Steroid-sparing effects and acceptability of a new skin gel containing the anti-inflammatory medicinal substance-nicotinamide.

Background/aim: Adex gel (DENI) is a leave-on emollient, containing an ancillary anti-inflammatory medicinal substance, nicotinamide, for use in the treatment and management of dry skin conditions prone to inflammation. The aim of the study was to obtain patients' and a Medical Investigator's feedback on the clinical performance and acceptability of the product, and to assess the product's potential for reducing patients' reliance on topical corticosteroids and immunomodulators. Methods: Forty-eight patients were enrolled with 43 patients completing the study. These patients used the product on its own, or as adjunctive therapy, for two weeks instead of their usual emollient, applying it three times daily or more often if necessary. Using a questionnaire, subjects then indicated whether they were in agreement or not with various statements about the clinical performance and acceptability of the product. In the second part of the study, twenty patients used the product for four weeks, this time using it as often as they liked. The Medical Investigator looked at both the performance and the acceptability of the treatment. Patients completed a questionnaire again to indicate how they used it and whether their use of topical corticosteroids and/or immunomodulator treatments had changed. Results: Patient's responses were very positive, ranging from 81% to 100% agreement with each performance statement in relation to beneficial effects on the skin. The Medical Investigator considered that for nearly all patients, DENI gel was a helpful and convenient addition to their treatment regime. When questioned on steroid-sparing effects, more than half reported that they needed to use less of their other anti-inflammatory treatments, and nearly 95% reported that they felt their skin condition had benefited from using DENI gel. Conclusion: This new anti-inflammatory emollient appears to be a helpful addition to the treatment armamentarium for eczema and psoriasis that may reduce reliance on topical corticosteroids and immunomodulators.

Rescue therapy for hypercapnia due to high PEEP mechanical ventilation in patients with ARDS and renal failure.

Extracorporeal removal of carbon dioxide in patients experiencing severe hypercapnia due to lung protective mechanical ventilation was first described over four decades ago. There have been many devices developed and described in the interim, many of which require additional training, resources, and staff. This manuscript describes a readily available and relatively simple adjunct that can provide partial lung support in patients with acute respiratory distress syndrome complicated by severe hypercapnia and acute kidney injury requiring dialysis.

The Impact of an Advanced ECMO Program on Traumatically Injured Patients.

In June 2016, an advanced extracorporeal membrane oxygenation (ECMO) program consisting of a multidisciplinary team was initiated at a large level-one trauma center. The program was created to standardize management for patients with a wide variety of pathologies, including trauma. This study evaluated the impact of the advanced ECMO program on the outcomes of traumatically injured patients undergoing ECMO. A retrospective cohort study was performed on all patients sustaining traumatic injury who required ECMO support from January 2014 to September 2017. The primary outcome was to determine survival in trauma ECMO patients in the two timeframes, before and after initiation of the advanced ECMO program. Secondary outcomes included complication rates, length of stay, ventilator usage, and ECMO days. One hundred and thirty eight patients were treated with ECMO during the study period. Of the 138 patients, 22 sustained traumatic injury. Seven patients were treated in our pre-group and 15 in our post-group. The majority of patients were treated with VV ECMO. Our post group VV ECMO extracorporeal survival rate was 64% and our survival to discharge was 55%. This study demonstrated an improvement in survival after implementation of our advanced ECMO program. The implementation of a multidisciplinary trauma ECMO team dedicated to the rescue of critically ill patients is the key for achieving excellent outcomes in the trauma population.

The Use of Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome in Severe Burns Without Inhalation Injury.

Burn injury results in a severe systemic inflammatory response which is associated with the development of acute respiratory distress syndrome (ARDS), even without associated inhalation injury. Venous-venous extracorporeal membrane oxygenation (VV-ECMO) has been implemented in various cases of ARDS to provide support and allow for protective lung ventilation strategies. We report the case of a 27-year-old man presenting with a 60% total body surface area partial thickness burn who developed refractory ARDS with Murray Score of 3.75. ECMO was initiated on hospital day 9 for a total of 10 days with concurrent lung-protective ventilation. He subsequently recovered and was discharged on hospital day 48. ECMO should be considered as an adjunctive strategy in burn patients without inhalation injury to minimize ventilator-induced lung injury when high levels of support are needed to achieve adequate ventilation in patients with ARDS.

A Weaning Protocol for Venovenous Extracorporeal Membrane Oxygenation With a Review of the Literature.

Several articles have discussed the weaning process for venoarterial extracorporeal membrane oxygenation; however, there is no published report to outline a standardized approach for weaning a patient from venovenous extracorporeal membrane oxygenation (ECMO). This complex process requires an organized approach and a thorough understanding of ventilator management and ECMO physiology. The purpose of this article is to describe the venovenous ECMO weaning protocol used at our institution as well as provide a review of the literature.

