Pulsed dye laser and adjuvant topical therapies for the treatment of port-wine stains: A systematic review.

OBJECTIVES: The current gold standard treatment for port-wine stains (PWS) is pulsed dye laser (PDL). However, multiple treatment sessions may be necessary and complete resolution is often not achieved. Neoangiogenesis can occur soon after treatment and is thought to be a major factor contributing to treatment failure. Adjuvant antiangiogenic topical therapies may therefore improve the efficacy of pulsed dye laser treatment of port-wine stains. MATERIAL AND METHODS: Following PRISMA guidelines, we searched PubMed, Embase, Web of Science, and clinicaltrials.gov using "port-wine stain," "nevus flammeus," "capillary malformation," "sturge weber," and "pulsed dye laser" as keywords and medical subject heading (MeSH) terms. Articles were included if they (1) were a randomized controlled trial (RCT); (2) studied patients with PWS; and (3) investigated topical adjuvant therapies with PDL. Bias was assessed using the Critical Appraisal Skills Programme (CASP) Randomized Controlled Trial Standard Checklist. RESULTS: 1835 studies were identified, with six studies meeting inclusion criteria. The total number of patients studied was 103 (range: 9-23), with 8-36 week follow-up. The average age ranged from 11 to 33.5 years old. Three studies examined adjuvant topical sirolimus (n = 52), two examined timolol (n = 29), and one studied imiquimod (n = 22). Two of three RCTs reported no improvement through colorimetric analysis with topical sirolimus; however, one of these studies did show a significant improvement through Investigator Global Assessment (IGA) score. The last sirolimus study showed significant improvement through digital photographic image scoring (DPIA). Studies examining topical timolol reported no change in PWS appearance compared to placebo. The addition of 5% adjuvant imiquimod cream did lead to significant improvement. A variety of outcome measures were used. Imiquimod and sirolimus led to mild cutaneous adverse events, while timolol caused no side effects. None of the adverse events led to treatment discontinuation. Study quality was moderate in three, high in two, and low in one. CONCLUSION: The efficacy of adjuvant topical therapy was unclear. Limitations included variation in concentration and duration of adjuvant therapies, differences in follow-up time, and inconsistent outcome measure reporting. Given their potential clinical promise, larger prospective studies examining topical adjuvant therapies should be considered.

Describing the evidence linking interprofessional education interventions to improving the delivery of safe and effective patient care: a scoping review.

Empirical evidence indicates that collaborative interprofessional practice leads to positive health outcomes. Further, there is an abundance of evidence examining student and/or faculty perceptions of learning or satisfaction about the interprofessional education (IPE) learning experience. However, there is a dearth of research linking IPE interventions to patient outcomes. The objective of this scoping review was to describe and summarize the evidence linking IPE interventions to the delivery of effective patient care. A three-step search strategy was utilized for this review with articles that met the following criteria: publications dated 2015-2020 using qualitative, quantitative or mixed methods; the inclusion of healthcare professionals, students, or practitioners who had experienced IPE or training that included at least two collaborators within coursework or other professional education; and at least one of ten Centers for Medicare & Medicaid Services quality measures (length of stay, medication errors, medical errors, patient satisfaction scores, medication adherence, patient and caregiver education, hospice usage, mortality, infection rates, and readmission rates). Overall, n=94 articles were identified, providing overwhelming evidence supporting a positive relationship between IPE interventions and several key quality health measures including length of stay, medical errors, patient satisfaction, patient or caregiver education, and mortality. Findings from this scoping review suggest a critical need for the development, implementation, and evaluation of IPE interventions to improve patient outcomes.

Expanding the scope of problem-based-learning at Hackensack Meridian School of Medicine; integrating domain-general skills with domain-specific content.

