Tolerability of electrodiagnostic studies in patients: a prospective study.

Introduction: Nerve conduction study (NCS) and electromyography (EMG) are electrodiagnostic studies that are highly tolerated by patients despite their nature of causing pain and discomfort. However, few studies have focused on the true tolerability of these procedures in patients. This study aimed to determine the true tolerance rate of NCS and EMG in patient populations and the factors that might be associated with them. Methods: Participants scheduled for electrodiagnostic studies were prospectively recruited between March 2023 and September 2023. After completion of the study, the physicians completed a questionnaire on each patient's tolerance of the studies. Results: Of the 103 patients enrolled in the study, 98 were able to tolerate both tests, and 5 patients were intolerant to 1 or both tests. The overall tolerance rate of NCS and EMG was 95.1% (0.951, 95% CI 0.897 to 0.981). Age, sex, ethnicity, the type of NCS performed and the type of EMG performed were not associated with NCS or EMG intolerance. Conclusion: Most patients tolerated the NCS and EMG; however, a small percentage of patients were intolerant. Clinicians should recognise the intolerance of certain patients when introducing and performing electrodiagnostic tests.

Risk factors for readmission of patients with amputation to acute care from inpatient rehabilitation: A retrospective cohort study.

INTRODUCTION: Amputation is a major condition that requires inpatient rehabilitation. Some research has been conducted to explore the risk factors for readmission of patients from inpatient rehabilitation facilities to acute care hospitals. However, few studies have included patients with amputation in the study population. OBJECTIVE: To identify the risk factors for readmission of patients with amputation to acute care hospitals from an inpatient rehabilitation facility. DESIGN: Retrospective cohort study. SETTING: An acute rehabilitation hospital associated with a community-based tertiary medical center. PATIENTS: A retrospective review of 156 independent admissions of 145 patients from June 2019 to July 2022. MAIN OUTCOME MEASURE: The study outcome measure was readmission to acute care from an acute rehabilitation unit. RESULTS: Of the 156 independent admissions, the readmission rate was 19% (29/156). The most common cause of transfer was incision-site complications (9/29, 31%), including wound infection and wound dehiscence. Patients with amputation readmitted to acute care are more likely to be receiving dialysis (p < .001), have a longer length of stay in acute care before admission to the rehabilitation facility (p = .039), and have a lower Section GG score on admission (p < .001). Age, sex, ethnicity, amputation level, and history of diabetes mellitus were not associated with acute care hospital readmission. The logistic regression model revealed that patients being on dialysis was the only significant risk factor predictive of readmission to acute care (odds ratio [OR] 4.82, p = .006). CONCLUSIONS: This study showed that incision-site complications were the most common cause of disruption in inpatient rehabilitation via acute hospital readmission in patients with amputation. Being on dialysis was associated with a higher risk of readmission to acute care hospitals. Based on the results of this study, specific rehabilitation plans might be required for patients with amputation who carry certain risk factors to reduce rehospitalization to the acute care unit.

The Impact of Peripheral Intravenous Catheter Insertion Technique and Catheter-to-Vein Ratio on Postinsertion Failure.

BACKGROUND: Peripheral intravenous catheter (PIVC) postinsertion failure rates are unacceptable. Ultrasonography is an adjunctive tool that may improve PIVC utilization success. OBJECTIVES: Determine if ultrasonographically guided (USG) PIVCs placed in the emergency department (ED) significantly decreases postinsertion failure rate, increases utility time, and decreases postremoval complication rate. Determine if catheter-to-vein ratio (CVR) predicts postinsertion failure. METHODS: Participants were randomized to either standard or USG cohort. Data collection included participant and PIVC characteristics, vein measurements, postinsertion failure, and postremoval complication. Chi-square analysis compared postinsertion failure rates. Group t-test compared utility times. Postremoval complication rates were compared with standard rate analysis. The receiver operating characteristic curve was calculated to determine if CVR could predict postinsertion failure. An enrollment of 582 was estimated. RESULTS: A total of 223 patients were enrolled, with 222 PIVCs investigated. Standard cohort included 116 PIVCs and USG cohort included 106 PIVCs. A total of 212 vein diameters were analyzed. USG PIVC insertion did not result in fewer postinsertion failures (p = 0.654) or longer utility time (p = 0.808). Postremoval complications were not significantly lower (p = 0.414). Receiver operating characteristic curve showed a cut-off CVR of ∼ 0.21. Area under the curve was 0.621 (p = 0.063, 95% confidence interval 0.508-0.734). CONCLUSION: The USG technique did not decrease postinsertion failure rate, increase utility time, or significantly decrease postremoval complication rate. A CVR predictive of postinsertion failure could not be determined.

