The predictive value of infrared thermal imaging (IRT) for peripheral artery disease: A systematic review.

BACKGROUND: Medical infrared thermal imaging (IRT) has been applied to research blood flow, breast cancer detection, and human body muscle performance. The benefits of IRT include the fact that it is noninvasive, quick, dependable, non-contact, capable of creating several recordings in a short period of time, and secure for both patients and medical professionals. We aimed to determine the predictive value of IRT for identifying and evaluating any interventional procedure in patients affected by peripheral artery disease (PAD) of any severity. METHODS: We searched the Cochrane Library, EMBASE, and PubMed on the topic of IRT and PAD until January 20,2023. We excluded gray literature as it is lacking credibility for not undergoing a peer-reviewed process. The search strategy includes the medical topic headings for "infrared thermal imaging" and "peripheral vascular disorders." The primary outcome of this systematic review was the variation in tissue perfusion in PAD patients. Each technique's technical characteristics and therapeutic use within PAD must be described in each included study. RESULTS: This systematic review included 2 case reports and 3 observational studies. By comparing the temperatures of PAD patients hands, legs, and feet, IRT might prove to be an unduly valuable tool for treating vascular illnesses, especially in light of the knowledge gained from the temperature distribution maps. CONCLUSION: This noninvasive method demonstrated encouraging results in the detection of various areas of foot perfusion and the screening of PAD, and it gave good findings in gauging the effects of any type of intervention.

Chronic wounds in a multiethnic Asian population: a cost of illness study.

OBJECTIVE: To estimate the 'cost of illness' arising from chronic wounds in Singapore. DESIGN: Incidence-based cost of illness study using evidence from a range of sources. SETTING: Singapore health services. PARTICIPANTS: We consider 3.49 million Singapore citizens and permanent residents. There are 16 752 new individuals with a chronic wound in 2017, with 598 venous ulcers, 2206 arterial insufficiency ulcers, 6680 diabetic ulcers and 7268 pressure injuries.Primary outcome measures expressed in monetary terms are the value of all hospital bed days lost for the population; monetary value of quality-adjusted life years (QALYs) lost in the population; costs of all outpatient visits; and costs of all poly clinic, use of Community Health Assist Scheme (CHAS) and emergency departments (EDs) visits. Intermediate outcomes that inform the primary outcomes are also estimated. RESULTS: Total annual cost of illness was $350 million (range $72-$1779 million). With 168 503 acute bed days taken up annually (range 141 966-196 032) that incurred costs of $139 million (range 117-161 million). Total costs to health services were $184 million (range $120-$1179 million). Total annual costs of lost health outcomes were 2077 QALYs (range -2657 to 29 029) valued at $166 million (range -212 to 2399 million). CONCLUSIONS: The costs of chronic wounds are large to Singapore. Costs can be reduced by making positive investments for comprehensive wound prevention and treatment programmes.

Drug allergy knowledge, attitude, and practice: A survey among doctors and pharmacists in public health facilities of Sabah, Malaysia.

Background: Given the deficits in allergists and testing capacity, the diagnosis of drug allergy is largely dependent on the clinician's and pharmacist's judgment. The ability to recognize drug allergies and respond appropriately is crucial to patient safety. Currently, there is a void in the evidence that limits the ability to recommend comprehensive and swift improvements on this front. Objective: This study thus aimed to evaluate the knowledge, attitude, and practice toward drug allergy among doctors and pharmacists working in public healthcare facilities in Sabah, Malaysia. Methods: This cross-sectional study was conducted in 24 hospitals and 11 clinics in Sabah. A validated Drug Allergy Knowledge, Attitude, and Practice Questionnaire was adapted from a published study and developed on an online survey platform. The questionnaire was distributed to all listed eligible respondents via email and personal messenger service. Results: A total of 549 doctors and pharmacists responded, with an overall response rate of 18.2%. The total mean knowledge, attitude, and practice scores were 8.3 (SD, 1.98), 18.9 (SD, 2.55), and 17.3 (SD, 4.4), respectively. It was found that pharmacists performed significantly poorer than both medical officers (mean score difference = -0.5; P = 0.006) and specialists (mean score difference = -0.9; P = 0.020) in the knowledge domain. As the time in service doubles, the knowledge score increases significantly by 0.3 (P = 0.015). Conclusion: Knowledge, attitude, and practice on drug allergy among doctors and pharmacists in Sabah were poor. It is thus timely for advanced educational programs on drug allergy to be formalized and implemented.