The Master Adaptive Learner is a model used to develop students to become self-regulated and adaptable lifelong learners to practice medicine in a complex and ever-changing environment. The Hackensack Meridian School of Medicine (HMSOM) proposes a new course, Patient Presentation Problem-Based Learning Curriculum (PPPC), a dynamic and integrated course that goes beyond the scope of traditional Problem-Based-Learning (PBL). PPPC allows students to build domain-general skills in tandem with domain-specific content learned during a pre-clerkship curriculum. An integrated case provides weekly scaffolding, such that the course takes place throughout the week and is not isolated from the rest of the curriculum. Students receive iterative feedback and structured assignments which allows development of self-directed learning skills along with integration and consolidation of weekly curricular content. A layered analysis approach was used to outline the philosophies, principles and techniques that link to our course objectives. Techniques used could easily be translated to other pre-clerkship curriculum to promote development of self-directed learning and clinical reasoning skills, as well as promote more meaningful learning of basic, clinical, and health system science content.

Introducing Life-long Learning Skills in a Patient Presentation Problem-Based Curriculum: The Case for Librarian Integration.

Medical students must learn how to find, critically appraise, and apply high-quality information to support their clinical decisions. To reinforce these skills, the Hackensack Meridian School of Medicine embedded medical librarians into a longitudinal case-based, problem-based learning curriculum, where they provide individualized feedback on student's skills in this area.

Anthropometric Outcomes of Children and Adolescents Using Telehealth with Weight Management Interventions Compared to Usual Care: A Systematic Review and Meta-analysis.

Objective:This systematic review and meta-analysis evaluated the effect of telehealth (TH) weight management interventions compared to usual care on anthropometric outcomes in children and adolescents with overweight and obesity.Methods: Comprehensive searches were conducted identifying randomized controlled trials (RCTs) published between January 1, 2005 and June 1, 2019. Studies using a web-based, smartphone or email TH intervention in children between 2-18 years of age were included. Outcome measures of interest included body mass index (BMI) z-score, BMI percentile, waist circumference (WC) and waist-to-hip-ratio (WHR). The Grade Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to rate strength of evidence (SOE) and a random-effects meta-analysis was performed when five or more RCTs reported the same outcome.Results: Thirteen RCTs met the inclusion criteria for the systematic review. Random effects meta-analysis of 10 RCTs detected a small effect for TH interventions compared to usual care in reducing BMI z-score (pooled net change in BMI z-score = -0.04; 95% CI -0.07, 0.00: I2 = 12%). No significant differences were found between groups for other outcomes. Strength of evidence ratings were low or very low in part due to concerns with heterogeneity in study designs, intervention durations, ages of participants, the type of TH used and risk of bias (ROB) of included studies.Conclusions: There is a low strength of evidence that TH had a small effect on anthropometric outcomes compared to usual care. Future RCTs should be well designed to minimize clinical heterogeneity and ROB. Studies of longer intervention duration with adequate, statistically powered analyses should be conducted.Key teaching pointsStudies using TH with pediatric weight management interventions may be effective to improve health of children with overweight and obesity.Future RCTs should consider clinical heterogeneity of study design for setting, age-group of children, preferences for type of TH and ROB.Studies that include children with severe obesity (<95th%) may need more sensitive outcome measures.Studies of longer duration are needed to better understand long-term weight management success.

The associations between pediatric weight status and cystic fibrosis-related diabetes status and health-related quality of life among children and young adults with cystic fibrosis: A systematic review.

