Reduction of Infusion Time Using a 10% Intravenous Immunoglobulin Formulation With a 15-Minute Rate Escalation Protocol During Staffing Shortages Due to COVID-19.

The COVID-19 pandemic changed home infusion nursing dramatically by increasing demand for home infusion nurses while decreasing their availability. Home infusion of intravenous immunoglobulin (IVIg) is an option for treatment of numerous conditions and requires considerable infusion time. Use of a higher-concentration IVIg product and shorter escalation increments may decrease required infusion time. The authors conducted a retrospective database analysis that identified 23 patients receiving IVIg before transitioning to a 10% IVIg product with a 15-minute rate escalation protocol (Gammaplex 10% IVIg) and evaluated the total infusion time before and after the transition. Among the 23 who received IVIg, the mean ± SD IVIg dose per dosing cycle before transitioning was 1.2 ± 0.7 g/kg given in 1 to 5 infusions per cycle. The mean ± SD time per infusion was 2.8 ± 0.8 hours before the transition and 2.6 ± 0.7 hours per infusion after the transition. The infusion time decreased after transition in 13 patients (56.5%), did not change in 5 patients (21.7%), and increased in 5 patients (21.7%). Nurse education on IVIg rate escalation may facilitate faster achievement of the maximum safe infusion rate and reduce infusion times. A trial transition to this 10% IVIg product with a 15-minute rate escalation protocol may also reduce infusion times.

Probing atomic physics at ultrahigh pressure using laser-driven implosions.

Spectroscopic measurements of dense plasmas at billions of atmospheres provide tests to our fundamental understanding of how matter behaves at extreme conditions. Developing reliable atomic physics models at these conditions, benchmarked by experimental data, is crucial to an improved understanding of radiation transport in both stars and inertial fusion targets. However, detailed spectroscopic measurements at these conditions are rare, and traditional collisional-radiative equilibrium models, based on isolated-atom calculations and ad hoc continuum lowering models, have proved questionable at and beyond solid density. Here we report time-integrated and time-resolved x-ray spectroscopy measurements at several billion atmospheres using laser-driven implosions of Cu-doped targets. We use the imploding shell and its hot core at stagnation to probe the spectral changes of Cu-doped witness layer. These measurements indicate the necessity and viability of modeling dense plasmas with self-consistent methods like density-functional theory, which impact the accuracy of radiation transport simulations used to describe stellar evolution and the design of inertial fusion targets.

Quantifying Treatment-Related Fluctuations in CIDP: Results of the GRIPPER Study.

OBJECTIVE: The objective of this study was to explore the extent of IV immunoglobulin (IVIG) treatment-related fluctuations (TRFs) by using home collection of daily grip strength in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and to use that information to develop evidence-based treatment optimization strategies. METHODS: This prospective observational study included 25 patients with well-defined CIDP. Participants recorded grip strength daily for 6 months. Disability and gait metrics were collected weekly. Serum immunoglobulin G levels were obtained at peak, trough, and midcycle IVIG intervals. Day-to-day grip strength changes <10% were considered random. To identify patients with TRFs, 3-day averaged grip strength was calculated on each consecutive day after an IVIG infusion. TRFs were defined as ≥10% 3-day averaged grip strength difference compared to the pre-IVIG baseline. RESULTS: Participants successfully recorded grip strength on all but 9% of recordable days. Twelve patients (48%) were classified as low/no fluctuaters and 13 (52%) as frequent fluctuaters. In the frequent fluctuating group, grip strength improved over 1 week and thereafter was relatively stable until the third week after infusion. Grip strength was significantly correlated with measures of disability. CONCLUSIONS: Grip strength collection by patients at home is reliable, valid, and feasible. A change in grip strength by ≥10% is a useful, practical, and evidence-based approach that may be used to identify clinically meaningful TRFs. From these data, we propose a treatment optimization strategy for patients with CIDP on chronic IVIG that may be applied to routine clinic care during both face-to-face and virtual video or telephone patient encounters. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT02414490.

Physiotherapy and Guillain-Barré syndrome: results of a national survey.

