Practical management of ocular surface disease in patients with atopic dermatitis, with a focus on conjunctivitis: A review.

Atopic dermatitis (AD) is a chronic inflammatory skin disease that can significantly decrease quality of life. AD is commonly associated with comorbidities including ocular surface disease (OSD). Conjunctivitis is the most common OSD associated with AD and can increase in incidence with use of monoclonal antibody biologics that target the type 2 inflammatory pathway. The objective of this review is to raise awareness of comorbid OSD in AD patients that dermatologists may encounter, with a focus on conjunctivitis, and equip dermatologists to address mild ocular concerns. We provide background on the subtypes and pathogenesis of comorbid OSD in AD patients and describe OSD associated with type 2 inflammation-inhibiting AD biologics. We also discuss screening and diagnosis, recommended treatment options for dermatologists, and when to refer to an eye care specialist. This multispecialty approach aims to support the overall health of AD patients and provide optimal patient care.

Nurses Can Resuscitate.

Fluid resuscitation in the first 48 hours postburn is crucial in the management of burn shock. The primary purpose of this study was to evaluate nurses' adherence to a nurse-driven fluid resuscitation protocol at one adult burn center. Their secondary goal was to establish that the use of a nursing-driven protocol did not result in over resuscitation. Following implementation of a nurse-driven burn resuscitation protocol, a 48-hour data resuscitation data collection tool was developed by the burn physicians and nurses. All resuscitations were reviewed in real-time and in burn leadership meeting to identify opportunities for improvement. Follow-up with nursing staff was done in real time by the clinical nurse specialist following each burn resuscitation. Twenty-two patients requiring formal fluid resuscitation were included in the review. Patients had a median age of 36.5(IQR: 38.74) years and were predominantly male. They found that in the first 24 hours that patients received 3.47 ml/kg/hr and then in the next 24 hours they received an average of 2.68 ml/kg/hr. All 22 patients' resuscitation was initiated using the Parkland formula in the emergency department, and nurses were successful in consistently adjusting fluid infusions consistent with the protocol. Using a multidisciplinary approach and preparatory and real-time education processes, burn nurses can successfully guide burn resuscitation. Providing education and follow-up in real time can improve the process.

Exploration of critical care data by using unsupervised machine learning.

BACKGROUND AND OBJECTIVE: Identification of subgroups may be useful to understand the clinical characteristics of ICU patients. The purposes of this study were to apply an unsupervised machine learning method to ICU patient data to discover subgroups among them; and to examine their clinical characteristics, therapeutic procedures conducted during the ICU stay, and discharge dispositions. METHODS: K-means clustering method was used with 1503 observations and 9 types of laboratory test results as features. RESULTS: Three clusters were identified from this specific population. Blood urea nitrogen, creatinine, potassium, hemoglobin, and red blood cell were distinctive between the clusters. Cluster Three presented the highest blood products transfusion rate (19.8%), followed by Cluster One (15.5%) and cluster Two (9.3%), which was significantly different. Hemodialysis was more frequently provided to Cluster Three while bronchoscopy was done to Cluster One and Two. Cluster Three showed the highest mortality (30.4%), which was more than two-fold compared to Cluster One (14.1%) and Two (12.2%). CONCLUSION: Three subgroups were identified and their clinical characteristics were compared. These findings may be useful to anticipate treatment strategies and probable outcomes of ICU patients. Unsupervised machine learning may enable ICU multi-dimensional data to be organized and to make sense of the data.

Prediction Model for Hospital-Acquired Pressure Ulcer Development: Retrospective Cohort Study.

