, 86% Non‐Hispanic White), 51% were aged 65–74 years, 36% were 75–84 years, and 13% were ≥ 85 years. The most commonly reported AF symptoms were non‐specific, non‐cardiac symptoms (fatigue, dyspnea, lightheadedness) with similar prevalence and impact on QoL in all age groups. Cardiac‐specific AF symptoms (palpitations, irregular heartbeat, pause in heart activity) were less prevalent, but most commonly reported by the youngest participants (65–74 years), who endorsed considerable impact of these symptoms on their QoL. Overall, those who reported experiencing any AF symptoms during their clinic visit were more likely to have received rhythm compared with rate control (OR: 1.56; 95% CI: 1.18–2.04) with similar findings for all age groups except those aged ≥85 years. Conclusions: Our findings suggest a high prevalence of non‐specific, non‐cardiac symptoms among older adults with AF and that cardiac‐specific AF symptoms may exert considerable impact on their QoL. The presence of any AF symptoms may drive more rhythm control in a majority of older adults. See related Editorial by Blachman et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Non‐small cell lung cancer (NSCLC) is the leading cause of cancer‐related mortality worldwide. It is advisable to select the appropriate treatment based on characteristics of the cancer such as pathology, mutations, and programmed death‐ligand 1 (PD‐L1) levels. In this study, by remarking squamous NSCLC with low PD‐L1 expression without mutations, we investigated the efficacy and safety of regimens that included molecularly targeted drugs such as immune checkpoint inhibitors (ICIs) through a network meta‐analysis. Methods: Databases were searched systematically to identify appropriate articles, in which randomized trials with incurable squamous NSCLC were described. Suitable studies were manually checked by two reviewers. A random model network meta‐analysis was conducted, in which the primary outcome was the overall survival rate. Results: We identified 48 studies, which included 16 391 patients. When a platinum + third‐generation cytotoxic agent regimen (platinum regimen) was a reference, the platinum regimen + pembrolizumab (Pemb) yielded the best results in regard to the overall survival rate when compared with chemotherapy (hazard ratio [HR] = 0.57, 95% confidence interval [CI] = 0.36–0.90, p = 0.016) followed by the platinum regimen + nivolumab (Niv) + ipilimumab (Ipi) (HR = 0.61, 95% CI = 0.44–0.84, p = 0.003). However, the efficacy of ICI monotherapy was not statistically different from that of the platinum regimen. Conclusions: The combination therapies, which were the platinum regimen + Pemb and the platinum regimen + Niv + Ipi, rather than ICI monotherapy were effective first‐line agents for treating squamous NSCLC with low PD‐L1 levels. [ABSTRACT FROM AUTHOR]

Objectives: The aims of the study were to i) explore the current practice, roles, and perceptions of physiotherapists who treat older people with and without dementia in Indonesia, ii) identify the characteristics of physiotherapists associated with treating older people and older people with dementia, and iii) identify the level of knowledge and attitudes about dementia among physiotherapists treating people with dementia in Indonesia. Methods: This was a cross‐sectional study in which registered physiotherapists in Indonesia were surveyed online using Qualtrics. Descriptive statistics, linear regression and univariate logistic regression were used in this study. Multiple logistic regression was conducted to identify the characteristics of physiotherapists associated with treating older people and/or people with dementia. The Dementia Knowledge Assessment Scale (DKAS) was used to assess level of knowledge and attitudes about dementia. Qualitative data from the survey were analyzed using thematic content analysis. Results: The online survey was sent to 6327 physiotherapists who met the inclusion criteria and 1061 (16.8%) returned the survey. Eight hundred and eighty‐four (83.3%) respondents worked with older patients, and 632 (59.6%) worked with people with dementia. The multiple regression analysis showed that physiotherapists who have been practicing for longer (years) (OR: 1.0, 95%CI: 1.0–1.1, p ≤ 0.001) and were working in a geriatrics area (OR: 3.0, 95%CI: 1.4–6.5, p = 0.005) were more likely to treat older people with dementia. The DKAS mean score (SD) was 32.1 (±5.1)/50 indicating some limitations in dementia knowledge by respondents, and 62% of physiotherapists reported low levels of confidence in treating older people with dementia. Conclusions: The relatively low dementia knowledge, and generally low confidence in treating people with dementia among Indonesian physiotherapists were important findings in this study. This study highlights opportunities for improvement in physiotherapist's knowledge and skills in this emerging area of practice in Indonesia. [ABSTRACT FROM AUTHOR]

Objective: Currently, several immune checkpoint inhibitors (ICIs) treatment for advanced non‐small‐cell lung cancer (NSCLC) have been investigated; their overall efficacy and safety remain unclear. Methods: We searched electronic databases such as PubMed, EMBASE, and the Cochrane library. The randomized controlled trials (RCTs) that compared ICIs with or without chemotherapy to chemotherapy in advanced NSCLC. We collected and compaired thier parameters, including overall survival (OS), progression‐free survival (PFS), objective response rate (ORR), and treatment‐related adverse events (TRAEs) of grade ≥3. Results: A total of 15 RCTs involving 8869 patients with NSCLC were included. Pembrolizumab plus platinum‐based chemotherapy had higher OS and PFS than platinum‐based chemotherapy (hazard ratio [HR] 0.55, 95% CI 0.46–0.67; HR 0.54, 95% CI 0.41–0.70, respectively). Pembrolizumab plus platinum‐based chemotherapy had higher ranked ORR than platinum‐based chemotherapy (odds ratio [OR] 2.92, 95% CI 1.99–4.22). In terms of OS, atezolizumab, pembrolizumab plus platinum‐based chemotherapy, and nivolumab plus ipilimumab ranked as the best treatments for patients with programmed death‐ligand 1 (PD‐L1) expression levels of ≥50%, 1–49%, and <1%, respectively. In terms of PFS, pembrolizumab plus platinum‐based chemotherapy ranked as the best treatment for patients with any PD‐L1 expression levels. However, ipilimumab plus platinum‐based chemotherapy, nivolumab plus platinum‐based chemotherapy, and atezolizumab plus platinum‐based chemotherapy have higher TRAEs of grade ≥3 than platinum‐based chemotherapy. Conclusions: Pembrolizumab plus platinum‐based chemotherapy prevailed in rank in OS, PFS, and ORR benefit. The TRAEs of pembrolizumab plus platinum‐based chemotherapy were more than ICI monotherapy and chemotherapy. [ABSTRACT FROM AUTHOR]