Effectiveness of a Perioperative Transthoracic Ultrasound Training Program for Students and Residents.

OBJECTIVE: Focused ultrasound (US) is being incorporated across all levels of medical education. Although many comprehensive US courses exist, their scope is broad, requiring expert instructors, access to simulation, and extensive time commitment by the learner. We aim to compare learning across levels of training and specialties using a goal-directed, web-based course without live skills training. DESIGN: A prospective observational study of students and residents from medicine, surgery, and anesthesiology. Analysis compared pretests and posttests assessing 3 competencies. Individual mean score improvement (MSI) was compared by paired-sample t-tests and MSI among cohorts by analysis of variance, with significance set at p ≤ 0.05. McNemar test compared those who agreed or strongly agreed with survey items with those who did not before and after intervention. SETTING: Jackson Memorial Hospital, Miami, FL residency training programs in Medicine, Surgery, and Anesthesiology. RESULTS: A total of 180 trainees participated. A significant MSI was noted in each of 3 competencies in all 3 cohorts. Students' (S) MSI was significantly higher than residents' (R) and interns' (I) in US "knobology" and window recognition [S = 2.28 ± 1.29/5 vs R = 1.63 ± 1.21/5 (p = 0.014); vs I = 1.59 ± 1.12/5 (p = 0.032)]; students' total score MSI was significantly higher than residents [7.60 ± 3.43/20 vs 5.78 ± 3.08/20 (p < 0.008)]. All cohorts reported improved comfort in using transthoracic US and improved ability to recognize indications for use. More than 81% of all participants reported improved confidence in performing transthoracic US; more than 91% reported interest in additional training; and more than 88% believed course length was appropriate. CONCLUSIONS: Learners across levels of medical training and specialties can benefit from a brief, goal-directed, web-based training with early incorporation producing maximal yield.

Emollient efficacy and acceptability in the treatment of eczematous dry skin: A double-blind, randomised comparison of two UK-marketed products.

OBJECTIVE: The aim of this study was to compare the moisturising efficacy and acceptability of physical characteristics of two commonly prescribed emollients licenced in the UK, Doublebase Dayleve gel (DELP) and Diprobase cream (DIPC). METHODS: The study was a double-blind, concurrent bi-lateral comparison in female eczema subjects with dry skin. RESULTS: In Part 1, comparing the area under the curve (AUC) change from baseline corneometer readings over 24 h following single applications of the emollients to the volar forearms of 34 subjects, the AUC for DELP was more than three times that seen for DIPC (p < 0.0001). In Part 2, comparing the same outcome measured over 5 days of twice daily applications to the lower legs in 36 subjects, the AUC for DELP was approximately five times that for DIPC (p < 0.0001). 69% of subjects "Like Slightly" or "Like Strongly" DELP compared to 33% for DIPC (p = 0.025). 72% indicated they would use DELP again compared to 33% for DIPC (p = 0.033). 75% of subjects preferred DELP, 17% preferred DIPC and 8% expressed no preference (p = 0.0004).

The concept of "the will to thrive" in mental health.

Mental health nursing is focused on patients moving along the continuum between failing and thriving in terms of emotional functioning. This differs dramatically from a medical model of disease/cure. A variety of nursing theorists have both directly and indirectly identified the importance of patient's "will to thrive" although this term has never been used. Peplau spoke of self-efficacy and self-esteem. Barrett's model focuses on the patient's participation in their own recovery as a key component. This article explores the concept, akin to failure to thrive in infants, of the will to thrive in the chronically ill and its role in assessment and nursing intervention. A particular emphasis on the importance of patient responsibility is identified as vital to the process of true change.

Objective and subjective in vivo comparison of two emollient products.

BACKGROUND: Few studies have directly compared the effectiveness of different emollients in vivo, and the important matter of patient preference is generally overlooked. METHODS: We report the results of an assessor-blinded, bilateral, concurrent comparison of two emollient pharmaceutical presentations, ie, Doublebase gel (DB) and Aqueous cream BP (AC), applied by 20 participants three times daily for 7 consecutive days. The primary efficacy endpoint was cumulative improvement in skin hydration measured by corneometry on days 1, 3, and 5 immediately before the first application and approximately 2 hours after the third application of the day. Secondary endpoints were investigator assessment of skin condition at these time points and participant assessment of product acceptability at the end of the study. RESULTS: Both products increased skin hydration, but the effect of AC was relatively modest, with morning values readily returning to pretreatment levels. Hydration levels were higher for DB gel, maintained at all time points, and showed stepwise, cumulative increases over the 7 days of use. Overall patient satisfaction scores were higher for DB gel, and especially for "consistency," "ease of use," and "ease of absorption into the skin." Eighty-five percent of participants expressed a desire to use DB gel again as compared with 40% for AC.