Changes to same day discharge after minimally invasive hysterectomy throughout COVID-19 pandemic.

BACKGROUND: Minimally invasive hysterectomy is a common gynecologic procedure. Numerous studies have found that a same day discharge (SDD) is safe following this procedure. Research has found that SDDs decrease resource strain, nosocomial infections, and financial burden for both the patient and healthcare system. Due to the recent COVID-19 pandemic, the safety of hospital admissions and elective surgeries was called into question. OBJECTIVE: To assess the rates of SDD among patients who underwent a minimally invasive hysterectomy before and during the COVID-19 pandemic. STUDY DESIGN: A retrospective chart review was performed from September 2018 to December 2020 on 521 patients, who met inclusion criteria. Descriptive analysis, chi-square tests of association, and multivariable logistic regression were used for analysis. RESULTS: There was a significant difference between rate of SDDs pre-COVID-19 (12.5%) versus during the COVID-19 period (28.6%) (p < 0.001). Surgical complexity was predictive of not being discharged the same day of surgery (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 2.2-8.8), as was surgical completion time after 4 p.m. (OR = 5.2, 95% CI = 1.1-25.2). There was no difference in readmissions (p = 0.209) and emergency department (ED) visits (p = 0.973) between SDD and overnight stay. CONCLUSION: Rates of SDD for patients undergoing minimally invasive hysterectomy were significantly increased during the COVID-19 pandemic. SDDs are safe; the number of readmissions and ED visits did not increase among patients who were discharged on the same day.

Implementing Centering Parenting Model With an Urban Pediatric Population to Measure and Improve Clinical Outcomes and Parent Satisfaction.

INTRODUCTION: For CenteringParenting-a patient-centered, group family approach to child health-this study aimed to determine how the CenteringParenting model affects clinical outcomes compared with the traditional well-child care model and how the CenteringParenting model affect parent satisfaction as compared with the traditional well-child care model. This study was conducted at the Children's Health Center in West Reading, PA-a single-site pediatric practice that serves primarily an inner city with a population currently at 95,112. METHOD: Quantitative data collection was obtained from a retrospective chart review for both groups of patients to obtain outcome data. Phone interviews were completed, and participants were asked to respond to a series of questions using a 5-point Likert scale and several open-ended questions. All statistical analyses for this research were performed using SPSS (version 25.0; IBM Corp., Armonk, NY). Two groups were coded as the centering group and control group. Significance testing was performed using chi-square analysis for categorical data and t test for continuous data. RESULTS: CenteringParenting children are more likely to be UTD with their scheduled visits and vaccines than those receiving the traditional model of well-child care. Maternal depression screenings were more likely to be completed and documented and open discussions about maternal depression. Parents involved with group visits found it to be great care, liked being with other parents, learned a lot, and would recommend it to other parents. DISCUSSION: Limitations of the study include being a new site offering the CHI program for group well-child visits. As the program has continued to progress over the years, it has continued to grow and is now offered in both English and Spanish. Another limitation was not having trained breastfeeding professionals such as lactation counselors, consultants, or breastfeeding resource nurses. Future research is needed to study the implementation of breastfeeding in minority populations. In addition, a more in-depth study about triage calls and if parents feel more comfortable calling if they have a better connection to their provider and health care team. This issue was not addressed or questioned in this research and would be very beneficial to understand in the future how it relates to CPGs.

Assessing the accuracy and quality of YouTube videos on early pregnancy loss.

Objective: To assess the accuracy and quality of YouTube videos pertaining to early pregnancy loss for use as a patient education tool. Methods: A cross-sectional study was conducted via YouTube search using the keywords "miscarriage," "spontaneous abortion," "pregnancy loss," and "pregnancy failure." The first 20 results for each keyword search, sorted by both relevance and view count, were compiled into a list. Descriptive characteristics, including the numbers of views, likes, dislikes, video length, and duration of upload were collected. All videos were independently evaluated by two physician researchers using two unique assessment tools. The Currency, Relevance, Authority, Accuracy, and Purpose (CRAAP) test was used to measure the reliability of video content. The Miscarriage-Specific Question Score (MSQS) criterion was used to objectively assess video content specific to miscarriage. Inter-rater agreement was analyzed via kappa coefficient and Pearson correlation. Results: 160 videos were screened, among which 74 videos were included for analysis. The mean CRAAP score was 8.3 out of a total possible score of 15, demonstrating good quality sources, though not of academic level. Mean MSQS score was 8.1 out of a total possible score of 24, demonstrating "fair" accuracy and comprehensiveness. Pearson correlations were 0.87 and 0.86 for CRAAP and MSQS total scores, respectively, demonstrating excellent inter-rater reliability. Conclusion: YouTube videos related to early pregnancy loss span a wide range of quality, accuracy, and purpose. While some videos provide effective content, mean rater scores demonstrate that YouTube is not a reliable source for patient education on early pregnancy loss.

Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians.

PURPOSE: To test the hypothesis that interventional radiologists (IRs) and neurointerventional (NI) physicians have similar outcomes of endovascular stroke thrombectomy (EVT), which could be used to improve the availability of thrombectomy. MATERIALS AND METHODS: Eight hospitals providing EVT performed by IRs and NI physicians at the same institution submitted sequential retrospective data limited to the era of modern devices. Good clinical outcomes (a 90-day modified Rankin score [mRS] of 0-2) and technically successful revascularization (a modified thrombolysis in cerebral infarction score of ≥2b) were compared between the specialties after adjusting for treating hospital, patient age, stroke severity, Alberta stroke program early computed tomography score, time from symptom onset to door, and clot location. Propensity score matching was used to compare the outcomes. A total of 1,009 patients were evaluated (622 treated by IRs and 387 treated by NI physicians). RESULTS: The median time from stroke onset to puncture was 245 versus 253 minutes (P = .49), the technically successful revascularization rate was 81.8% versus 82.4% (P = .81), and the good clinical outcome rate was 45.5% versus 50.1% (P = .16). After adjusting, the physician specialty was not a significant predictor of good clinical outcomes (odds ratio, 1.028; 95% confidence interval, 0.760-1.390; P = .86). After matching, an mRS of 0-2 was present in 47.7% of IR treated patients and 51.1% of NI treated patients (P = .366). CONCLUSIONS: There were no significant differences in the successful revascularization rate and good clinical outcomes between IRs and NI physicians. The outcomes of EVT performed by IRs were similar to those of EVT performed by NI physicians, as determined using previously published trials and registries. This may be useful for addressing coverage and access to stroke interventions.

Increased Experimental Pain Sensitivity in Chronic Pain Patients Who Developed Opioid Use Disorder.

OBJECTIVE: Although the great majority of individuals who take opioids for chronic pain use them appropriately and to good effect, a certain minority will develop the problematic outcome of opioid use disorder (OUD). Characteristics associated with the development of OUD in individuals with chronic pain have been described; however, relatively unexplored is how sensitivity to pain is associated with OUD outcomes. MATERIALS AND METHODS: We examined for differences in response to static and dynamic experimental pain stimuli between individuals with chronic nonmalignant pain who developed OUD after starting opioid therapy (n=20) and those on opioid therapy who did not (n=20). During a single experimental session, participants underwent cold pressor and quantitative sensory testing pain assays, and objective and subjective responses were compared between groups; the role of pain catastrophizing in mediating pain responses was examined. RESULTS: Results suggested that both groups of opioid-dependent patients were similarly hyperalgesic to the cold pressor pain stimulus, with nonparametric testing revealing worsened central pain sensitization (temporal summation) in those who developed OUD. Significant group differences were evident on subjective ratings of experimental pain, such that those who developed OUD rated the pain as more severe than those who did not. Pain catastrophizing was unrelated to pain responses. DISCUSSION: Despite the small sample size and cross-sectional design, these findings suggest that experimental pain testing may be a novel technique in identifying patients with chronic pain likely to develop OUD, in that they are likely to evidence exacerbated temporal summation and to rate the associated pain as more severe.

Hypochloraemia and 30 day readmission rate in patients with acute decompensated heart failure.