A prospective study on the wound healing and quality of life outcomes of patients with venous leg ulcers in Singapore-Interim analysis at 6 month follow up.

Venous leg ulceration results in significant morbidity. However, the majority of studies conducted are on Western populations. This study aims to evaluate the wound healing and quality of life for patients with venous leg ulcers (VLUs) in a Southeast Asian population. This is a multi-centre prospective cohort study from Nov 2019 to Nov 2021. All patients were started on 2- or 4-layer compression bandage and were reviewed weekly or fortnightly. Our outcomes were wound healing, factors predictive of wound healing and the EuroQol 5-dimensional 5-level (EQ-5D-5L) health states. Within our cohort, there were 255 patients with VLU. Mean age was 65.2 ± 11.6 years. Incidence of diabetes mellitus was 42.0%. Median duration of ulcer at baseline was 0.30 years (interquartile range 0.136-0.834). Overall, the median time to wound healing was 4.5 months (95% confidence interval [CI]: 3.77-5.43). The incidence of complete wound healing at 3- and 6-month was 47.0% and 60.9%, respectively. The duration of the wound at baseline was independently associated with worse wound healing (Hazard ratio 0.94, 95% CI: 0.89-0.99, P = .014). Patients with healed VLU had a significantly higher incidence of perfect EQ-5D-5L health states at 6 months (57.8% vs 13.8%, P < .001). We intend to present longer term results in subsequent publications.

Using a reduced-order model to investigate the effect of the heart rate on the aortic dissection.

The computational cost of a three-dimensional (3D) fluid-structure interaction (FSI) simulation of a dissected aorta has prevented researchers from investigating the effect of a wide range of the heart rate on the hemodynamic quantities in the disease. We have presented a systematic procedure to develop a zero-dimensional (0D) model for a dissected aorta. A series of numerical experiments were used to calculate the values for the resistance, inertance, and compliance of each lumen with irregular geometries. Having validated the results from the 0D model against those from the 3D model for one heart rate, we used the 0D model to investigate the effect of the heart rate of 50-150 bpm on the flow rates and the pressures in an idealized geometry of an aortic dissection. The 0D model showed acceptable accuracy when compared with the 3D FSI simulation. For instance, at peak systole, 7.18% relative error in the flow rate in the true lumen was observed for 0D and 3D simulations. The flow rate in the true lumen showed a stronger dependency on the heart rate, that is, 300% for the true lumen and 1.5% for the false lumen. The pressure difference between the lumina increased non-monotonically as the heart beats faster. Because of its efficiency, the reported procedure can be used for uncertainty and sensitivity analysis of the hemodynamic quantities in a diseased aorta with complex geometries such as that of the aortic dissection.

SIroliMus coated angioPlasty versus plain balloon angioplasty in the tREatment of dialySis acceSs dysfunctION (IMPRESSION): study protocol for a randomized controlled trial.

BACKGROUND: Percutaneous transluminal angioplasty is the current standard treatment for arteriovenous fistula (AVF) stenosis. The mid- and long-term patency with plain balloon angioplasty (PBA) is however far from satisfactory. While paclitaxel-coated balloon angioplasty has been shown to be superior to PBA, concern over its safety profile has recently arisen after a reported possible increased mortality risk with a meta-analysis of large lower limb studies. An angioplasty balloon with a new type of drug coating, the sirolimus-coated balloon (SCB), has been proven to improve patency in the coronary arteries. However, its effect on AV access has yet to be studied. METHODS/DESIGN: This is an investigator-initiated, prospective, multicenter, double-blinded, randomized controlled clinical trial to assess the effectiveness of SCB compared to PBA in improving the patency of AVF after angioplasty. A total of 170 patients with mature AVF that requires PTA due to AVF dysfunction will be randomly assigned to treatment with a SCB or PBA at a 1:1 ratio, stratified by location of AVF and followed up for up to 1 year. The inclusion criteria include [1] adult patient aged 21 to 85 years who requires balloon angioplasty for dysfunctional arteriovenous fistula [2]; matured AVF, defined as being in use for at least 1 month prior to the angioplasty; and [3] successful angioplasty of the underlying stenosis with PBA, defined as less than 30% residual stenosis on digital subtraction angiography (DSA) and restoration of thrill in the AVF on clinical examination. The exclusion criteria include thrombosed or partially thrombosed access circuit at the time of treatment, presence of symptomatic or angiographically significant central vein stenosis that requires treatment with more than 30% residual stenosis post angioplasty, and existing stent placement within the AVF circuit. The primary endpoint of the study is access circuit primary patency at 6 months. The secondary endpoints are target lesion primary patency; access circuit-assisted primary patency; access circuit secondary patency at 3, 6, and 12 months; target lesion restenosis rate at 6 months; total number of interventions; complication rate; and cost-effectiveness. The trial is supported by Concept Medical. DISCUSSION: This study will evaluate the clinical efficacy and safety of SCB compared to PBA in the treatment of AVF stenosis in hemodialysis patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT04409912 . Registered on 1 June 2020.

Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment.

INTRODUCTION: In the USA over 30% of medication errors occur at the point of administration. Among non-surgical patients in US hospitals exposed to opioids, 0.6% experience a severe opioid-related adverse event. In September 2018, Sierra View Medical Center identified two areas of opportunity for quality improvement: bedside bar code medication administration (BCMA) and pain reassessments. At baseline (April 2018 to September 2018) only 81% of medications were scanned prior to administration with pain reassessments completed only 41% of the time 1 hour postopioid administration. OBJECTIVE: To improve BCMA scanning rates (goal ≥95%) and pain reassessments within 1 hour postopioid administration (goal ≥90%). METHODS: Implementation methods included data transparency, weekly dashboards, education and plan-do-study-act (PDSA) cycles informed by feedback from key stakeholders. RESULTS: Following a series of PDSA cycle implementations, barcode medication administration (BCMA) scanning rates improved by 14% (from 81% to 95%) and pain reassessments improved by 50% (from 41% to 91%), sustained 17 months postproject implementation (October 2018 to February 2019). The number of adverse drug events (ADEs) related to administration errors decreased by 17% (estimated annual cost savings of $120 750-239 725 per year) and opioid-related ADEs decreased by 2.6% (estimated annual cost savings of $72 855-80 928 per year). CONCLUSION: Adopting John Kotter's model for change, developing performance dashboards and sustaining engagement among stakeholders on a weekly basis improved bar code medication scanning rates and pain reassessment compliance. The stakeholders created momentum for change in both practice and culture resulting in improved patient safety with a favourable financial impact.

The effect of the entry and re-entry size in the aortic dissection: a two-way fluid-structure interaction simulation.

Aortic dissection (AD) is one of the most catastrophic cardiovascular diseases. AD occurs when a layer inside the aorta is disrupted and gives rise to the formation of a true lumen and a false lumen. These lumens can be connected through tears in the intimal flap which are known as entries. Despite being known for about two centuries, the effects of many factors on the morbidity and mortality of this disease are still unknown. As the blood interaction with the aorta is crucial in the severity and the progression of the aortic dissection, a biomechanical approach is chosen to investigate the influence of different morphologies on the severity of this disease. Using the finite element method (FEM) and the fluid-structure interaction (FSI) approach, we have evaluated the blood flow characteristics along the diseased aorta, in conjunction with the deformation of the aortic wall. In this study, an idealized geometry of a dissected descending aorta (type B) with two entries has been studied. The values for the diameter of the entry tear were chosen to be 5 mm and 10 mm. Therefore, a total of four conditions were investigated. According to our results, the retrograde flow through the proximal tear is dependent on the size of the distal re-entry and vice versa. Our results revealed that when both entry and re-entry tears are 10 mm in diameter, the flow passes through the true and false lumens with smaller resistance, resulting in a smaller flutter of the intimal flap, and therefore more stable intimal flap. Major oscillation frequencies of 2.5 Hz and 7.4 Hz were observed for the oscillation of the intimal flap, and amplitudes of the waves with higher frequencies were negligible.

Integrating patient-centric indications into the prescribing process: Experience at a tertiary academic medical center.