Background and aims: Evidence for efficacy of brief alcohol interventions (BAIs) is mainly limited to primary care and at‐risk drinkers. The aim was to test the efficacy of a BAI addressing the full spectrum of alcohol use in a general population sample and across alcohol risk groups. Design Two‐parallel‐group randomized controlled trial (allocation ratio 1:1) with post‐baseline assessments at months 3, 6 and 12. Setting: One municipal registry office in Germany responsible for registration, passport and vehicle admission issues. Participants: A total of 1646 proactively recruited 18–64‐year‐old adults with past year alcohol use (56% women, 66% low‐risk drinkers) were randomized to intervention (n = 815) or control (n = 831). Intervention and comparator: The intervention consisted of assessment plus computer‐generated individualized feedback letters at baseline and months 3 and 6. Comparator was assessment only. Measurements Primary outcome was change in the self‐reported number of drinks/week from baseline to 12 months. Changes at 3 and 6 months were secondary outcomes. Moderator was alcohol risk group (low‐risk versus at‐risk drinking) according to the Alcohol Use Disorders Identification Test–Consumption, with scores from 1‐3 (women) and from 1‐4 (men) indicating low‐risk drinking. Findings For the whole sample, significant group differences were observed neither at 12‐month follow‐up [incidence rate ratio (IRR) = 1.01, 95% confidence interval (CI) = 0.87–1.17, Bayes factor (BE) = 0.52] nor at previous assessments (month 3: IRR = 1.01, 95% CI = 0.92–1.12, BE = 0.41; month 6: IRR = 0.93, 95% CI = 0.81–1.07, BE = 1.10). Moderator analyses revealed that low‐risk drinkers were more likely to benefit from BAI only at month 6 than at‐risk drinkers (IRR = 0.77, 95% CI = 0.70–0.86). Conclusions: In a randomized controlled trial, there was no clear evidence for efficacy of a computer‐based brief alcohol intervention in a general population sample, but there was some evidence of medium‐term benefits in the large but understudied group of low‐risk drinkers. [ABSTRACT FROM AUTHOR]

Ready‐to‐use therapeutic foods (RUTF) used to treat children with severe acute malnutrition (SAM) are costly, and the prescribed dosage has not been optimized. The MANGO trial, implemented by Action Contre la Faim in Burkina Faso, proved the non‐inferiority of a reduced RUTF dosage in community‐based treatment of uncomplicated SAM. We performed a cost‐minimization analysis to assess the economic impact of transitioning from the standard to the reduced RUTF dose. We used a decision‐analytic model to simulate a cohort of 399 children/arm, aged 6–59 months and receiving SAM treatment. We adopted a societal perspective: direct medical costs (drugs, materials and staff time), non‐medical costs (caregiver expenses) and indirect costs (productivity loss) in 2017 international US dollar were included. Data were collected through interviews with 35 caregivers and 20 informants selected through deliberate sampling and the review trial financial documents. The overall treatment cost for 399 children/arm was $36,550 with the standard and $30,411 with the reduced dose, leading to $6,140 (16.8%) in cost savings ($15.43 saved/child treated). The cost/consultation was $11.6 and $9.6 in the standard and reduced arms, respectively, with RUTF accounting for 56.2% and 47.0% of the total. The savings/child treated was $11.4 in a scenario simulating the Burkinabè routine SAM treatment outside clinical trial settings. The reduced RUTF dose tested in the MANGO trial resulted in significant cost savings for SAM treatment. These results are useful for decision makers to estimate potential economic gains from an optimized SAM treatment protocol in Burkina Faso and similar contexts. [ABSTRACT FROM AUTHOR]

Background: The influence of health insurance systems on the treatment of end‐stage kidney disease (ESKD) patients ispoorly understood. Aim: We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalitiesand patient outcomes. The influence of health insurance systems on the treatment of end‐stage kidney disease (ESKD) patients is poorly understood. We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalities and patient outcomes. Methods: All adult patients commencing ESKD treatment in New South Wales, Australia from 2000 to 2010 were identified using the Australia and New Zealand Dialysis and Transplant Registry. Data were linked to the state hospitalisation dataset to obtain insurance status, allowing the comparisons of mortality, ESKD treatment modality and health service utilisation between privately insured and public patients. Results: The cohort of 5737 patients included 38% (n = 2152) with PHI. At 1 year after ESKD treatment initiation, PHI patients had lower mortality (hazard ratio 0.84, 95% confidence interval (CI) 0.74–0.95, P = 0.01), were more likely to be receiving home haemodialysis (HD) (odds ratio (OR) 1.38, 95% CI 1.01–1.89, P = 0.04), to have been transplanted (OR 1.75, 95% CI 1.25–2.46, P = 0.001) and used fewer hospital days (incidence rate ratio 0.85, 95% CI 0.74–0.96, P = 0.01). After adjustment, PHI patients were more likely to initiate ESKD treatment with facility‐based HD (OR 1.22, 95% CI 1.01–1.46, P = 0.03) but were less likely to be started on peritoneal dialysis (OR 0.81, 95% CI 0.67–0.98, P = 0.03). Conclusion: Our findings suggest that supplemental PHI in Australia is associated with lower‐risk ESKD treatment attributes and improved health outcomes. A greater understanding of the treatment pathways that deliver these outcomes may inform treatment for the broader ESKD treatment population. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the accuracy of the defining characteristics of the nursing diagnosis of sexual dysfunction in women undergoing pharmacological treatment for breast cancer. Methods: A cross‐sectional accuracy study with statistical analysis. Findings: Alteration in sexual satisfaction was the defining characteristic with the highest sensitivity value, while perceived sexual limitation was the defining characteristic with the highest value for both sensitivity and specificity. Conclusions: Perceived sexual limitation is a good clinical indicator to infer initial stages of sexual dysfunction and to confirm its presence. Implications For Nursing Practice: Accurate diagnostics allow devising an action plan directed to the patients' real needs, helping prescribe and deliver the appropriate nursing interventions. [ABSTRACT FROM AUTHOR]

Objectives: To compare 3 mouthwashes: 0.20% chlorhexidine (CHX) with Anti‐Discoloration System (ADS), 0.20% CHX and 0.12% CHX with 0.05% cetylpyridinium chloride (CPC), in terms of reduction of plaque and gingival bleeding and side effects. Methods: Mild gingivitis patients were randomly divided into three Groups: they underwent professional oral hygiene and received instructions: oral rinse with 10 mL for 1', twice a day, 30' after tooth brushing, for 14 days. Primary outcomes were plaque and gingival bleeding, assessed with Plaque Control Record and Gingival Bleeding Index. Feedback questionnaire and spectrophotometer evaluated secondary outcomes: adverse events. Timing of the study was T0 (baseline), T1 (professional oral hygiene) and T2 (14th day after mouthwash use). Results: Sixty‐six patients were recruited, two patients dropped out, and 64 patients completed the study. PCR T1‐T2 mean variation was 30.67 (SD = 15.22; 95% CI 23.55 to 37.80; P = 0.000), 19.93 (SD = 11.03; 95% CI 14.90 to 24.95; P = 0.000) and 16.24 (SD = 15.35; 95% CI 9.60 to 22.88; P = 0.000) respectively in Groups 0.2% CHX + ADS, 0.2% CHX and 0.12% CHX + CPC. GBI mean variation (T0‐T2) was −9.82 (SD = 9.27; 95% CI −5.48 to 14.16; P = 0.000), −19.31 (SD = 11.33; 95% CI −14.15 to −24.47; P = 0.000) and −21.13 (SD = 12.56; 95% CI −15.70 to −26.56; P = 0.000) respectively in Groups 0.2% CHX + ADS, 0.2% CHX and 0.12% CHX + CPC. Statistical significance was found in lower efficacy of 0.2% CHX + ADS Group. Patients tolerated 0.12% CHX + CPC mouthwash better in bleeding perception (95.5%; P = 0.046), burning sensation (13.6%; P = 0.006), and mouthwash taste (100%; P = 0.000). Results on staining were no statistically significant (P = 0.106). Conclusions: Addition of CPC allows reduction of CHX percentage in mouthwash formulation while keeping equal efficacy and less side effects. ADS addition decreases CHX efficacy in reducing plaque and bleeding, while resulting more tolerated than CHX. [ABSTRACT FROM AUTHOR]