AIMS: Despite recent advances in guideline-directed therapy, rehospitalization rates for acute decompensated heart failure (ADHF) remain high. Recently published studies demonstrated the emerging role of hypochloraemia as a predictor of poor outcomes in patients with ADHF. This study sought to determine the correlation between low serum chloride and 30 day hospital readmission in patients with ADHF. METHODS AND RESULTS: We retrospectively reviewed electronic medical records of 1504 patients who were admitted to one 700 bed US tertiary care centre with the diagnosis of ADHF between June 2013 and December 2014. Of the 1504 reviewed records, 1241 were selected for further analysis. Hypochloraemia (either on admission or at discharge) was identified in 289 patients (23.3%) and was associated with significantly higher 30 day hospital readmission rate or death (42.2% vs. 33.7%, P = 0.008). This association persisted in multivariate analysis when controlling for serum sodium, weight loss, diuretic dose, adjunct thiazide use, serum blood urea nitrogen, and BNP levels (OR: 1.35, 95% CI: 1.02-1.77, P = 0.033); however, the predictive value of the overall model was low (Naglkerke R2 = 0.040). Hypochloraemia was also found to be associated with increased 12 month mortality in our cohort (31.4% vs. 20.2%, P = 0.015) that correlates with the results of previously published studies. CONCLUSIONS: Low serum chloride measured in patients admitted for ADHF is independently but weakly associated with increased 30 day readmission rate and demonstrated low predictive value as a potential biomarker in this cohort.

Epidural catheters are associated with an increased risk of venous thromboembolism in trauma.

Little is known about the association between epidural catheters (EC) and venous thromboembolism (VTE) in trauma. We sought to study this association and hypothesized that trauma patients with EC were more likely to develop VTE. Using the Pennsylvania Trauma Outcomes Study (PTOS) registry, we identified all adult trauma patients (age ≥ 18) admitted for at least 2 days between 1/2013 and 12/2017. Baseline characteristics and outcome variables were compared between patients who underwent EC placement and those who did not. The primary outcome was development of VTE. 147,721 patients met inclusion criteria; 2247 (1.5%) developed a VTE. Patients were mostly white (85%), male (56%), with blunt trauma (94%). 776 (0.5%) had an EC placed. Patients who underwent EC placement were more likely to develop a VTE (2.8% vs. 1.5%, p = 0.003). After adjusting for covariates, patients with EC were 1.6 times more likely to develop VTE (95% CI 1.1-2.5). The overall rate of VTE was low and associated with the use of EC. Future work should focus on determining the underlying mechanisms.

The impact of interhospital transfer on mortality benchmarking at Level III and IV trauma centers: A step toward shared mortality attribution in a statewide system.

BACKGROUND: Many injured patients presenting to Level III/IV trauma centers will be transferred to Level I/II centers, but how these transfers influence benchmarking at Level III/IV centers has not been described. We hypothesized that the apparent observed to expected (O:E) mortality ratios at Level III/IV centers are influenced by the location at which mortality is measured in transferred patients. METHODS: We conducted a retrospective study of adult patients presenting to Level III/IV trauma centers in Pennsylvania from 2008 to 2017. We used probabilistic matching to match patients transferred between centers. We used a risk-adjusted mortality model to estimate predicted mortality, which we compared with observed mortality at discharge from the Level III/IV center (O) or observed mortality at discharge from the Level III/IV center for nontransferred patients and at discharge from the Level I/II center for transferred patients (O). RESULTS: In total, 9,477 patients presented to 11 Level III/IV trauma centers over the study period (90% white; 49% female; 97% blunt mechanism; median Injury Severity Score, 8; interquartile range, 4-10). Of these, 4,238 (44%) were transferred to Level I/II centers, of which 3,586 (85%) were able to be matched. Expected mortality in the overall cohort was 332 (3.8%). A total of 332 (3.8%) patients died, of which 177 (53%) died at the initial Level III/IV centers (O). Including posttransfer mortality for transferred patients in addition to observed mortality in nontransferred patients (O) resulted in worse apparent O:E ratios for all centers and significant differences in O:E ratios for the overall cohort (O:E, 0.53; 95% confidence interval, 0.45-0.61 vs. O:E, 1.00, 95% confidence interval, 0.92-1.11; p < 0.001). CONCLUSION: Apparent O:E mortality ratios at Level III/IV centers are influenced by the timing of measurement. To provide fair and accurate benchmarking and identify opportunities across the continuum of the trauma system, a system of shared attribution for outcomes of transferred patients should be devised.

Impact of adrenaline dose and timing on out-of-hospital cardiac arrest survival and neurological outcomes.