BACKGROUND: Cystic fibrosis (CF) is a life-shortening genetic disease, yet life expectancy has recently increased, shifting the focus to disease management and health-related quality of life (HRQoL). Identification of clinical factors, such as weight status and CF-related diabetes (CFRD), that are associated with HRQoL can inform clinicians about the patient's health perception. The goal of this systematic review was two prong: identify the association of pediatric weight status and HRQoL and determine how CFRD status impacts HRQoL. METHODS: A systematic review of published research was conducted following the methodology in the Cochrane Handbook on Systematic Reviews for Interventional Studies. Results were reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses. Risk of bias was assessed using the National Heart Lung & Blood Institute tool. A meta-analysis was not performed due to variability of the inclusion/exclusion criteria, differences in outcome reporting, and insufficient primary outcome data to pool. RESULTS: Nine studies met inclusion criteria (n = 6 explored weight status and n = 3 studied CFRD), for a total of 1585 subjects (CFRD cases = 87). Pediatric weight status was positively associated with HRQoL, most commonly the Body Image and Eating Disturbance domains. CFRD was negatively associated with HRQoL, specifically the Treatment Burden and Weight domains. CONCLUSIONS: Based on the limited data available, improved pediatric weight status appears to increase HRQoL while a CFRD diagnosis appears to decrease HRQoL. More research is needed to fully understand the role of these clinical factors on HRQoL, especially with life expectancy increasing among those with CF.

Risk factors for hypertensive crisis in adult patients: a systematic review.

OBJECTIVE: The objective of this review was to examine the best available evidence on the risk factors for hypertensive crisis in adult patients with hypertension. INTRODUCTION: Hypertensive crisis is an acute severe elevation in blood pressure, which can present as hypertensive urgency or emergency. In contrast to hypertensive urgency, which is a markedly elevated blood pressure without acute target organ damage, hypertensive emergency is associated with equally high blood pressure in the presence of potentially life-threatening target organ damage, such as myocardial infarction, stroke, pulmonary edema, or acute kidney injury. Hypertensive crisis results in adverse clinical outcomes and high utilization of health care. INCLUSION CRITERIA: This review considered studies of non-modifiable factors (age, sex, ethnicity) and modifiable factors such as socioeconomic factors (lack of medical insurance, lack of access to medical care), adherence to medical therapies, presence of comorbidities (diabetes, hyperlipidemia, coronary artery disease, history of stroke, chronic kidney disease, congestive heart failure), and substance abuse in persons of either sex, older than 18 years with a diagnosis of hypertension. METHODS: A search of four databases, seven gray literature sites, and relevant organizational websites revealed 11,387 titles. After duplicates were removed, 9183 studies were screened by the title and abstract for eligibility. Forty full-text articles were retrieved, and each was assessed for eligibility. Twenty-one articles were excluded. The remaining 19 full-text studies were critically appraised and included in this review. RESULTS: The risk of hypertensive crisis was higher in patients with a history of comorbid cardiovascular conditions, such as chronic kidney disease (odds ratio [OR] 2.899, 95% confidence interval [CI] 1.32, 6.364), coronary artery disease (OR 1.654, 95% CI 1.232, 2.222), or stroke (OR 1.769, 95% CI 1.218, 2.571). Patients with hypertensive emergency had higher mean systolic blood pressure (mean difference [MD] 2.413, 95% CI 0.477, 4.350) and diastolic blood pressure (MD 2.043, 95% CI 0.624, 3.461). Hypertensive emergency was more common in men (OR 1.390, 95% CI 1.207,1.601), older patients (MD 5.282, 95% CI 3.229, 7.335), and those with diabetes (OR 1.723, 95% CI 1.485, 2.000) and hyperlipidemia (OR 2.028, 95% CI 1.642, 2.505). Non-adherence to antihypertensive medications (OR 0.939, 95% CI 0.647,1.363) and hypertensive diagnosis unawareness (OR 0.807, 95% CI 0.564, 1.154) did not increase the risk of hypertensive emergency. CONCLUSIONS: Comorbid cardiac, renal, and cerebral comorbidities (coronary artery disease, congestive heart failure, cerebrovascular disease, and chronic kidney disease) increase the risk of hypertensive crisis. The risk of hypertensive crisis is higher in patients with unhealthy alcohol and recreational drug use. Systolic and diastolic blood pressure are marginally higher in patients with hypertensive emergency compared to patients with hypertensive urgency. Since these differences are small and not clinically significant, clinicians should rely on other symptoms and signs to differentiate between hypertensive urgency and hypertensive emergency. The risk of hypertensive emergency is higher in older adults. The coexistence of diabetes, hyperlipidemia, and chronic kidney disease increases the risk of hypertensive emergency. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42019140093).