Objective: Describe current practice of medication prescribing for acute whiplash‐associated disorders (WAD) in the ED and explore attitudes towards pregabalin prescription for WAD. Methods: Questionnaire‐based survey in two EDs collected data on demographics and self‐reported medication prescribing for WAD. Comfort in various scenarios for pregabalin prescribing was rated. Results: A total of 145/170 (85%) doctors responded; 42.8% were junior doctors. Self‐reported medications prescribed were nonsteroidal anti‐inflammatory drug (77.9% [95% confidence interval (CI) 70.1–84.2]), paracetamol (75.2% [95% CI 67.2–81.8]), opioids (43.5% [95% CI 35.3–51.9]) and benzodiazepines (11.0% [95% CI 6.6–17.6]). Most were comfortable to prescribe pregabalin in evidence‐based or advised‐by‐specialists scenarios. Conclusions: Opioids appear to be over‐prescribed. Further research into pregabalin prescription in ED is warranted. [ABSTRACT FROM AUTHOR]

Objectives: The primary aim of this systematic review was to evaluate the effect of external tooth‐bleaching products on plaque indices and to compare it to a placebo or a negative control. Methods: A protocol was developed aimed to answer the next focused question: What is the effect of tooth bleaching compared to no treatment or a placebo, in subjects without periodontitis aged ≥18 years in the levels of plaque and gingivitis? Two electronic databases were used as sources in the search for studies satisfying the inclusion criteria: (a) The National Library of Medicine (MEDLINE via PubMed); (b) Cochrane Central Register of Controlled Trials. Results: Only randomized controlled trials were included. The initial search found 382 potential publications. Seven of them were finally included, and six were used in the meta‐analyses. The use of bleaching products showed higher reductions in plaque (n = 6; standardized mean difference [SMD] = 0.47; 95% confidence interval [CI] = 0.06, 0.88; P < 0.001) and gingivitis indices (n = 4; SMD = 0.47; 95% CI = 0.22, 0.73; P < 0.001), when compared to a control group (no treatment or placebo). Conclusions: External tooth bleaching is associated with statistically significant short‐term reductions in plaque and gingivitis indices. However, no data were available to evaluate long‐term effects. [ABSTRACT FROM AUTHOR]

Objective: To evaluate radiographic progression in the sacroiliac (SI) joints and to identify its predictors during long‐term treatment (up to 6 years) with the tumor necrosis factor (TNF) inhibitor etanercept in patients with early axial spondyloarthritis (SpA). Methods: Patients with early axial SpA who were treated with etanercept for up to 6 years in the Etanercept versus Sulfasalazine in Early Axial Spondyloarthritis (ESTHER) trial were selected based on the availability of radiographs of the SI joints. Two readers who were blinded with regard to clinical data scored the radiographs according to the modified New York criteria (range 0–4 per SI joint). A sacroiliitis sum score (total range 0–8) was calculated as the mean of the scores of the 2 readers. Active and chronic inflammatory changes in the SI joints on magnetic resonance imaging (MRI) performed at baseline, year 2, and year 4 were assessed according to the Berlin MRI scoring system. Results: Of the 76 patients originally included in the study, 42 had radiographs of the SI joints available at baseline and at least 1 follow‐up time point (year 2, 4, or 6). The mean ± SD change in the sacroiliitis sum score was 0.13 ± 0.73, −0.27 ± 0.76, and −0.09 ± 0.68, in the time intervals baseline to year 2, year 2 to year 4, and year 4 to year 6, respectively. In the longitudinal mixed model analysis, elevated C‐reactive protein level (β = 0.58 [95% confidence interval 0.24, 0.91]) and MRI SI joint osteitis score (β = 0.06 [95% confidence interval 0.03, 0.10]) were independently associated with progression of the sacroiliitis sum score. Conclusion: Our findings indicate that long‐term anti‐TNF therapy decelerates the progression of structural damage in the SI joints. Elevated CRP level and presence of osteitis on MRI were independently associated with radiographic sacroiliitis progression. [ABSTRACT FROM AUTHOR]

Objective: The aim of this review was to evaluate the efficacy and safety of prochlorperazine (PCP) in patients with acute migraine headache in the emergency department (ED). Methods: Electronic databases (Medline, Scopus, Web of Science, and Cochrane) were searched for randomized clinical trials that investigated the effect of PCP on headache relief. The outcomes were the number of patients without headache or with reduced headache severity, the number of adverse events, and the need for rescue analgesia. Results: From 450 citations, 11 studies (n = 771) with 15 comparison arms met the inclusion criteria. Overall, PCP was more effective than placebo (OR = 7.23; 95% CI = 3.82‐3.68), metoclopramide (OR = 2.89; 95% CI = 1.42‐5.86), and other active comparators (OR = 3.70; 95% CI = 2.41‐5.67) for headache relief. The odds ratio of experiencing adverse events with PCP compared with placebo was 5.79 (95% CI = 2.43‐13.79). When PCP compared with other active comparators, no statistical difference was found regarding the overall number of adverse events (OR = 1.88; 95% CI = 0.99‐3.59). However, PCP significantly increased the odds of akathisia/dystonia (OR = 2.55; 95% CI = 1.03‐6.31). The request for rescue analgesia was significantly lower in the PCP group compared with other groups (16% vs 84%; OR = 0.16; 95% CI = 0.09‐27). Conclusions: For adult patients with acute migraine, PCP could effectively abort the acute attack and reduce the request for rescue analgesia in the ED. However, compared with placebo, PCP could increase the risk of adverse events. [ABSTRACT FROM AUTHOR]

Background: Electropalatography (EPG) records details of the location and timing of tongue contacts with the hard palate during speech. It has been effective in treating articulation disorders that have failed to respond to conventional therapy approaches but, until now, its use with children and adolescents with intellectual/learning disabilities and speech disorders has been limited. Aims: To evaluate the usefulness of EPG in the treatment of speech production difficulties in children and adolescents with Down syndrome (DS) aged 8–18 years. Methods & Procedures: A total of 27 children with DS were assessed on a range of cognitive and speech and language measures and underwent additional EPG assessment. Participants were randomly allocated to one of three age‐matched groups receiving either EPG therapy, EPG‐informed conventional therapy or 'treatment as usual' over a 12‐week period. The speech of all children was assessed before therapy using the Diagnostic Evaluation of Articulation and Phonology (DEAP) and reassessed immediately post‐ and 3 and 6 months post‐intervention to measure percentage consonants correct (PCC). EPG recordings were made of the DEAP assessment items at all time points. Per cent intelligibility was also calculated using the Children's Speech Intelligibility Measure (CSIM). Outcomes & Results: Gains in accuracy of production immediately post‐therapy, as measured by PCC, were seen for all groups. Reassessment at 3 and 6 months post‐therapy revealed that those who had received therapy based directly on EPG visual feedback were more likely to maintain and improve on these gains compared with the other groups. Statistical testing showed significant differences between groups in DEAP scores across time points, although the majority did not survive post‐hoc evaluation. Intelligibility across time points, as measured by CSIM, was also highly variable within and between the three groups, but despite significant correlations between DEAP and CSIM at all time points, no statistically significant group differences emerged. Conclusions & Implications: EPG was an effective intervention tool for improving speech production in many participants. This may be because it capitalizes on the relative strength of visual over auditory processing in this client group. The findings would seem to warrant an increased focus on addressing speech production difficulties in current therapy. [ABSTRACT FROM AUTHOR]