STUDY OBJECTIVE: The 2015 ILCOR Advanced Cardiovascular Life Support Guidelines recommend intravenous adrenaline (epinephrine) as a crucial pharmacologic treatment during cardiac arrest resuscitation. Some recent observational studies and clinical trials have questioned the efficacy of its use and suggested possible deleterious effects on overall survival and long-term outcomes. This study aimed to describe the association between time and dose of adrenaline on return of spontaneous circulation (ROSC) and neurologic function. METHODS: We performed a retrospective analysis of the Penn Alliance for Therapeutic Hypothermia (PATH) data registry. The timing of the first dose of adrenaline and the total dose of adrenaline during cardiac arrests was compared between survivors to discharge and non-survivors for arrests lasting greater than 10 min. RESULTS: The registry contained 5594 patients. After excluding patients with an in-hospital cardiac arrest, a non-shockable rhythm, or no adrenaline administration, 1826 were included in the final analysis. Survivors to discharge received adrenaline sooner (median 5.0 vs. 7.0 min, p = 0.022) and required a lower total dose than non-survivors (2.0 vs. 3.0 mg, p < 0.001). For survivors, there was no significant association between the time to first adrenaline dose and favorable neurological outcome as measured by Cerebral Performance Category (CPC). Among survivors, those that received less than 2 mg of adrenaline had a more favorable neurologic outcome than those administered > 3 mg. (CPC 1-2 16.6% vs. 12.5%, p = 0.004). CONCLUSION: Early adrenaline administration is associated with a higher percentage of survival to discharge but not associated with favorable neurological outcome. Those patients with a favorable neurologic outcome received a lower total adrenaline dose prior to ROSC.

Development of the Revised Opioid Risk Tool to Predict Opioid Use Disorder in Patients with Chronic Nonmalignant Pain.

The Opioid Risk Tool (ORT) is a commonly used measure of risk of aberrant drug-related behaviors in patients with chronic pain prescribed opioid therapy. In this study, the discriminant predictive validity of the ORT was evaluated in a unique cohort of patients with chronic nonmalignant pain (CNMP) on long-term opioid therapy who displayed no evidence of developing an opioid use disorder (OUD) and a sample of patients with CNMP who developed an OUD after commencing opioid therapy. Results revealed that the original ORT was able to discriminate between patients with and without OUDs (odds ratio = 1.624; 95% confidence interval [CI] = 1.539-1.715, P < .001). A weighted ORT eliminating the gender-specific history of preadolescent sexual abuse item revealed comparable results (odds ratio = 1.648, 95% CI = 1.539-1.742, P < .001). A revised unweighted ORT removing the history of preadolescent sexual abuse item was notably superior in predicting the development of OUD in patients with CNMP on long-term opioid therapy (odds ratio = 3.085; 95% CI = 2.725-3.493; P < .001) with high specificity (.851; 95% CI = .811-.885), sensitivity (.854; 95% CI = .799-.898), positive predictive value (.757; 95% CI = .709-.799), and negative predictive value (.914; 95% CI = .885-.937). Perspective: The revised ORT is the first tool developed on a unique cohort to predict the risk of developing an OUD in patients with CNMP receiving opioid therapy, as opposed to aberrant drug-related behaviors that can reflect a number of other issues. The revised ORT has clinical usefulness in providing clinicians a simple, validated method to rapidly screen for the risk of developing OUD in patients on or being considered for opioid therapy.

A Pragmatic Clinical Trial to Compare the Real-World Effectiveness of V-Go versus Standard Delivery of Insulin in Patients with Advanced Type 2 Diabetes.

BACKGROUND: Many patients with type 2 diabetes mellitus (T2DM) do not have adequate glycemic control, leading to poor patient outcomes and high healthcare costs. OBJECTIVE: This prospective pragmatic clinical trial evaluated V-Go, a wearable insulin delivery device, compared with standard treatment optimization (STO) among insulin-treated patients with T2DM in a real-world, community-based practice setting. METHODS: Study sites, rather than individual patients, were randomized to V-Go or STO via cluster randomization. Patients were treated according to routine clinical practice and followed up to 4 months. T2DM medications and supplies were purchased utilizing usual insurance and co-pay systems. The primary analysis was an unadjusted treatment group comparison of glycosylated hemoglobinA1c (HbA1c) change from baseline to end of study (EOS). A cost of therapy analysis was completed on patients who had received comparable baseline T2DM treatment with multiple daily basal-bolus insulin injections (MDI). RESULTS: Analysis included 415 patients (169 V-Go, 246 STO) enrolled from 52 US sites. Mean baseline HbA1c (9.6%) was higher in V-Go (9.9%, range 8.0% - 14.2%) than STO (9.3%, range 7.9% - 13.9%, p <.001). HbA1c decreased from baseline to EOS in both V-Go (-1.0%, p<.001) and STO (-0.5%, p<.001); V-Go had significantly larger decrease (p=.002). V-Go had a significant reduction (p<.001) in mean insulin total daily dose (TDD; 0.76 U/kg baseline, 0.57 U/kg EOS), not seen in STO (0.72 U/kg baseline and EOS). The MDI group included 95 (56.2%) V-Go and 113 STO (45.9%) patients. Mean baseline HbA1c was significantly higher in V-Go (9.9%) than STO (9.4%). V-Go also experienced larger decrease in HbA1c from baseline (-1.0%) than STO (-0.36%) (p=.006) with a decrease in TDD, while STO TDD remained unchanged. EOS mean per patient per day cost of diabetes treatment was lower for V-Go ($30.59) vs STO ($32.20) (p=.006). V-Go was more cost effective than STO ($24.02 per 1% drop in HbA1c vs $58.86, respectively). CONCLUSIONS: This pragmatic clinical trial demonstrated improved HbA1c levels, lower cost, and decreased insulin dose in patients with T2DM initiating V-Go vs STO in a real-world community-based practice setting. Observed baseline HbAlc indicated use of V-Go in more difficult to manage diabetes patients.