Bioactive oat ß-glucan reduces LDL cholesterol in Caucasians and non-Caucasians.

BACKGROUND: There is increasing global acceptance that viscous soluble fibers lower serum LDL cholesterol (LDL-C), but most evidence for this comes from studies in Caucasians. To see if oat ß-glucan lowers LDL-C in Caucasians and non-Caucasians we conducted a post-hoc analysis of the results of a randomized, controlled, double-blind, multi-center clinical trial whose primary aim was to determine if molecular-weight (MW) influenced the LDL-C-lowering effect of oat ß-glucan. RESULTS: Caucasian and non-Caucasian subjects with LDL-C-C ≥ 3.0 and ≤ 5.0 mmol/L (n = 786 screened, n = 400 ineligible, n = 19 refused, n = 367 randomized, n = 345 completed, n = 1 excluded for missing ethnicity) were randomly assigned to consume cereal containing wheat-fiber (Control, n = 74:13 Caucasian:non-Caucasian) or 3 g high-MW (3H, 2,250,000 g/mol, n = 67:19), 4 g medium-MW (4 M, 850,000 g/mol, n = 50:17), 3 g medium-MW (3M, 530,000 g/mol, n = 54:9) or 4 g low-MW (4 L, 210,000 g/mol, n = 51:12) oat ß-glucan daily for 4 weeks. LDL-C after 4 weeks was influenced by baseline LDL-C (p < 0.001) and treatment (p = 0.003), but not ethnicity (p = 0.74). In all subjects, compared to control, 3 H, 4 M and 3 M reduced LDL-C significantly by 4.8 to 6.5%, but 4 L had no effect. Compared to control, the bioactive oat ß-glucan treatments (3H, 4M and 3M) reduced LDL-C by a combined mean (95% CI) of 0.18 (0.06, 0.31) mmol/L (4.8%, n = 171, p = 0.004) in Caucasians, a value not significantly different from the 0.37 (0.09, 0.65) mmol/L (10.3%, n = 45, p = 0.008) reduction in non-Caucasians. CONCLUSION: We conclude that oat ß-glucan reduces LDL-C in both Caucasians and non-Caucasians; there was insufficient power to determine if the magnitude of LDL-C-lowering differed by ethnicity. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00981981.

Black tea is not significantly different from water in the maintenance of normal hydration in human subjects: results from a randomised controlled trial.

There is a belief that caffeinated drinks, such as tea, may adversely affect hydration. This was investigated in a randomised controlled trial. Healthy resting males (n 21) were recruited from the general population. Following 24 h of abstention from caffeine, alcohol and vigorous physical activity, including a 10 h overnight fast, all men underwent four separate test days in a counter-balanced order with a 5 d washout in between. The test beverages, provided at regular intervals, were 4 × 240 ml black (i.e. regular) tea and 6 × 240 ml black tea, providing 168 or 252 mg of caffeine. The controls were identical amounts of boiled water. The tea was prepared in a standardised way from tea bags and included 20 ml of semi-skimmed milk. All food taken during the 12 h intervention period was controlled, and subjects remained at rest. No other beverages were offered. Blood was sampled at 0, 1, 2, 4, 8 and 12 h, and a 24 h urine sample was collected. Outcome variables were whole blood cell count, Na, K, bicarbonate, total protein, urea, creatinine and osmolality for blood; and total volume, colour, Na, K, creatinine and osmolality for urine. Although data for all twenty-one participants were included in the analysis (mean age 36 years and mean BMI 25·8 kg/m(2)), nineteen men completed all conditions. Statistical analysis, using a factorial ANOVA approach within PROC MIXED, revealed no significant differences between tea and water for any of the mean blood or urine measurements. It was concluded that black tea, in the amounts studied, offered similar hydrating properties to water.

Physicochemical properties of oat ß-glucan influence its ability to reduce serum LDL cholesterol in humans: a randomized clinical trial.