PURPOSE: To describe the development of and implementation of a patient-centric clinical indications library (CIL) into the prescribing process and determine the operational and humanistic outcomes (from prescriber, pharmacist, and patient perspectives) of including indications on outpatient prescription labels. METHODS: A descriptive retrospective data analysis was conducted. Multiple stakeholder groups were engaged to develop and integrate the CIL into the prescription package. After CIL integration, prescribers, pharmacists, and patients were surveyed. A focus group discussion consisting of Veterans and caregivers was held. RESULTS: Following implementation of the CIL, the proportion of prescriptions associated with an indication increased from 88% to 96%. Surveyed clinicians responded that indications helped them better understand a patient's profile (61.1% of prescribers and 100% of pharmacists). Among surveyed pharmacists, 61.5% and 53.8%, respectively, believed that indications helped them catch instances of wrong medications and wrong doses ordered. Veterans surveyed found that indications on their prescription labels helped them know what their medications were for (91.0% of respondents) and why it is important to take their medications (70.7%). In focus group discussions, Veterans and family members and/or caregivers expressed a preference to see indications that describe how a medication works (eg, "to lower blood sugar" vs "for diabetes") because they felt that type of phrasing is measurable, action oriented (which was appealing due to Veterans' military background), provides surreptitious education, and tells the users what to expect. CONCLUSION: Engaging multidisciplinary stakeholder groups, optimizing the electronic health record system, and authorizing pharmacists to add known indications to prescriptions increased the number of prescriptions with indications, decreased the perceived time spent on order entry and verification, and enabled better understanding of each medication's purpose by providers and patients.

Treatment of tricuspid valve endocarditis with daptomycin and linezolid therapy.

PURPOSE: A case report of the use of linezolid and daptomycin for the treatment of multidrug-resistant right-sided infective endocarditis is presented. SUMMARY: A 36-year-old patient with a history of intravenous drug use was hospitalized for treatment of native tricuspid valve endocarditis resulting in persistent methicillin-resistant Staphylococcus aureus bacteremia. During the admission the patient was unsuccessfully treated with vancomycin monotherapy (final E-test minimum inhibitory concentration, 4 µg/mL). The patient's treatment was switched to daptomycin and gentamicin, with no improvement in blood culture results over 4 days. Gentamicin was discontinued, and linezolid was administered in combination with daptomycin; bacteremia was cleared after 13 days of linezolid and daptomycin combination therapy. Due to daptomycin resistance (minimum inhibitory concentration, 4 µg/mL), gentamicin was substituted for daptomycin due to the former agent's synergistic effects with linezolid. After 23 days of therapy the patient was transferred to another facility for a tricuspid valve replacement procedure, which was completed without complications. The patient was transferred in stable condition to a skilled nursing facility to continue antibiotic therapy lasting 6 weeks from the date of surgery. The patient's blood cultures remained negative. CONCLUSION: A 36-year-old woman with resistant tricuspid valve endocarditis was successfully treated with linezolid in combination with daptomycin.

Coccidioidal Meningitis: A Review on Diagnosis, Treatment, and Management of Complications.

PURPOSE OF REVIEW: This article summarizes the diagnosis and treatment of coccidioidal meningitis (CM) and its complications. An overview of current and prospective pharmacologic treatment options and monitoring parameters is provided. A consensus has not been reached regarding universally accepted therapeutic serum levels for azoles because of insufficient evidence. We describe the preferred therapeutic drug level ranges that our institution uses to monitor azole therapy. RECENT FINDINGS: Ho et al. described the preparation and administration of intrathecally delivered amphotericin B deoxycholate. Thompson et al. described possible benefits of controversial adjuvant corticosteroid therapy for secondary prevention of vasculitic infarction secondary to CM. CM was universally fatal until the advent of intrathecal amphotericin B deoxycholate therapy, the introduction of which changed the natural history of the disease in much the same way as penicillin changed the natural history of bacterial meningitis. Although there was still significant morbidity, survival rates drastically increased to approximately 70%. The introduction of azole therapy has decreased the side effects and burden of treatment but without a significant change in CM-related mortality and morbidity compared with the use of intrathecal amphotericin B deoxycholate therapy.

Relationship Between Grit with Academic Performance and Attainment of Postgraduate Training in Pharmacy Students.