Background: This study aimed to determine the failure rate of a combination of the PERC and the YEARS rules for the diagnosis of pulmonary embolism (PE) in the emergency department (ED). Methods: We performed a retrospective analysis of two European cohorts of emergency patients with low gestalt clinical probability of PE (PROPER and PERCEPIC). All patients we included were managed using a conventional strategy (D‐dimer test, followed, if positive, by computed tomographic pulmonary angiogram (CTPA). We tested a diagnostic strategy that combined PERC and YEARS to rule out PE. The primary endpoint was a thromboembolic event diagnosed in the ED or at 3‐months follow‐up. Secondary endpoints included a thromboembolic event at baseline in the ED and a CTPA in the ED. Ninety‐five percent confidence intervals (CIs) of proportions were calculated with the use of Wilson's continuity correction. Results: We analyzed 1,951 patients (mean ± SD age = 47 ± 18 years, 56% women) with an overall proportion of patients with PE of 3.5%. Both PERC and YEARS strategies were associated with 11 missed PE in the ED: failure rate 0.57 (95% CI = 0.32–1.02). At 3‐month follow‐up, the overall failure rate was 0.83% (95% CI = 0.51–1.35). Among the 503 patients who underwent a CTPA (26%), the use of the PERC–YEARS combination would have ruled out PE without CTPA in 249 patients (50% [95%CI = 45%–54%], absolute reduction 13% (95% CI = 11%–14%]). Conclusion: The combination of PERC then YEARS was associated with a low risk of PE diagnostic failure and would have resulted in a relative reduction of almost half of CTPA. [ABSTRACT FROM AUTHOR]

Background: Severe word production difficulties remain one of the most challenging clinical symptoms to treat in individuals with jargon aphasia. Clinically, it is important to determine why some individuals with jargon aphasia improve following therapy when others do not. We report a therapy study with AM, an individual with severe neologistic jargon aphasia, and provide a subsequent comparison with previous cases, with the purpose of informing both our theoretical and clinical understanding of jargon aphasia. Aims: To investigate AM's locus of word production deficit and determine the effectiveness of phonological component analysis (PCA) therapy, a phonological cueing therapy, in the re‐learning and generalization of naming responses for words. In addition, AM's performance in therapy, linguistic profile and ability to engage with therapy/cues were compared in a retrospective analysis with the background linguistic and therapy data of two other individuals with jargon aphasia (P9 and FF), who responded differentially to PCA. This was undertake to explore possible prognostic indicators of phonological therapy for jargon aphasia. Methods & Procedures: A battery of linguistic and neuropsychological tests was used to identify AM's word production deficit. A single‐subject multiple probe design across behaviours was employed to evaluate the effects of PCA therapy on the re‐learning and generalization of naming responses. In the retrospective analysis of AM, P9 and FF, we compared differences and similarities in performance on various linguistic tasks, the ability to engage in therapy (i.e., ability to generate and use the cues), as well as to retain and maintain cues. Outcomes & Results: AM's locus of deficit was identified in the mapping between semantics and phonology. PCA was found to be effective in improving naming in two of the three treated word lists during the treatment phase; however, these gains were not maintained. Generalization to untreated picture names was not observed. Findings from the retrospective analysis illustrated that oral reading skills, the ability to segment phonological information from words and active engagement with provided cues are likely prerequisites for obtaining robust and long‐term gains. Conclusions & Implications: We demonstrated that phonological therapy could be beneficial for the remediation of naming abilities at least in the re‐learning phase; however, maintenance and generalization of these gains were limited. This research helps to elucidate the considerations and evaluations necessary for the appropriateness of phonological therapy and candidacy of individuals with jargon aphasia for this treatment approach. [ABSTRACT FROM AUTHOR]

Objectives: Pediatric asthma is a leading cause of emergency department (ED) utilization and hospitalization. Earlier identification of need for hospital‐level care could triage patients more efficiently to high‐ or low‐resource ED tracks. Existing tools to predict disposition for pediatric asthma use only clinical data, perform best several hours into the ED stay, and are static or score‐based. Machine learning offers a population‐specific, dynamic option that allows real‐time integration of available nonclinical data at triage. Our objective was to compare the performance of four common machine learning approaches, incorporating clinical data available at the time of triage with information about weather, neighborhood characteristics, and community viral load for early prediction of the need for hospital‐level care in pediatric asthma. Methods: Retrospective analysis of patients ages 2 to 18 years seen at two urban pediatric EDs with asthma exacerbation over 4 years. Asthma exacerbation was defined as receiving both albuterol and systemic corticosteroids. We included patient features, measures of illness severity available in triage, weather features, and Centers for Disease Control and Prevention influenza patterns. We tested four models: decision trees, LASSO logistic regression, random forests, and gradient boosting machines. For each model, 80% of the data set was used for training and 20% was used to validate the models. The area under the receiver operating characteristic (AUC) curve was calculated for each model. Results: There were 29,392 patients included in the analyses: mean (±SD) age of 7.0 (±4.2) years, 42% female, 77% non‐Hispanic black, and 76% public insurance. The AUCs for each model were: decision tree 0.72 (95% confidence interval [CI] = 0.66–0.77), logistic regression 0.83 (95% CI = 0.82–0.83), random forests 0.82 (95% CI = 0.81–0.83), and gradient boosting machines 0.84 (95% CI = 0.83–0.85). In the lowest decile of risk, only 3% of patients required hospitalization; in the highest decile this rate was 100%. After patient vital signs and acuity, age and weight, followed by socioeconomic status (SES) and weather‐related features, were the most important for predicting hospitalization. Conclusions: Three of the four machine learning models performed well with decision trees preforming the worst. The gradient boosting machines model demonstrated a slight advantage over other approaches at predicting need for hospital‐level care at the time of triage in pediatric patients presenting with asthma exacerbation. The addition of weight, SES, and weather data improved the performance of this model. [ABSTRACT FROM AUTHOR]

This retrospective study was conducted to identify the incidence and characteristics associated with readmissions for surgical site infections following caesarean section in a tertiary hospital from 2012 to 2015. Of 6334 patients who underwent caesarean section, 165 (2.6%) were readmitted, most commonly for surgical site infection (25.5%, n = 42). Thirty‐seven of these patients (88%) had an emergency caesarean compared to five (12%) following an elective caesarean section. Of the women with surgical site infections, 69% were overweight and 14% had diabetes. Emergency caesarean sections were responsible for the majority of readmissions, particularly in women with co‐morbidities that predisposed them to infection. [ABSTRACT FROM AUTHOR]