Art of prevention: The importance of dermatologic care when using aromatase inhibitors.

As of January 2021, there are more than 3.8 million women in the United States with a history of breast cancer. The current standard of care for breast cancer involves surgical resection, radiation therapy, adjuvant endocrine therapy, and/or adjuvant chemotherapy. Aromatase inhibitors (AIs) are the gold standard for endocrine therapy in postmenopausal women. Dermatologic adverse events (dAEs) associated with AIs are rare but have been reported in the literature. Commonly reported dAEs include unspecified rash, pruritus, alopecia, vulvovaginal atrophy, vasculitis, and autoimmune/connective tissue disorders. Appropriate preventative strategies and careful management considerations have the potential to optimize the comprehensive care of patients with cancer and improve quality of life. Furthermore, prevention of dAEs can lead to a reduction in cancer treatment interruptions and discontinuations. Herein, we characterize dAEs of AIs and discuss preventative management to reduce the incidence of AI therapy interruption.

Experiences of multiple sclerosis patients with self-management of fatigue: a qualitative systematic review protocol.

OBJECTIVE: The objective of this review is to explore and synthesize the evidence on the experience of self-managing multiple sclerosis fatigue among adult patients. INTRODUCTION: Multiple sclerosis is a growing neurologic auto-immune disease, and fatigue is considered one of the most common and debilitating side effects. Understanding how multiple sclerosis patients experience fatigue, the cause of their fatigue, as well as how they self-manage their fatigue will better inform healthcare providers and patients. INCLUSION CRITERIA: The review will consider qualitative studies investigating the perceptions, experiences and meaning of fatigue associated with multiple sclerosis, the factors contributing to fatigue and the self-management strategies used to control fatigue in adults. Studies that include adult patients diagnosed with multiple sclerosis and experiencing fatigue, regardless of their participation in pharmacological interventions and non-pharmacological interventions, will be included. Any patients with multiple sclerosis residing in hospital-based care or residential in patient care will not be included. METHODS: A three-step search strategy will be utilized in this review. The initial step consists of a limited search in MEDLINE and CINAHL using "multiple sclerosis" and "fatigue" as search terms. Studies will be excluded if they have not been translated into English, but will not be limited by date. Each article will go through a preliminary review based on title and abstract to exclude any articles not pertaining to this study. After the search is completed, two reviewers will individually appraise retrieved qualitative studies for methodological quality prior to inclusion in the review. Findings will be pooled using meta-aggregation, and a ConQual Summary of Findings will be presented.

Multi-dimensional wellness interventions for older adults with serious mental illness: A systematic literature review.

OBJECTIVE: Aging persons with serious mental illness present unique challenges for community mental health services. This population is increasing in numbers in mental health treatment settings. The combination of serious mental illness with the vicissitudes of aging suggest that a broader conceptualization of this population may improve services. SAMHSA's 8 Dimension of Wellness offers a comprehensive strengths-based framework for interventions to maximize older persons' abilities and address the complex bidirectional effects of physical, emotional, social, spiritual, occupational, financial, intellectual, and environmental challenges to wellness. This systemic literature review identifies unidimensional and multidimensional wellness interventions for older adults with mental illness. METHOD: We conducted a systematic literature review to identify wellness interventions provided to persons with serious mental illness with a mean age of 45 or higher. RESULTS: Twenty-six articles representing 14 distinct wellness interventions were identified. None of the articles used SAMHSA's 8 Dimensions of Wellness framework. The physical wellness (n = 21) and social (n = 15) dimensions were the most frequently described in the literature. There was no mention of either the intellectual or spiritual dimensions. The quality of the research of these interventions varied; 14 papers described a randomized controlled trial. CONCLUSIONS: The SAMHSA wellness framework has not been used to design interventions for older persons with serious mental illness. Interventions for aging persons should support comprehensive wellness, including the intellectual and spiritual domains. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effectiveness of provision of animal-source foods for supporting optimal growth and development in children 6 to 59 months of age.