BACKGROUND: A pressure ulcer is injury to the skin or underlying tissue, caused by pressure, friction, and moisture. Hospital-acquired pressure ulcers (HAPUs) may not only result in additional length of hospital stay and associated care costs but also lead to undesirable patient outcomes. Intensive care unit (ICU) patients show higher risk for HAPU development than general patients. We hypothesize that the care team's decisions relative to HAPU risk assessment and prevention may be better supported by a data-driven, ICU-specific prediction model. OBJECTIVE: The aim of this study was to determine whether multiple logistic regression with ICU-specific predictor variables was suitable for ICU HAPU prediction and to compare the performance of the model with the Braden scale on this specific population. METHODS: We conducted a retrospective cohort study by using the data retrieved from the enterprise data warehouse of an academic medical center. Bivariate analyses were performed to compare the HAPU and non-HAPU groups. Multiple logistic regression was used to develop a prediction model with significant predictor variables from the bivariate analyses. Sensitivity, specificity, positive predictive values, negative predictive values, area under the receiver operating characteristic curve (AUC), and Youden index were used to compare with the Braden scale. RESULTS: The total number of patient encounters studied was 12,654. The number of patients who developed an HAPU during their ICU stay was 735 (5.81% of the incidence rate). Age, gender, weight, diabetes, vasopressor, isolation, endotracheal tube, ventilator episode, Braden score, and ventilator days were significantly associated with HAPU. The overall accuracy of the model was 91.7%, and the AUC was .737. The sensitivity, specificity, positive predictive value, negative predictive value, and Youden index were .650, .693, .211, 956, and .342, respectively. Male patients were 1.5 times more, patients with diabetes were 1.5 times more, and patients under isolation were 3.1 times more likely to have an HAPU than female patients, patients without diabetes, and patients not under isolation, respectively. CONCLUSIONS: Using an extremely large, electronic health record-derived dataset enabled us to compare characteristics of patients who develop an HAPU during their ICU stay with those who did not, and it also enabled us to develop a prediction model from the empirical data. The model showed acceptable performance compared with the Braden scale. The model may assist with clinicians' decision on risk assessment, in addition to the Braden scale, as it is not difficult to interpret and apply to clinical practice. This approach may support avoidable reductions in HAPU incidence in intensive care.

Perceived stress and worldview influence sleep quality in Bolivian and United States university students.

OBJECTIVE: This study investigated predictors of poor sleep quality among American and Bolivian students. DESIGN: A cross-sectional survey was designed and administered to undergraduate university students. SETTING AND PARTICIPANTS: Psychology classes from 2 public universities (Texas, USA, and Bolivia) were convenience sampled (n = 80 American students; 60 Bolivian students). MEASUREMENTS: We used a sleep quality index and the Perceived Stress Scale. We added questions concerning worldview, sleep hygiene, sleep deficiency, health behaviors, and demographics. RESULTS: Five variables predicted poor sleep quality: perceived stress, sleep hygiene, sleep deficiency, worldview, and site. Greater stress positively associated with poorer sleep in both cultures. Yet, Bolivian students reported significantly more stress than American students but experienced significantly better sleep quality. Worldview, a measure of optimism or pessimism about the world, negatively associated with sleep quality in both cultures. CONCLUSION: Three variables that predict sleep quality (worldview, sleep hygiene, and sleep deficiency) did not differ significantly between countries. Only perceived stress differed by country but contrary to the predicted direction. Thus, this work reveals new avenues for future work to the investigation of sleep in different cultures. Lastly, we offer recommendations to ameliorate poor sleep in university students.

Risk Factors for Dupilumab-Associated Conjunctivitis in Patients With Atopic Dermatitis.