Abstract: Background: The modifications of fluid viscosity and/or volume are common strategies in dysphagia management, with increased viscosity or reduced volume intended to reduce aspiration. Little attention has been given to whether cough response to aspiration varies across different viscosities and volumes. Aims: This prospective observational study investigated aspiration prevalence and cough response to aspiration in thin and thick fluids of two different volumes in patients referred for flexible endoscopic evaluation of swallowing (FEES) in an acute hospital setting. Methods & Procedures: Consecutive inpatients (N = 180) referred for FEES were recruited: stroke 51 (28%); other neurological condition (traumatic brain injury, progressive neurological) 33 (18%); cardiovascular critical care 51 (28%); respiratory illness/condition 23 (13%); spinal injury 9 (5%); and other 13 (7%). A standardized protocol was completed on 268 FEES (180 first FEES, 88 repeat FEES). Penetration‐aspiration scale (PAS) scores were obtained for thin and mildly thick fluids at two volumes: 5 ml teaspoon and 50 ml continuous drinking. Outcomes & Results: The incidence of aspiration (PAS > 5) was 32% for thin fluids and 18% for thick fluids. There was a significant association between cough response to aspiration and viscosity (p < .001) and volume (p < .001). There was a higher prevalence of silent aspiration in thick fluids than thin fluids. Some patients demonstrated variable cough responsiveness to aspiration across different viscosities and volumes. With 5 ml volumes, 20 patients coughed when they aspirated thin fluids but silently aspirated thick fluids. In comparison, discrepancies in the 50 ml volume were fewer, with three patients coughing when they aspirated thin fluids but silently aspirating thick fluids. Conclusions & Implications: Cough response to aspiration differs across bolus volumes and viscosities. The finding of inconsistent cough response to aspiration in some patients strongly encourages the use of instrumental assessment to guide decisions regarding diet modifications. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to systematically evaluate the effectiveness of low level laser therapy (LLLT) as an adjunct to connective tissue graft (CTG) procedure for the treatment of gingival recession (GR). Materials and Methods: The addressed PICO question was; "In patients with Miller Class I or II recession defects (Population), what is the effect of LLLT as adjunct to CTG (Intervention) in comparison to CTG alone (Comparison) on gingival recession depth (Outcome)" Electronic databases were searched up to December 2017. Primary outcomes included gingival recession depth (GRD), whereas secondary outcomes were width of keratinized tissue (WKT) and relative clinical attachment level gain (RCAL). The weighted mean differences (WMD) of outcomes and 95% confidence intervals (CI) for each variable were calculated using random effect model. Results: Four randomized clinical studies were included. Two studies showed significantly greater improvements with LLLT whereas, 2 studies showed comparable outcomes between LLLT and CTG group. Considering the effects of adjunctive LLLT as compared to CTG, a high degree of heterogeneity for GRD (Q value = 9.40, P = .02, I2 =68.11%) and WKT ((Q value = 16.04, P = .001, I2 =81.31%) was noticed among both the groups. Meta‐analysis showed a statistically significant GRD (WMD= −0.61, 95% CI= −1.23 to 0.004, P = .05) for LLLT + CTG treatment versus CTG alone only. Conclusions: LLLT improves clinical and patient‐centered outcomes of CTG procedures for the treatment of GR remains debatable. However, due to the small number of included studies and high heterogeneity in the laser parameters, precautions must be exercised when interpreting the results of the present systematic review. Clinical Significance: Gingival recessions in dentistry are of major esthetic concern. Minimal gingival recessions can be treated by flap operations, but the predictability and stability of the outcomes is debatable. In the present review, low level laser therapy (LLLT) adjunct to connective tissue graft (CTG) depicted a significant improvement in the predictability and stability of root coverage outcomes compared with CTG alone. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To investigate whether smokers prescribed varenicline had lower risks of serious ill‐health during the 4 years following treatment compared with those prescribed nicotine replacement therapy (NRT). Design: Observational cohort study of electronic medical records. Setting: A total of 370 UK general practices sampled from the Clinical Practice Research Datalink. Participants: A total of 126 718 patients aged 18 and over who were issued smoking cessation prescriptions between 1 September 2006 and 31 March 2014. Measurements: Our primary outcome was all‐cause mortality within 2 years of first prescription as indicated by linked Office of National Statistics data. Our secondary outcomes were cause‐specific mortality, all‐cause, cause‐specific hospitalization, primary care diagnosis of myocardial infarction or chronic obstructive pulmonary disease (COPD), body mass index and attendance rate to primary care within 2 years of first prescription. Risk differences and 95% confidence intervals were estimated by multivariable adjusted regression and propensity score matched regression. We used instrumental variable analysis to overcome residual confounding. Findings: People prescribed varenicline were healthier at baseline than those prescribed NRT in almost all characteristics, highlighting the potential for residual confounding. Our instrumental variable analysis results found that people prescribed varenicline had a similar risk of mortality at 2 years [risk difference per 100 patients treated = 0.67, 95% confidence interval (CI) = ‐0.11 to 1.46)] to those prescribed NRT, and there were similar rates of all‐cause hospitalization, incident primary‐care diagnoses of myocardial infarction and COPD. People prescribed varenicline subsequently attended primary care less frequently. Conclusions: Smokers prescribed varenicline in primary care in the United Kingdom do not appear to be less likely to die, be hospitalized or experience a myocardial infarction or chronic obstructive pulmonary disease during the following 2 years compared with smokers prescribed nicotine replacement therapy, but they gain more weight and attend primary care less frequently. [ABSTRACT FROM AUTHOR]

Background: The use of neuromodulation is growing and it is an established therapy for conditions such as bladder dysfunction. It is an increasingly used therapy for the management of chronic perineal pain but little research is currently available looking at its efficacy. Aim: We present a series of 52 patients who underwent placement of a neuromodulator, the majority of whom suffered from perineal pain, with most placements via the sacral hiatus. Method: Patients were asked to complete a survey recalling their symptoms prior to implantation and describing their symptoms and experience after. The majority had two leads placed via the sacral hiatus. Results: Fifty‐two patients had implantation of a permanent neuromodulator and 44 completed at least part of the survey. Forty‐eight had leads placed via the sacral hiatus, 29 of whom had these leads only. Forty patients had perineal pain as an indicator and 32 reported that their pain improved; this difference was statistically significant (95% CI: 2.60–4.27, P < 0.001). Bladder, bowel and sexual dysfunction were reported by about half the cohort with smaller numbers of improvement for each. Thirty‐five patients reported improved quality of life and 32 said they would have the procedure done again. Ten patients had the device removed. Conclusion: We present the largest published case series looking at the use of sacral neuromodulation as a treatment option for pelvic pain and the overall results of our audit are promising for the ongoing use and further development of this modality as a management option. [ABSTRACT FROM AUTHOR]