OBJECTIVE: To discover the extent to which persons with Guillain-Barré syndrome receive treatment by a physiotherapist (as inpatients and outpatients), and to assess whether the amount of treatment received is related to outcome. DESIGN: Survey method using self-administered questionnaires distributed through a national database. PARTICIPANTS: Members of the Guillain-Barré Syndrome Support Group (n=1535). MAIN OUTCOME MEASURES: General patient data, general mobility, F-score, Hospital Anxiety and Depression Scale, Short Form-36 and Fatigue Severity Scale. RESULTS: In total, 884/1535 (58%) complete responses were received. Nearly 10% of respondents had not received treatment by a physiotherapist in hospital despite their average functional level being the same as respondents who had received treatment in hospital. One-quarter of respondents said that they had not received treatment following hospital discharge despite the identification of relatively high levels of disability. Those who did not receive treatment by a physiotherapist following discharge were less severely disabled. This may indicate that physiotherapists tend to offer treatment to more severely disabled patients. The majority of patients reported disabling fatigue; whilst not statistically related to receipt of treatment by a physiotherapist, this highlights the importance of assessing fatigue in treatment plans to improve physical functioning. CONCLUSION: Improvements to policy and practice can be made by widening inpatient accessibility to treatment by a physiotherapist and increasing outpatient provision of treatment for patients with Guillain-Barré syndrome of all degrees of severity.

A study to assess the effect of nursing interventions at the weekend for people with stroke.

OBJECTIVE: To examine whether additional therapy provided by nurses at the weekend improved the physical outcome for people with stroke on a stroke rehabilitation unit. DESIGN: A single blind randomized controlled trial. SETTING: A 16-bed stroke rehabilitation unit in the north of England. SUBJECTS: Forty-one people with stroke were randomized by means of minimization to intervention and control groups. INTERVENTIONS: The intervention group received additional exercise at the weekend provided by the nursing staff and the control group received their usual care. Both groups received usual care during weekdays. MAIN OUTCOME MEASURES: The Motor Assessment Scale (MAS), the Barthel Index (BI) and length of stay in hospital. RESULTS: No significant differences were found between the groups in terms of MAS and BI at discharge but there was a borderline significant difference between the groups on unconditional testing in terms of length of stay in hospital and on the stroke unit (p = 0.05 and p = 0.07 respectively). However, these findings were in favour of the control group. On conditional testing (adjusting for BI on admission and age) these differences disappeared (p = 0.14 and p = 0.15) for length of stay in hospital and on the stroke unit respectively. CONCLUSIONS: The present study indicates that an increase in one-to-one input by nurses for people with stroke did not lead to a measurable difference in outcome in this small study.

Bleeding complications following percutaneous tendoachilles tenotomy in the treatment of clubfoot deformity.

Ponseti demonstrated correction of most clubfeet in infants using proper manipulative techniques followed by application of well-molded long-leg plaster casts and a percutaneous tendoachilles tenotomy to correct residual equinus contracture. Medical complications occurring as a result of this technique have not to our knowledge been reported. The authors retrospectively reviewed 134 consecutive infants with 219 idiopathic clubfeet treated with the Ponseti method. A percutaneous tendoachilles tenotomy was performed on 200 clubfeet (91%) at a mean age of 16 weeks (range, 6-77 weeks) when less than 10 degress of ankle dorsiflexion was present after casting. A total of 4 patients had serious bleeding complications following the percutaneous tendoachillis tenotomy--3 due to presumed injury to the peroneal artery and 1 due to injury to the lesser saphenous vein. The authors detail the technique of performing a percutaneous tendoachilles tenotomy and offer guidelines that may help others avoid this same complication.

Nuclear translocation of nuclear transcription factor-kappa B by alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors leads to transcription of p53 and cell death in dopaminergic neurons.

We describe a new molecular mechanism of cell death by excitotoxicity mediated through nuclear transcription factor kappa B (NF kappa B) in rat embryonic cultures of dopaminergic neurons. Treatment of mesencephalic cultures with alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) resulted in a number of changes that occurred selectively in dopaminergic neurons, including persistent elevation in intracellular Ca(2+) monitored with Fura-2, and a significant increase in intramitochondrial oxidation of dihydrorhodamine 123, probably associated with transient increase of mitochondrial permeability, cytochrome c release, nuclear translocation of NF kappa B, and transcriptional activation of the oncogene p53. Interruption of any of these steps by specific antagonists prevented neurite pruning and programmed cell death. In contrast, cell death was not prevented by caspase antagonists and only partly prevented by nitric-oxide synthase inhibitors. This signal transduction pathway might be a contributing mechanism in ongoing neuronal death in Parkinson disease.