Importance: Clinical trials of dupilumab for atopic dermatitis (AD) have reported an increased incidence of conjunctivitis in patients who received dupilumab compared with those who received placebo. Objective: To describe the characteristics of patients who develop conjunctivitis secondary to dupilumab treatment for AD. Design, Setting, and Participants: Case series of 12 patients who reported development of conjunctivitis from a cohort of 142 patients treated with dupilumab for AD at a secondary care center from March 14, 2017, to March 29, 2018. Exposures: Patients received a 600-mg injection of dupilumab as a loading dose and a 300-mg injection every 2 weeks thereafter. Main Outcomes and Measures: Primary outcome measures were severity of AD as measured by the Investigator Global Assessment (IGA) score, a 5-point scale from 0 (clear) to 4 (severe), at the time of dupilumab initiation and at conjunctivitis onset. Results: Of the 12 patients included in this series, 7 (58%) were male. The mean (SD) age of patients was 30 (8.1) years at the time conjunctivitis developed. All patients showed improvement of their AD at the time of conjunctivitis diagnosis, with a mean (SD) 1.9 (0.8)-point decrease in IGA score and 47.8% (11.2%) decrease in body surface area affected. Nine of the 12 patients (75%) had severe baseline AD with an IGA score of 4. All patients who discontinued treatment had severe AD at the time of initial dupilumab administration and had at least 1 atopic condition in addition to AD. Conclusions and Relevance: Conjunctivitis that develops after administration of dupilumab to treat AD may be severe enough to necessitate stopping therapy. Severe conjunctivitis was more likely to develop in patients with more severe baseline AD who had a good response to dupilumab and an increased atopic phenotype. Studies are needed to confirm risk factors associated with development of conjunctivitis and to determine effective treatment.

Structured Exercise in Obese Diabetic Patients with Chronic Kidney Disease: A Randomized Controlled Trial.

BACKGROUND: Patients with type 2 diabetes mellitus (DM), obesity, and chronic kidney disease (CKD) are generally physically inactive and may benefit from exercise. Our objective was to determine the effects of structured exercise on physical fitness, kidney function, endothelial function, inflammation, and body composition in such patients. METHODS: In this randomized, controlled trial, 36 male patients (age 49-81) were randomly assigned to exercise + diet management (n = 18) or diet alone (n = 18). Participants were eligible if they had type 2 DM, body mass index >30 kg/m2, CKD stages 2-4, and persistent proteinuria (>200 mg/g creatinine for >3 months). The exercise intervention was a 12-week (3 days per week) program of aerobic and resistance training followed by 40 weeks of home exercise. The primary outcome measure was change from baseline in urine protein to creatinine ratio (UPCR) at 12 and 52 weeks. RESULTS: Thirty-two participants completed the study (14 exercise + diet, 18 diet-alone group). The change from baseline in UPCR was slightly greater in the diet-alone group at 12 weeks but not at 52 weeks. Changes in both symptom-limited and constant-workrate treadmill times were significantly higher in the exercise + diet group at 12 weeks but not at 52 weeks. There were no significant differences in urine albumin to creatinine ratio, estimated glomerular filtration rate, endothelial function, inflammation, or body composition between the groups. CONCLUSIONS: In obese diabetic subjects with CKD, structured exercise improved exercise capacity but not body composition or renal function. This is a work of the US Government and is not subject to copyright protection in the USA. Foreign copyrights may apply. Published by S. Karger AG, Basel.

Making Lemonade Out of Life's Lemons: A View Into the World of Aging With Parkinson's Disease.

Pictures can aid in understanding individual perspectives of an experience. Photovoice, a visual elicitation research approach, was used to engage nine participants with Parkinson's disease in taking photographs that, for them, represented important aspects of living with the disease. Participants' descriptions of their photographs revealed perspectives that can be theoretically linked to two psychosocial stages of development: (a) generativity versus stagnation and (b) integrity versus despair. Clear examples of generativity and integrity were present in participants' responses, reflecting determination and optimism in living with the disease. Findings highlight the need to seek understanding of patients' individual experiences of living with an illness so it is not falsely assumed that they are not adjusting or managing their disease.

Bone mineral density in Hispanic women: a review of the literature with implications for promoting culturally relevant osteoporosis education.

Osteoporosis is a disease that primarily affects postmenopausal women of all ethnicities. Demographic projections indicate that the number of Hispanics over age 65 in the U.S. will increase from 2.9 million currently, to 17.5 million in 2050. A majority will be women. Recent research has increased understanding about biocultural correlates of osteoporosis in Hispanic women, and indicates that their risk for the disease is about equal to that of non-Hispanic White (NHW) women. Although Hispanics living in the U.S. share many biological and cultural characteristics with the general population, there are important differences in disease pre-disposition and associated morbidity that present challenges to osteoporosis prevention efforts. The purpose of this article is to provide a review of selected bone density studies that have included Hispanic women, to summarize the findings, and to discuss implications of these findings for osteoporosis prevention education for this population.