Objective. To determine if Grit-S scores correlate with academic success in a doctor of pharmacy (PharmD) program, as well as the pursuit and attainment of pharmacy postgraduate (residency or fellowship) training. Methods. A 28-item survey was administered to third- and fourth-year (P3 and P4) pharmacy students. Variables queried included Grit-S score, demographics, pharmacy experience prior to the PharmD program, and factors that may affect academic performance during didactic coursework. Didactic coursework GPA was used as a surrogate for academic success. Information about pursuit and attainment of a postgraduate training position was also documented and used in the analyses. Results. There was no significant correlation between Grit-S scores and variables related to academic success. However, students were more likely to pursue postgraduate training with higher academic success and higher Grit-S. Lastly, students with higher Grit-S were also more likely to obtain a postgraduate training position. Conclusion. Grit-S scores correlated with the pursuit and successful attainment of postgraduate training, but not with academic success during the didactic years of a PharmD program.

Intrathecal Amphotericin B: A 60-Year Experience in Treating Coccidioidal Meningitis.

Coccidioidal meningitis (CM) is a devastating complication of coccidioidomycosis. Since the late 1950s, intrathecal (IT) amphotericin B deoxycholate (AmBd) has been successfully used to treat and often cure this disease, reducing mortality rates from 100% to approximately 30%. The introduction of azoles further revolutionized the treatment of coccidioidal infections. However, IT AmBd remains the only known curative option in the management of CM. While the use of IT AmBd is well described in many articles, few discuss the actual methods behind preparation, titration, and dosing strategies utilized. The practitioners at Kern Medical (Bakersfield, California) have >60 years of experience in the utilization of IT AmBd and the treatment of CM. This article describes the practice experience in the treatment of CM, preparation of IT AmBd, and the different dosing strategies used in regard to route of administration (ie, cisternal, lumbar, ventricular).

Treatment of Polymicrobial Osteomyelitis with Ceftolozane-Tazobactam: Case Report and Sensitivity Testing of Isolates.

Stenotrophomonas maltophilia is an inherently multidrug resistant (MDR) opportunistic pathogen with many mechanisms of resistance. SENTRY studies reveal decreasing sensitivities of S. maltophilia to trimethoprim-sulfamethoxazole and fluoroquinolones. Ceftolozane-tazobactam (Zerbaxa, Merck & Co., Inc.) a novel intravenous combination agent of a third-generation cephalosporin and ß-lactamase inhibitor was demonstrated to have in vitro activity against many Gram-positive, Gram-negative, and MDR organisms. Data for ceftolozane-tazobactam's use outside of Food and Drug Administration (FDA) approved indications has been limited thus far to two case reports which demonstrated its efficacy in pan-resistant Pseudomonas aeruginosa pneumonia. Herein, we describe the first published case of treatment of MDR S. maltophilia in polymicrobial osteomyelitis with long-term (>14 days) ceftolozane-tazobactam and metronidazole. Ceftolozane-tazobactam may offer a possible alternative for clinicians faced with limited options in the treatment of resistant pathogens including MDR S. maltophilia.

Submillimeter Diameter Poly(Vinyl Alcohol) Vascular Graft Patency in Rabbit Model.

Microvascular surgery is becoming a prevalent surgical practice. Replantation, hand reconstruction, orthopedic, and free tissue transfer procedures all rely on microvascular surgery for the repair of venous and arterial defects at the millimeter and submillimeter levels. Often, a vascular graft is required for the procedure as a means to bridge the gap between native arteries. While autologous vessels are desired for their bioactivity and non-thrombogenicity, the tedious harvest process, lack of availability, and caliber or mechanical mismatch contribute to graft failure. Thus, there is a need for an off-the-shelf artificial vascular graft that has low thrombogenic properties and mechanical properties matching those of submillimeter vessels. Poly(vinyl alcohol) hydrogel (PVA) has excellent prospects as a vascular graft due to its bioinertness, low thrombogenicity, high water content, and tunable mechanical properties. Here, we fabricated PVA grafts with submillimeter diameter and mechanical properties that closely approximated those of the rabbit femoral artery. In vitro platelet adhesion and microparticle release assay verified the low thrombogenicity of PVA. A stringent proof-of-concept in vivo test was performed by implanting PVA grafts in rabbit femoral artery with multilevel arterial occlusion. Laser Doppler measurements indicated the improved perfusion of the distal limb after implantation with PVA grafts. Moreover, ultrasound Doppler and angiography verified that the submillimeter diameter PVA vascular grafts remained patent for 2 weeks without the aid of anticoagulant or antithrombotics. Endothelial cells were observed in the luminal surface of one patent PVA graft. The advantageous non-thrombogenic and tunable mechanical properties of PVA that are retained even in the submillimeter diameter dimensions support the application of this biomaterial for vascular replacement in microvascular surgery.