Exploring nurses' and patients' perceptions of hope and hope-engendering nurse interventions in an eating disorder facility: A descriptive cross-sectional study.

WHAT IS KNOWN ON THE SUBJECT?: Individuals with eating disorders (EDs) experience hopelessness, suicidal thoughts and behaviours at elevated rates compared to the general population. Current knowledge of recovery from EDs does not address nurse engendered hope. This study aimed to explore differences between patients' and nurses' perceptions of hope-engendering nurse actions and the relationship actions have with patients' perception of hope. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study to explore differences between patients' and nurses' perceptions of hope-engendering nurse actions in an inpatient ED facility and find significant differences; nurses' scores were higher than patients' scores. The study explored the relationship perceived self-reported nurse hope-engendering actions have with patients' and nurses' perception of hope. There were no significant relationships. This study provides additional evidence to support that there are common patient needs for nurse hope-engendering practices such as caring and providing for patients; supporting and encouraging patients' connection to others; facilitating patients' adaptive belief systems; and helping to set goals and attain resources for patients. WHAT ARE THE IMPLICATIONS FOR MENTAL HEALTH NURSING PRACTICE?: Nurses who work with patients who have EDs should be prepared to work with patients who are feeling hopeless about their future. Thus, nursing continuing education should focus on strategies that enable nurses to deliver care that reduces hopelessness, improves connection, and inspires hope in those who are recovering from EDs. The results revealed that nurses perceived that they offered patients with EDs hope-engendering actions more often and effectively than patients believed; this finding pinpoints a future direction for research that may improve care for patients. Patient feedback identified ways nurses may improve care to engender hope: providing an open caring environment, nurse presence, comfort/pain relief, and involving patients in their care. Actions by nurses aimed to enhance interpersonal connection and nurse presence could facilitate hope in patients with ED. ABSTRACT: Introduction Individuals with eating disorders (EDs) experience suicidal thoughts and behaviours at elevated rates compared to the general population. Hope-engendering nursing actions may increase patients' levels of hope for the future, improve coping self-efficacy, and possibly reduce suicidality. Although nursing staff are integral ED treatment team members, little is known about nursing actions targeting hopefulness. Aim Explore differences between patients' and nurses' perceptions of hope-engendering nurse actions and the relationship actions have with patients' perception of hope. Methods Descriptive, cross-sectional, comparative, correlational research design was used. Responses for 97 ED patients and 10 nurses were entered into analysis. Hope-engendering nurse intervention and hope questionnaires were administered and analysed. Results Nurses' total hope-engendering nurse intervention and hope scores were higher than patients' scores. Discussion Patients reported that the most effective nursing actions were providing an open caring environment, comfort/pain relief, and involving patients in their care and treatment. Nurses perceived that they offered patients hope-engendering actions more often and effectively than the patients believed. Implications for Practice Findings indicate that patients with EDs have low levels of hope. Nursing educators should further develop strategies that enable nurses to deliver care that inspires hope and improves connectedness in those who have EDs.

Race and Ethnicity Do Not Clinically Associate with Quality of Life Among Patients with Chronic Severe Pain in a Federally Qualified Health Center.