BACKGROUND: Adequate nutrients early in life promote cognitive development and are critical for proper growth and functioning. The effect of individual nutrients consumed through food is often not the same as consuming the same nutrients in supplementary form due to 'food synergy', the biological and chemical interrelations that occur between nutrients. Animal-source foods, such as eggs, meat, fish, and dairy, are energy dense and contain multiple micronutrients and essential fatty acids with high bioavailability. The benefits of animal-source foods may include higher food synergy relative to fortified foods as well as decreasing dependence on external suppliers of fortified foods. OBJECTIVES: To assess the effectiveness of animal-source foods compared to any other feeding interventions or no intervention in improving growth and developmental outcomes in children aged 6 to 59 months. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, 18 other databases, and three trials registers up to August 2018. We also contacted authors and known experts in the field for assistance in identifying ongoing or unpublished data, and searched the reference lists of included studies and reviews, and websites of relevant organizations, for other studies that may not have been captured by our electronic searches. SELECTION CRITERIA: We included randomized controlled trials and quasi-randomized controlled trials of any duration, where children between 5 months and 59 months (6 years) of age were provided with an animal-source food (e.g. consumption of milk, meat, or eggs), prepared with any cooking method, compared with any intervention or no intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility using prespecified criteria, extracted data, assessed risk of bias, and graded the quality of the evidence using the GRADE approach. MAIN RESULTS: Study characteristicsWe included 6 studies that analyzed data from 3036 children aged 5 to 50 months. The studies were conducted in China, the Democratic Republic of Congo, Ecuador, Guatemala, Pakistan, the USA, and Zambia, and lasted between 5 and 12 months. Three studies were funded, in part, by government entities; one study was supported by a nonprofit organization. Two studies did not report a funding source.Three studies compared the effects of feeding an animal-source food with a fortified (iron or iron and zinc), or unfortified cereal; two used a control group with no intervention; one compared a meat-based diet to a dairy-based diet. The types of animal-source foods tested included yogurt, eggs, cheese, lyophilized (freeze-dried) beef product, ground and frozen pork, puréed and jarred beef with gravy or pork, and powdered whey protein.We judged four studies to be at unclear risk of bias overall; three studies because they were funded by an industry with a plausible interest in the outcome of the intervention; and one study because there was insufficient information to assess five of the seven bias 'Risk of bias' domains. We judged two of the six studies to be at high risk of bias overall; one study because there was significant baseline imbalance in length-for-age z scores (LAZ) between groups and evidence of selective reporting; the other study because there there was both a significant baseline imbalance in LAZ and weight-for-age z scores (WAZ) between groups, and a large-scale social media campaign that may have influenced care received at home in the control group.Key resultsAnimal-source foods versus cereal-based foods or no interventionFive studies (2972 children) measured change in linear growth with either height-for-age z scores (HAZ) or LAZ. Three studies (592 children) reported a significant increase in HAZ and LAZ in the intervention group compared to the control group. Two studies (2380 children) reported a decline in LAZ in both groups. In one study (1062 children) there was no difference between the groups in the rate of decline; in the other (1318 children) the decrease in LAZ was significantly smaller in the intervention group.Five studies (2972 children) measured weight gain using WAZ. Three studies (592 children) reported a significant increase in WAZ in the intervention group compared to the control group. In two studies (2380 children), WAZ decreased in both groups. In one of these studies (1318 children), the decrease in the intervention group was significantly smaller than in the control group. In the other study (1062 children), there was no difference between the groups.Three studies (1612 children) reported impacts on all-cause morbidity, but metrics were inconsistent between studies. One study with yogurt (402 children) reported a significant reduction in duration and incidence of diarrhea and upper respiratory infections in the intervention group. One study with eggs (148 children) reported a significant increase in the incidence of diarrhea in the intervention group, but this may have been due to cultural associations with eggs and gastrointestional problems. There were no other significant differences in fever, respiratory infections, or skin conditions between groups. The third study (1062 children) found no differences between intervention and control groups across morbidity measures.No studies reported data on anemia.Meat-based diet versus dairy-based dietOne study (64 children) measured change in LAZ and WAZ in infants fed either a meat-based diet or dairy-based diet. There was a significant increase in LAZ among infants consuming the meat-based diet and a significant decrease in LAZ among infants consuming a dairy-based diet. WAZ increased in both groups, with no significant difference between groups.The study did not assess all-cause morbidity or anemia.Quality of the evidenceWe rated the quality of the evidence as very low overall due to baseline imbalances between intervention and control groups, high heterogeneity in meta-analysis, and imprecision due to wide confidence intervals and inconsistent direction of effects. We have little confidence in the results; further research is likely to change the estimate of magnitude and direction of treatment effect. AUTHORS' CONCLUSIONS: Given the limited quality of the evidence, we are uncertain of the effects of the provision of animal-source food versus cereal products or no intervention on the growth or development of children. More adequately powered trials with deliberately selected animal-source foods are needed.