Association of ABC (HbA1c, blood pressure, LDL-cholesterol) goal attainment with depression and health-related quality of life among adults with type 2 diabetes.

AIMS: To determine the relationship between ABC goal attainment, depression, and health-related quality of life (HRQoL) among a national sample of patients with type 2 diabetes (T2DM). METHODS: A retrospective, cross-sectional analysis was performed examining 808 non-pregnant patients ≥20 years old with T2DM from the National Health and Nutrition Examination Survey (NHANES) 2007-2012. ABC goals were defined as HbA1c<7%, BP<130/80 mm Hg, and LDL-C<100 mg/dL. Patient characteristics associated with ABC goal attainment were examined. RESULTS: Overall, 23.7% of participants achieved simultaneous ABC goals. Severe depression was significantly associated with lower rates of ABC goal attainment compared to those with no depression (5.0% vs. 25.4%, p=0.048). ABC goal attainment rates were lower among females, Hispanic and non-Hispanic black minority groups, and patients with a duration of diabetes over five years, while increased visits with health care professionals were significantly associated with meeting all three ABC goals for patients with T2DM. CONCLUSIONS: The relationship between simultaneous ABC goal attainment, depression and HRQoL is complex. Patients with T2DM unable to meet ABC goals may benefit from increased contact with health care professionals.

Implementation of an accelerated physical examination course in a doctor of pharmacy program.

OBJECTIVE: To describe the implementation of a 1-day accelerated physical examination course for a doctor of pharmacy program and to evaluate pharmacy students' knowledge, attitudes, and confidence in performing physical examination. DESIGN: Using a flipped teaching approach, course coordinators collaborated with a physician faculty member to design and develop the objectives of the course. Knowledge, attitude, and confidence survey questions were administered before and after the practical laboratory. ASSESSMENT: Following the practical laboratory, knowledge improved by 8.3% (p<0.0001). Students' perceived ability and confidence to perform a physical examination significantly improved (p<0.0001). A majority of students responded that reviewing the training video (81.3%) and reading material (67.4%) prior to the practical laboratory was helpful in learning the physical examination. CONCLUSION: An accelerated physical examination course using a flipped teaching approach was successful in improving students' knowledge of, attitudes about, and confidence in using physical examination skills in pharmacy practice.

Insulin-like growth factors inhibit podocyte apoptosis through the PI3 kinase pathway.

BACKGROUND: Abnormal podocyte development and progressive podocyte injury have been implicated in a number of human kidney diseases. Factors necessary for regulating development and maintenance of this cell type are only beginning to emerge. METHODS: To study the role of the insulin-like growth factor (IGF) system in regulating podocyte survival, we induced human fetal podocytes to undergo apoptosis. We demonstrated a significant increase in apoptosis when these cells were incubated in the presence of etoposide, as measured by DNA fragmentation and nuclear membrane condensation and blebbing. RESULTS: Podocyte apoptosis was reduced to control levels when the cells were coincubated in the presence of IGF-1. We showed that the protective effect of IGFs in this cell type was mediated through the activation of the phosphatidylinositol 3'-kinase (PI3K) pathway. IGF-1 stimulation resulted in the formation of the insulin receptor substrate (IRS)-1-p85 complex, an increase in PI3 kinase activity, and activation of protein kinase B (AKT/PKB) and the bcl-2 family member bad. Incubation of the podocytes with inhibitors of the PI3 kinase pathway resulted in a loss of this IGF-1 protective effect. CONCLUSION: These data demonstrate an important role for the IGF system in fetal podocyte survival in vitro, and suggest potential mediators to slow or alleviate the loss or damage of the podocyte in progressive renal disease.