Objective: Previous research suggests that race/ethnicity predicts health-related quality of life (HRQL) in chronic pain populations but has not examined this in community settings. This study evaluated this association in 522 community-dwelling patients with chronic pain treated at a Federally Qualified Health Center (FQHC). Design: Cross-sectional secondary analysis. Setting: Six practice sites of an FQHC in New York. Subjects: One hundred forty-two non-Hispanic blacks, 121 non-Hispanic whites, 219 Hispanics, and 40 classified as "other" with severe chronic pain. Methods: Patients with chronic severe pain (three or more months with worst pain ≥ 4/10 or T-score > 60.5 on the Patient-Reported Outcomes Measurement Information System pain interference tool) were interviewed as part of a clinical trial. Race/ethnicity and other potential predictors of HRQL were assessed. Results: Mean age was 53.0 years, and 70.1% were women; 62.8% earned less than $10,000 per year, and 22.8% were Spanish-speaking with low acculturation. Mean worst pain during the past week was 8.6/10, and 39.6% used opioids. In multivariate analyses, race/ethnicity was not significantly associated with mental HRQL. Hispanics had significantly lower physical HRQL than non-Hispanic whites or blacks, but this difference was not clinically meaningful (mean T-scores = 33.9 [Hispanics], 35.8 [non-Hispanic whites], and 35.6 [non-Hispanic blacks]). Mental HRQL was predicted by depression, anxiety, pain disability, income, and physical HRQL; physical HRQL was predicted by race/ethnicity, anxiety, pain disability, age, care satisfaction, and mental HRQL. Conclusions: Race/ethnicity does not explain important variation in HRQL reported by diverse patients with chronic pain. Psychological distress, pain disability, age, and socioeconomic status predicted this health outcome. Future studies may clarify modifiers of these associations to guide treatment in FQHC populations.

Pre-admission functional status impacts the performance of the APACHE IV model of mortality prediction in critically ill patients.

BACKGROUND: Functional status (FS) before intensive care unit (ICU) admission is associated with short-term and long-term outcomes among critically ill patients. However, measures of FS are generally not integrated into ICU-specific mortality prediction models. METHODS: This retrospective cohort study used prospectively collected data from 9638 consecutive patients admitted to a single ICU between 1 October 2005 and 30 September 2015. For each ICU admission, FS was prospectively determined and classified into three discrete categories based on performance of basic daily living activities (FS1 - fully independent; FS2 - partly dependent; FS3 - completely dependent). We prospectively calculated Acute Physiology and Chronic Health Evaluation (APACHE) IV predicted mortality percentage (APIV PM) for each admission and calculated observed-expected mortality ratios (OEMR), stratified by FS category and APIV PM. We calculated area under the receiver operator characteristic curve (AUC) for APIV PM and mortality for the entire cohort and the three FS categories. RESULTS: Patients had a median (IQR) age of 67 (52-80) years and mean (SD) APIV PM was 18.3% (24.3%). Of these, 7714 (80.0%) were classified as FS1, 1728 (17.9%) as FS2 and 196 (2.0%) as FS3. FS1 patients were younger, had less comorbid disease, and lower APIV PM compared to FS2 and FS3. The OEMR were significantly lower for FS1 (0.67) than FS2 (0.93) or FS3 (0.90) (p < 0.0001 for both comparisons). Among patients with APIV PM 0-10%, 10-25%, 25-50% and ≥50% the OEMR for FS1 were 0.33, 0.49, 0.61 and 0.86. The AUC (95% CI) for APIV PM and mortality for FS1, FS2 and FS3 were 0.924 (0.914-0.933), 0.837 (0.816-0.858) and 0.775 (0.705-0.8456), respectively (p < 0.001 for each comparison). Multivariable analysis demonstrated that FS2 (OR 2.18 (1.84-2.57) (p < 0.0001)) and FS3 (OR 1.99 (1.34-2.96) (p = 0.0006)) were independently associated with increased risk of mortality. CONCLUSIONS: Baseline FS prior to critical illness is a strong independent predictor of mortality and impacts the relationship between observed and APIV PM in those with lower illness severity. Future iterations of mortality prediction models should integrate a baseline measure of FS to improve performance.

Internal Medicine Program Directors' Perceptions of the "All In" Match Rule: A Cross-Sectional Survey.

BACKGROUND: Since 2013, the National Resident Matching Program (NRMP) has asked all programs to declare themselves to be "all in" or "all out" for the NRMP. Before this rule was enacted, program directors who were surveyed expressed concerns about what they anticipated with the change, including resources for increased applications and potential delays with residency start times. OBJECTIVE: This study investigated the positive and negative effects of the rule change on recruiting seen from the perspective of internal medicine (IM) program directors. METHODS: In this mixed model cross-sectional survey, Accreditation Council for Graduate Medical Education-accredited IM program directors were surveyed regarding their impressions of the impact of the policy change. Data were aggregated using constant comparative analysis. RESULTS: A total of 127 of 396 (32%) IM program directors responded, and 122 of 127 (96%) identified their program as "all in." A total of 110 respondents expressed impressions of the rule change, with 48% (53 of 111) reporting positive responses, 28% (31 of 111) neutral responses, and 24% (27 of 111) negative responses. Programs with higher percentages of visa-holding residents had lower positive responses (37% [22 of 60] versus 61% [31 of 51]). Resident quality was felt to be unchanged or improved by most program directors (93%, 103 of 111), yet 24% (27 of 112) reported increases in delayed start times for visa-holding residents. Qualitative analysis identified increased fairness, at the expense of an increase in program resources as a result of the change. CONCLUSIONS: A slight majority of residency programs reported a neutral or negative impression of the rule change. Since the rule change, program directors noted increased application volume and delayed residency starts for visa-holding residents.