CE: Original Research: Recognizing Delirium in Hospitalized Children: A Systematic Review of the Evidence on Risk Factors and Characteristics.

: Purpose: The purpose of this study was to examine the evidence regarding the risk factors for and characteristics of acute pediatric delirium in hospitalized children. METHODS: The systematic review method within an epidemiological framework of person, place, and time was used. Fifty-two studies were selected for initial retrieval. Of these, after assessment for methodological quality, 21 studies involving 2,616 subjects were included in the review. RESULTS: Findings revealed five primary characteristics seen in children experiencing delirium: agitation, disorientation, hallucinations, inattention, and sleep-wake cycle disturbances. Children who were more seriously ill, such as those in a pediatric ICU (PICU) and those with a high Pediatric Risk of Mortality II (PRISM II) score, and children who were mechanically ventilated were at greater risk for development of delirium. Those with a developmental delay or a preexisting anxiety disorder were also more prone to delirium. Although delirium symptoms fluctuate, most episodes occurred at night. Boys were slightly more susceptible than girls, though this difference was not significant. A key finding of this review was that delirium is multifactorial, related to treatment (mechanical ventilation, for example) and to a hospital environment (such as a PICU) that deprives patients of normal sleep-wake cycles and familiar routines. CONCLUSION: These findings will be useful in efforts to achieve earlier recognition and better management or prevention of pediatric delirium. This may also help to prevent unnecessary laboratory testing and imaging studies, which can cause children and parents unnecessary pain and anxiety and increase hospital costs.

The Effectiveness of Computer-Assisted Instruction to Teach Physical Examination to Students and Trainees in the Health Sciences Professions: A Systematic Review and Meta-Analysis.

PURPOSE: To explore knowledge and skill acquisition outcomes related to learning physical examination (PE) through computer-assisted instruction (CAI) compared with a face-to-face (F2F) approach. METHOD: A systematic literature review and meta-analysis published between January 2001 and December 2016 was conducted. Databases searched included Medline, Cochrane, CINAHL, ERIC, Ebsco, Scopus, and Web of Science. Studies were synthesized by study design, intervention, and outcomes. Statistical analyses included DerSimonian-Laird random-effects model. RESULTS: In total, 7 studies were included in the review, and 5 in the meta-analysis. There were no statistically significant differences for knowledge (mean difference [MD] = 5.39, 95% confidence interval [CI]: -2.05 to 12.84) or skill acquisition (MD = 0.35, 95% CI: -5.30 to 6.01). CONCLUSIONS: The evidence does not suggest a strong consistent preference for either CAI or F2F instruction to teach students/trainees PE. Further research is needed to identify conditions which examine knowledge and skill acquisition outcomes that favor one mode of instruction over the other.