Background and aims Prescription opioid overdose is a leading cause of injury-related morbidity and mortality in the United States. We aimed to identify characteristics associated with clinical severity in emergency department patients with prescription opioid overdose. Design This was a secondary data analysis of adult prescription opioid overdoses from a large prospective cohort of acute overdoses. We examined elements of a typical emergency department evaluation using a multivariable model to determine which characteristics were associated with clinical severity, specifically severe respiratory depression (SRD). Setting This study was conducted at two urban academic emergency departments in New York City, USA. Participants Adult patients who presented with acute prescription opioid overdose between 2009 and 2013 were included in the current study. We analyzed 307 patients (mean age = 44.7, 42% female, 2.0% mortality). Measurements Patient demographics, reported substances ingested, suspected intent for ingesting the substance, vital signs, laboratory data, treatments including antidotes and intubation and outcome of death were recorded by trained research assistants. Intent was categorized into four mutually exclusive categories: suicide, misuse, therapeutic error and undetermined. The primary outcome was SRD, defined as administration of either (a) naloxone or (b) endotracheal intubation (ETI). Findings A total of 109 patients suffered SRD with 90 patients receiving naloxone alone, nine ETI alone and 10 both naloxone and ETI. The most common opioids were oxycodone ( n = 124) and methadone ( n = 116). Mean age was higher in patients with SRD (51.1 versus 41.1, P < 0.001). Opioid misuse was associated with SRD in the multivariable analysis [odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.21-3.55]. The unadjusted relative risk of SRD was high for fentanyl (83.3% SRD) and lowest for codeine (3.6% SRD). Conclusion In emergency department patients in the United States with prescription opioid overdose, worse clinical severity was associated with opioid misuse, increased with age and was widely variable, depending on the specific opioid medication involved. [ABSTRACT FROM AUTHOR]

Abstract: Background: The speech intelligibility of children with dysarthria and cerebral palsy has been observed to increase following therapy focusing on respiration and phonation. Aims: To determine if speech intelligibility change following intervention is associated with change in acoustic measures of voice. Methods & Procedures: We recorded 16 young people with cerebral palsy and dysarthria (nine girls; mean age 14 years, SD = 2; nine spastic type, two dyskinetic, four mixed; one Worster–Drought) producing speech in two conditions (single words, connected speech) twice before and twice after therapy focusing on respiration, phonation and rate. In both single‐word and connected speech we measured vocal intensity (root mean square—RMS), period‐to‐period variability (Shimmer APQ, Jitter RAP and PPQ) and harmonics‐to‐noise ratio (HNR). In connected speech we also measured mean fundamental frequency, utterance duration in seconds and speech and articulation rate (syllables/s with and without pauses respectively). All acoustic measures were made using Praat. Intelligibility was calculated in previous research. Outcomes & Results: In single words statistically significant but very small reductions were observed in period‐to‐period variability following therapy: Shimmer APQ –0.15 (95% CI = –0.21 to –0.09); Jitter RAP –0.08 (95% CI = –0.14 to –0.01); Jitter PPQ –0.08 (95% CI = –0.15 to –0.01). No changes in period‐to‐period perturbation across phrases in connected speech were detected. However, changes in connected speech were observed in phrase length, rate and intensity. Following therapy, mean utterance duration increased by 1.11 s (95% CI = 0.37–1.86) when measured with pauses and by 1.13 s (95% CI = 0.40–1.85) when measured without pauses. Articulation rate increased by 0.07 syllables/s (95% CI = 0.02–0.13); speech rate increased by 0.06 syllables/s (95% CI = < 0.01–0.12); and intensity increased by 0.03 Pascals (95% CI = 0.02–0.04). There was a gradual reduction in mean fundamental frequency across all time points (–11.85 Hz, 95% CI = –19.84 to –3.86). Only increases in the intensity of single words (0.37 Pascals, 95% CI = 0.10–0.65) and reductions in fundamental frequency (–0.11 Hz, 95% CI = –0.21 to –0.02) in connected speech were associated with gains in intelligibility. Conclusions & Implications: Mean reductions in impairment in vocal function following therapy observed were small and most are unlikely to be clinically significant. Changes in vocal control did not explain improved intelligibility. [ABSTRACT FROM AUTHOR]

Background/Objectives Off-label use of antipsychotics is common in hospitals, most often for delirium management. Antipsychotics have been associated with aspiration pneumonia in community and nursing home settings, but the association in hospitalized individuals is unexplored. We aimed to investigate the association between antipsychotic exposure and aspiration pneumonia during hospitalization. Design Retrospective cohort study. Setting Large academic medical center. Participants All adult hospitalizations between January 2007 and July 2013. We excluded outside hospital transfers, hospitalizations shorter than 48 hours, and psychiatric hospitalizations. Measurements Antipsychotic use defined as any pharmacy charge for an antipsychotic medication. Aspiration pneumonia was defined according to a discharge diagnosis code for aspiration pneumonia not present on admission and validated using chart review. A generalized estimating equation was used to control for 43 potential confounders. Results Our cohort included 146,552 hospitalizations (median age 56; 39% male). Antipsychotics were used in 10,377 (7.1%) hospitalizations (80% atypical, 35% typical, 15% both). Aspiration pneumonia occurred in 557 (0.4%) hospitalizations. The incidence of aspiration pneumonia was 0.3% in unexposed individuals and 1.2% in those with antipsychotic exposure (odds ratio ( OR) = 3.9, 95% confidence interval ( CI) = 3.2-4.8). After adjustment, antipsychotic exposure was significantly associated with aspiration pneumonia (adjusted OR = ( aOR) = 1.5, 95% CI = 1.2-1.9). Similar results were demonstrated in a propensity-matched analysis and in an analysis restricted to those with delirium or dementia. The magnitude of the association was similar for typical ( aOR = 1.4, 95% CI = 0.94-2.2) and atypical ( aOR = 1.5, 95% CI = 1.1-2.0) antipsychotics. Conclusion Antipsychotics were associated with greater odds of aspiration pneumonia after extensive adjustment for participant characteristics. This risk should be considered when prescribing antipsychotics in the hospital. [ABSTRACT FROM AUTHOR]

SUMMARY Background International guidelines recommend treatment of anaemia due to chronic kidney disease (CKD) with erythropoiesis-stimulating agents (ESAs). Objective To document the time required and the cost in terms of nursing time to prepare and administer ESAs to patients on facility based haemodialysis (HD) with anaemia due to CKD before and after the introduction of long-acting ESAs. Design A time and motion study was implemented at four HD units in Australia to determine the time and costs associated with preparing and administering ESAs before and after the introduction of long-acting ESAs. Participants This was a prospective, observational study of workplace practices at four HD units in Australia. Measurements Outcome data included the time taken to prepare, and administer ESAs. Results The time costs of preparation and administration per patient per year had a wide variability within each unit and ranged from Australian AUD$55.75 (38 euros) to AUD$90.49 (62 euros) before the introduction of long-acting ESAs. This dropped by 73-80% following the introduction of long-acting ESAs, representing an annual cost savings of between AUD$2,591 and AUD$5,914 if all patients on HD were switched to a long acting ESA. Conclusion Switching from a short-acting to a long-acting ESA in HD units leads to a significant reduction in time costs of health professionals in preparation and administration of ESAs by up to 80%. Practical application: This time and motion study has added further evidence on reduction of human effort by taking advantages of new research development, such as the long acting ESAs. [ABSTRACT FROM AUTHOR]