BACKGROUND: Consumption of 3 g oat ß-glucan/d is considered sufficient to lower serum LDL cholesterol, but some studies have shown no effect. LDL cholesterol lowering by oat ß-glucan may depend on viscosity, which is controlled by the molecular weight (MW) and amount of oat ß-glucan solubilized in the intestine (C). OBJECTIVES: Our 2 primary objectives were to determine whether consumption of 3 g high-MW oat ß-glucan/d would reduce LDL cholesterol and whether LDL cholesterol lowering was related to the log(MW × C) of oat ß-glucan. DESIGN: In a double-blind, parallel-design, multicenter clinical trial, subjects with LDL cholesterol ≥3.0 and ≤5.0 mmol/L (n = 786 screened, n = 400 ineligible, n = 19 refused, n = 367 enrolled, and n = 345 completed) were randomly assigned to receive cereal containing wheat fiber (n = 87) or 3 g high-MW (2,210,000 g/mol, n = 86), 4 g medium-MW (850,000 g/mol, n = 67), 3 g medium-MW (530,000 g/mol, n = 64), or 4 g low-MW (210,000 g/mol, n = 63) oat ß-glucan/d (divided doses, twice daily) for 4 wk. RESULTS: LDL cholesterol was significantly less with 3 g high-MW, 4 g medium-MW, and 3 g medium-MW oat ß-glucan cereals than with the wheat-fiber cereal by 0.21 (5.5%; 95% CI: -0.11, -0.30; P = 0.002), 0.26 (6.5%; 95% CI: -0.14, -0.37; P = 0.0007), and 0.19 (4.7%; 95% CI: -0.08, -0.30; P = 0.01) mmol/L, respectively. However, the effect of 4 g low-MW oat ß-glucan/d (0.10 mmol/L) was not significant (2.3%; 95% CI: 0.02, -0.20). By analysis of covariance, log(MW × C) was a significant determinant of LDL cholesterol (P = 0.003). Treatment effects were not significantly influenced by age, sex, study center, or baseline LDL cholesterol. CONCLUSIONS: The physicochemical properties of oat ß-glucan should be considered when assessing the cholesterol-lowering ability of oat-containing products; an extruded breakfast cereal containing 3 g oat ß-glucan/d with a high-MW (2,210,000 g/mol) or a medium-MW (530,000 g/mol) lowered LDL cholesterol similarly by ≈0.2 mmol/L (5%), but efficacy was reduced by 50% when MW was reduced to 210,000 g/mol. This trial was registered at www.clinicaltrials.gov as NCT00981981.

Measuring the glycemic index of foods: interlaboratory study.

BACKGROUND: Many laboratories offer glycemic index (GI) services. OBJECTIVE: We assessed the performance of the method used to measure GI. DESIGN: The GI of cheese-puffs and fruit-leather (centrally provided) was measured in 28 laboratories (n=311 subjects) by using the FAO/WHO method. The laboratories reported the results of their calculations and sent the raw data for recalculation centrally. RESULTS: Values for the incremental area under the curve (AUC) reported by 54% of the laboratories differed from central calculations. Because of this and other differences in data analysis, 19% of reported food GI values differed by >5 units from those calculated centrally. GI values in individual subjects were unrelated to age, sex, ethnicity, body mass index, or AUC but were negatively related to within-individual variation (P=0.033) expressed as the CV of the AUC for repeated reference food tests (refCV). The between-laboratory GI values (mean+/-SD) for cheese-puffs and fruit-leather were 74.3+/-10.5 and 33.2+/-7.2, respectively. The mean laboratory GI was related to refCV (P=0.003) and the type of restrictions on alcohol consumption before the test (P=0.006, r2=0.509 for model). The within-laboratory SD of GI was related to refCV (P<0.001), the glucose analysis method (P=0.010), whether glucose measures were duplicated (P=0.008), and restrictions on dinner the night before (P=0.013, r2=0.810 for model). CONCLUSIONS: The between-laboratory SD of the GI values is approximately 9. Standardized data analysis and low within-subject variation (refCV<30%) are required for accuracy. The results suggest that common misconceptions exist about which factors do and do not need to be controlled to improve precision. Controlled studies and cost-benefit analyses are needed to optimize GI methodology. The trial was registered at clinicaltrials.gov as NCT00260858.

Infertility and the role of psychotherapy.

Infertility affects 6 million American women and their partners, about 10% of the reproductive age population. Recent improvements in medication, microsurgery, and assisted reproductive technology (ART) make pregnancy possible for more than half the couples pursuing treatment, yet infertility is more than a medical condition. Infertility touches all aspects of a person's life. It affects how individuals feel about themselves, their relationships, and their life perspective. Stress is only one of a myriad of emotional realities that couples facing infertility deal with, often for extended periods of time. In addition to ongoing stress, infertility creates issues of guilt, anxiety, tension within the relationship, and feelings of depression and isolation. Treating couples and individuals who are involved in the journey of dealing with infertility is an opportunity for clinical specialists in psychiatric mental health nursing. The expertise of clinical specialists both in providing psychotherapy services as well as providing a bridge of understanding of sophisticated medical and surgical procedures places them in a unique position among the various disciplines offering mental health services. This paper provides an overview of the psychological issues that play a role in psychotherapy with this population and suggests specific clinical interventions and potential role expansion for psychiatric clinical specialists.