Tell me--show me: using combined focus group and photovoice methods to gain understanding of health issues in rural Guatemala.

As health researchers, our training is more literary than visual. We are only beginning to learn about the value of photography as a qualitative data collection method. In this article we describe a project utilizing focus groups and photovoice, sequentially, to gather information about health-related conditions in rural Guatemala. In the first phase, the perceptions of a group of comadronas (birth attendants) were elicited using traditional focus group methodology. In the second phase, conducted several months later, the photovoice method was utilized. During this phase, the same participants viewed and responded to photographs taken during the intervening period by some of the phase-one participants. The findings from this two-phase approach support those from other studies that suggest that photovoice provides more in-depth data and the potential for bringing out additional information that might not emerge during traditional interviews or focus group discussions.

Bone health in immigrant Hispanic women living in Texas.

Osteoporosis is a serious national public health problem, and is expected to increase significantly over the next few decades, especially in women. A limitation of bone health research exists since few studies have involved Hispanic women, and even fewer, Hispanic immigrant women. For this study we examined the effects of anthropometric, behavioral, and health history variables on bone mineral density (BMD) in 84 immigrant Hispanic women, age 40 and above. BMD was assessed at the spine, femur, and forearm using dual energy x-ray absorptiometry (DXA). Demographic information, health histories, and behavioral risk factors were obtained from a questionnaire. In the younger group (mean age = 44.1 years) 61% had spinal osteopenia, and in the postmenopausal group (mean age = 53.0 years) 59% had osteopenia and 13% had osteoporosis. Femur sites were free of osteoporosis. Mean body mass index (BMI) was 31.8 ± 6.1 and mean waist girth was 95.6 ± 12.5 cm, indicating overall and abdominal obesity. Partial correlations indicated a significant positive relationship between body fat variables and total femur BMD values. ANOVAs revealed no differences in BMD values at any bone site across tertile levels for calcium intake or for physical activity. However, supplemental and dietary calcium intakes were very low and few participants engaged in regular physical activity outside of work and activities of daily living (ADL). In light of the expected increase in osteoporosis in this population and the prevalence of spinal osteopenia in the younger participants, education about the health risks of osteoporosis should be made available to this group.

Aerobic exercise in obese diabetic patients with chronic kidney disease: a randomized and controlled pilot study.

BACKGROUND: Patients with obesity, diabetes, and chronic kidney disease (CKD) are generally physically inactive, have a high mortality rate, and may benefit from an exercise program. METHODS: We performed a 24-week randomized controlled feasibility study comparing aerobic exercise plus optimal medical management to medical management alone in patients with type 2 diabetes, obesity (body mass index [BMI] > 30 kg/m2), and stage 2-4 CKD (estimated glomerular filtration rate [eGFR] 15-90 mL/min/1.73 m2 with persistent proteinuria). Subjects randomized to exercise underwent thrice weekly aerobic training for 6 followed by 18 weeks of supervised home exercise. The primary outcome variable was change in proteinuria. RESULTS: Seven subjects randomized to exercise and 4 control subjects completed the study. Exercise training resulted in an increase in exercise duration during treadmill testing, which was accompanied by slight but insignificant decreases in resting systolic blood pressure and 24-hour proteinuria. Exercise did not alter GFR, hemoglobin, glycated hemoglobin, serum lipids, or C-reactive protein (CRP). Caloric intake and body weight and composition also did not change with exercise training. CONCLUSION: Exercise training in obese diabetic patients with CKD is feasible and may have clinical benefits. A large-scale randomized controlled trial to determine the effects of exercise on renal functions, cardiovascular fitness, inflammation, and oxidative stress in diabetic patients with CKD is planned.