Objectives: Rate control is an important component of the management of patients with atrial fibrillation (AF). Previous studies of emergency department (ED) rate control have been limited by relatively small sample sizes. We examined the use of beta-blockers (BBs) versus nondihydropyridine calcium channel blockers (CCBs) in ED patients from 24 sites and the associated hospital admission rates. Methods: In this preplanned substudy, we examined chart data on AF patients who visited one of 24 hospital EDs in Ontario, Canada, between April 2008 and March 2009. We describe the proportion of patients who received either a BB or a CCB, had a heart rate < 110 beats/min 2 hours later, and had any complications. We used hierarchical logistic regression modeling to determine the predictors of BB versus CCB use and to assess the between-hospital variation in use of BBs versus CCBs. Solely in patients who had no rhythm control attempts, we examined the difference in the probability of hospital admission after propensity score matching patients by medication class. Results: Of the 1,639 patients who received either a BB (n = 429) or a CCB (n = 1,210), 70.9% of the patients who received a BB had successful rate control versus 66.1% for a CCB. Complications were rare (2.4%), and the large majority were hypotension (2.0%). In adjusted analyses, predictors of receiving a BB (compared to a CCB) included already being on a BB, being sent in from a doctor’s office, or being seen at a teaching hospital. In contrast, patients with evidence of heart failure, prior use of a CCB, a higher presenting heart rate, or a successful pharmacologic cardioversion (vs. no attempt) or who were seen at the highest AF volume EDs were significantly less likely to receive a BB, compared to a CCB. Systematic between-hospital differences accounted for 8% of the variation in BB versus CCB use. Hospital characteristics accounted for the large majority of that variation: after accounting for patient characteristics the between-hospital variation decreased by a relative 2.8%. By further adjusting for hospital characteristics, it decreased by a relative 74.7%. Among propensity score–matched patients with no rhythm control attempts, more CCB patients were admitted (51.6%) compared to BB patients (40.0%; difference of 11.6%; 95% confidence interval = 7.9%–16.2%). Conclusions: In this study of 24 EDs, CCBs were used more frequently for rate control than BBs, and complications were rare and easily managed using both agents. Variation between hospitals in BB versus CCB use was predominantly due to hospital characteristics such as teaching status and AF volumes, rather than different case mix. Among patients who did not receive attempts at rhythm control, use of a BB for rate control was associated with a lower rate of hospitalization. [ABSTRACT FROM AUTHOR]

ABSTRACT Background As many delirium manifestations (e.g., hallucinations or fears) are linked to patients' experiences and personality traits, it is suggested that interventions should be tailored to optimize its management. The inclusion of family members, as part of an intervention, has recently emerged as a solution to developing individualised patient care, but has never been assessed in post-cardiac surgery intensive care unit where almost half of patients will present with delirium. Aims To assess the feasibility, acceptability and preliminary efficacy of an nursing intervention involving family caregivers ( FC) in delirium management following cardiac surgery. Design A randomized pilot study. Methods A total of 30 patient/ FC dyads were recruited and randomized to usual care ( n = 14) or intervention ( n = 16). The intervention was based on the Human Caring Theory, a mentoring model, and sources informing self-efficacy. It comprised seven planned encounters spread over 3 days between an intervention nurse and the FC, each including a 30-min visit at the patient's bedside. During this bedside visit, the FC used delirium management strategies, e.g. reorient the person with delirium. The primary indicator of acceptability was to obtain consent from 75% of approached FCs. The preliminary effect of the intervention on patient outcomes was assessed on (1) delirium severity using the Delirium Index, (2) occurrence of complications, such as falls, (3) length of postoperative hospital stay and (4) psycho-functional recovery using the Sickness Impact Profile. The preliminary effect on FC outcomes was assessed on FC anxiety and self-efficacy. Data were analysed using descriptive statistics, ANCOVAs and logistic regressions. Results The primary indicator of obtaining consent from FC was achieved (77%). Of the 14 dyads, thirteen (93%) dyads received all seven encounters planned in the experimental intervention. Intervention group patients presented better psycho-functional recovery scores when compared with control group patients ( p = 0·01). Mean delirium severity scores showed similar trajectories on days 1, 2 and 3 in both groups. Conclusion The mentoring intervention was acceptable and feasible and shows promising results in improving patients and FC outcomes. Relevance to clinical practice Nurses should involve, if willing, FC to participate in activities that optimise patient well-being FC to use recognized delirium management strategies like reorientation and reassurance. [ABSTRACT FROM AUTHOR]

Aim To examine the efficacy and safety of (1) midazolam-droperidol versus droperidol and (2) midazolam-droperidol versus olanzapine for methamphetamine-related acute agitation. Design and setting A multi-centre, randomized, double-blind, controlled, clinical trial was conducted in two Australian emergency departments, between October 2014 and September 2015. Participants Three hundred and sixty-one patients, aged 18-65 years, requiring intravenous medication sedation for acute agitation, were enrolled into this study. We report the results of a subgroup of 92 methamphetamine-affected patients. Intervention and comparator Patients were assigned randomly to receive either an intravenous bolus of midazolam 5 mg-droperidol 5 mg combined, droperidol 10 mg or olanzapine 10 mg. Two additional doses were administered, if required: midazolam 5 mg, droperidol 5 mg or olanzapine 5 mg, respectively. Measurements The primary outcome was the proportion of patients sedated adequately at 10 minutes. Odds ratios with 95% confidence intervals (ORs, 95% CI) were estimated. Findings The baseline characteristics of patients in the three groups were similar. At 10 minutes, significantly more patients in the midazolam-droperidol group [29 of 34 (85.3%)] were sedated adequately compared with the droperidol group [14 of 30 (46.7%), OR = 6.63, 95% CI = 2.02-21.78] or with the olanzapine group [14 of 28 (50.0%), OR 5.80, 95% CI = 1.74-19.33]. The number of patients who experienced an adverse event (AE) in the midazolam-droperidol, droperidol and olanzapine groups was seven of 34, two of 30 and six of 28, respectively. The most common AE was oxygen desaturation. Conclusion A midazolam-droperidol combination appears to provide more rapid sedation of patients with methamphetamine-related acute agitation than droperidol or olanzapine alone. [ABSTRACT FROM AUTHOR]

Background Limited studies of patient survival and alcoholic relapse following transplantation for alcoholic liver disease have been described in Australian populations. Aim To describe these outcomes in an Australian population, to determine the association between harmful alcoholic relapse and patient survival, and to examine pre-transplant variables associated with harmful relapse. Methods Single centre, retrospective review of consecutive patients transplanted at the South Australian Liver Transplant Unit. Relapse was identified by an independent investigator using case note review and confidential patient questionnaire. Results A total of 87 patients (median age 52 years, 84% male, median Model for End-Stage Liver Disease ( MELD) score 18) was included in the study with a median follow-up time of 50 months. The 1-, 3- and 5-year survival of patients was 93.1, 87.4 and 82.0% respectively. Two deaths were directly attributable to graft failure due to alcohol. Fourteen (16%) patients fulfilled criteria for harmful relapse and 18 (21%) patients experienced any form of relapse to alcohol. Harmful relapse was associated with increased mortality (hazard ratio ( HR) 3.2, 95% confidence interval ( CI) 1.1-9.7, P = 0.041). Only two factors were independently associated with harmful relapse on multivariate analysis; prior alcohol rehabilitation ( HR 8.4, 95% CI 2.5-28.4, P = 0.001) and single versus married status ( HR 0.09, 95% CI 0.02-1.2, P = 0.019). Conclusion Good patient survival outcomes were seen for this South Australian population. Harmful alcohol relapse occurs in a minority of patients and rarely results in direct graft loss. Modifiable pre-transplant factors that predict harmful relapse were not identified. [ABSTRACT FROM AUTHOR]