RS3PE revisited: a systematic review and meta-analysis of 331 cases.

OBJECTIVES: Remitting seronegative symmetrical synovitis with pitting oedema (RS(3)PE) syndrome is a rare inflammatory arthritis, characterised by symmetrical distal synovitis, pitting oedema of the hands and feet, absence of rheumatoid factor, and favourable response to glucocorticoids. The aim of our study is to further delineate the clinical and laboratory features, and response to treatment. METHODS: We performed a systematic electronic search of Medline, PubMed, EMBASE, ACR and EULAR databases for case reports, case series, and related articles of RS(3)PE. Statistical analysis was done comparing categorical variables with Chi-square tests and frequencies of means via t-tests. Binary logistic regression analysis was performed to identify predictors of erosions, recurrence, malignancy and rheumatologic disorders. RESULTS: 331 cases of RS(3)PE were identified from 121 articles. RS(3)PE was found in older patients (71±10.42 years) predominantly in males (n= 211, 63.36%), was symmetrical (n=297/311, 95.50%) involved the hands (n=294/311, 94.53%) A concurrent rheumatologic condition was reported in 22 cases (6.65%), and malignancy in 54 cases (16.31%). Radiographic joint erosions were found in 5.5%. Most patients responded to medium-dose glucocorticoids (16.12±9.5 mg/day). Patients with concurrent malignancy requiring non-significantly higher doses of prednisone (18.12 vs. 15.76 mg, p 0.304) and higher likelihood of recurrence of disease (OR 4.04, 95% CI 1.10-14.88, p=0.03). CONCLUSIONS: The symptoms and unique findings that make up RS(3)PE appear to represent a steroid-responsive disease that may be a harbinger of an underlying malignancy. More study is needed to understand the molecular origins of RS(3)PE in order to determine whether it is a separate disease process. Patients with concurrent cancer tend to have more severe presentations and higher rates of recurrence.

Initial Validation of the Daily Spiritual Experiences Scale in Chinese Immigrants With Cancer Pain.

CONTEXT: Evaluating religious/spiritual influences in the growing Chinese-American population may inform the development of culturally relevant palliative care interventions. OBJECTIVES: We assessed the psychometric properties and acceptability of the Daily Spiritual Experiences Scale-Chinese (DSES-C) in Chinese Americans with cancer-related pain. METHODS: The translated 16-item DSES-C was administered as part of a symptom intervention for Chinese-American cancer patients. Patients were recruited from four New York community oncology practices. RESULTS: Of 321 patients, 78.7% were born in Mainland China, 79.1% spoke Cantonese, and 70.2% endorsed a religious affiliation (Ancestor worship, 31.7%; Chinese God worship, 29.8%; Buddhism, 17.1%; Christianity, 14.0%). In total, 82.6% completed the DSES-C (mean age = 57.7 years; 60.8% women) and 17.4% declined (mean age = 59.3 years; 52.0% women). Reasons for declining included low religiosity or perceived relevance of the scale items and difficulties separating spirituality from religiosity terms. Individuals having a religious affiliation were more likely to complete the DSES-C, whereas those not engaging in individual spiritual/religious practices or frequent group spiritual/religious practices tended to decline (all P < 0.05). The DSES-C (mean total score = 43.6, SD = 19.3) demonstrated high reliability (alpha = 0.94). Exploratory factor analysis suggested a one-factor solution, with significant loadings (>0.40) across items except Item 14 ("Accept others"). Construct validity was suggested by a positive association between DSES-C scores and having a religious affiliation (P < 0.05). CONCLUSION: In Chinese Americans with cancer pain, the DSES-C demonstrated acceptable psychometrics. Some participants experienced linguistic or cultural barriers preventing completion. Future investigations should provide additional validation in different Asian subgroups and those with varied medical conditions.