Background Cord prolapse is an uncommon obstetric emergency, with potentially fatal consequences for the baby if prompt action is not taken. Simulation training provides a means by which uncommon emergencies can be practised, with the aim of improving teamwork and clinical outcomes. Aims This study aimed to determine if the introduction of a simulation-based training course was associated with an improvement in the management of cord prolapse, in particular the diagnosis to delivery interval. We also aimed to investigate if an improvement in perinatal outcomes could be demonstrated. Materials and methods A retrospective cohort study was performed. All cases of cord prolapse in the designated time period were identified and reviewed and a comparison of outcome measures pre- and post-training was undertaken. Results Thirty-one cases were identified in the pre-training period, and compared to 64 cases post-training. Documentation improved significantly post-training. There were non-significant improvements in use of spinal anaesthetic, and in the length of stay in the special care neonatal unit. There was a significant increase in the number of babies with Apgar scores less than seven at 5 min. There were no differences in the diagnosis to delivery interval, or in perinatal mortality rates. Conclusion Obstetric emergency training was associated with improved teamwork, as evidenced by the improved documentation post-training in this study, but not with improved diagnosis to delivery interval. Long-term follow-up studies are required to ascertain whether training has an impact on longer-term paediatric outcomes, such as cerebral palsy rates. [ABSTRACT FROM AUTHOR]

Objective To compare the enamel protection efficacy of a stabilized stannous fluoride (SnF2) dentifrice to a sodium fluoride (NaF)/triclosan dentifrice following acidic erosive challenge. Methods In this in situ, randomized, controlled, double-blind, two-treatment, four-period crossover clinical trial, subjects wore an appliance fitted with human enamel samples 6 h day−1 during each 15-day treatment period. Twice each treatment day they swished with their assigned dentifrice slurry: 0.454% SnF2/0.077% NaF or 0.32% NaF/0.3% triclosan. After each treatment and two other times daily, subjects swished with 250 ml of orange juice over a 10-min period (acidic erosive challenge). Enamel samples were measured for tooth surface loss using contact profilometry at baseline and days 10 and 15. Results Thirty-six subjects (mean age 44.8 years, range 23-65 years) were randomized to treatment; 33 subjects completed the final study visit. There were no statistically significant baseline differences ( P > 0.44) in the specimen surfaces of the two dentifrice treatment groups via profilometry. At day 10, the SnF2 dentifrice provided a statistically significant ( P < 0.0001) reduction in enamel loss by 67% versus the NaF/triclosan dentifrice with estimated medians of 1.22 and 3.68 μm, respectively. At day 15, the SnF2 dentifrice again provided a significantly greater benefit ( P < 0.0001) against tooth surface loss versus the NaF/triclosan dentifrice, with 68% less erosion, and estimated medians of 1.60 and 5.03 μm, respectively. Both dentifrices were well tolerated. Conclusion A stabilized SnF2 dentifrice provided superior protection against the initiation and progression of tooth enamel surface loss in situ after erosive challenge compared to a NaF/triclosan dentifrice. [ABSTRACT FROM AUTHOR]

Background Recommendations regarding caries-preventive self-care for children are provided by several health authorities. Objective To investigate recommendations given to the public regarding children's caries-preventive self-care by Norwegian dentists, dental hygienists, dental nurses and public health nurses. Methods Questionnaires were sent by e-mail and answered by 808 of 1132 persons who provide oral preventive promotion to children in dental services and health centres. The preventive advice was obtained through questions about the preferred preventive methods, fluoride recommendations and sources of knowledge on which the personnel based the advice about caries prevention in children. The responses were analysed using logistic regression. Results The majority (59-71%) in all professions judged oral hygiene education to be the most important caries-preventive method. Most personnel (84-98%) recommended all children to use fluoride toothpaste, and half of all personnel (53%) recommended fluoride lozenges for 50% or more of children. Multivariate analysis showed that dental nurses recommended lozenges to more children than dentists ( OR 2.5, 95% CI 1.7-3.7), while health nurses recommended lozenges to fewer children than dentists ( OR 0.5, 95% CI 0.3-0.8). The most important source of knowledge reported by dental personnel was professional education, while health nurses relied on information from dental personnel. Conclusions Health professions' recommendations regarding caries-preventive self-care for children were mainly similar, although variation existed both between and within professions. Collaboration between professions and awareness of the evidence base for preventive oral care may improve the consistency of information given by health professionals to the public. [ABSTRACT FROM AUTHOR]

Background and Aims In many countries, conflicting gradients in alcohol consumption and alcohol-associated mortality have been observed. To understand this 'alcohol harm paradox' we analysed the socio-economic gradient in alcohol-associated hospital admissions to test whether it was greater in conditions which were: (1) chronic (associated with long-term drinking) and partially alcohol-attributable, (2) chronic and wholly alcohol-attributable, (3) acute (associated with intoxication) and partially alcohol-attributable and (4) acute and wholly alcohol-attributable. Our aim was to clarify how (1) drinking patterns (e.g. intoxication linked to acute admissions or dependence linked to chronic conditions) and (2) non-alcohol causes (e.g. smoking and poor diet which are risks for partially alcohol-attributable conditions) contribute to the paradox. Design Regression analysis testing the modifying effects of condition-group (1-4 above) and sex on the relationship between area-based deprivation and admissions. Setting England, April 2010-March 2013. Participants A total of 9 239 629 English hospital admissions where a primary or secondary cause was one of 36 alcohol-associated conditions. Measurements Admissions by condition and deciles of Index of Multiple Deprivation (IMD). Socio-economic gradient measured as the relative index of inequality (RII, the slope of a linear regression of IMD on admissions adjusted for overall admission rate). Conditions were categorized by ICD-10 code. Findings A socio-economic gradient in hospitalizations was seen for all conditions, except partially attributable chronic conditions. The gradient was significantly steeper for conditions which were wholly attributable to alcohol and for acute conditions than for conditions partially alcohol-attributable and for chronic conditions. Gradients were steeper for men than for women in cases of wholly alcohol attributable conditions. Conclusions There is a socio-economic gradient in English hospital admission for most alcohol-associated conditions. The greatest inequalities are in conditions associated with alcohol dependence, such as liver disease and mental and behavioural conditions, and in acute conditions, such as alcohol poisoning and assault. Socio-economic differences in harmful drinking patterns (dependence and intoxication) may contribute to the 'alcohol harm paradox'. [ABSTRACT FROM AUTHOR]