What makes advance care planning discussion so difficult? A systematic review of the factors of advance care planning in healthcare settings.

OBJECTIVES: Existing systematic reviews related to advance care planning (ACP) largely focus on specific groups and intervention efficacy or are limited to contextual factors. This research aims to identify the modifiable factors perceived by different users of ACP in healthcare settings and inform healthcare professionals about the factors affecting ACP practice. METHODS: Five English-language databases (ProQuest, PubMed, CINAHL Plus, Scopus, and Medline) and two Chinese-language databases (CNKI and NCL) were searched up to November 2022. Empirical research identifying factors related to ACP in healthcare settings was included. ACP is defined as a discussion process on future end-of-life care. Thematic synthesis was performed on all included studies. RESULTS: A total of 1871 unique articles were screened; the full texts of 193 were assessed by 4 reviewers, and 45 articles were included for analysis. Twenty-two (54%) studies were qualitative, 15 (33%) were quantitative, and 6 (13%) used mixed methods. Foci varied from 28 (62%) studies on a single subject group (either patient, family, or physician), 11 (25%) on 2 subject groups (either patient and family or patient and healthcare professional), and 6 (13%) covered 3 subject groups (patient, family, and healthcare professional). Among the 17 studies involving more than 1 subject group, only 2 adopted a dyadic lens in analysis. Complex interwoven factors were categorized into (1) intrapersonal factors, (2) interpersonal factors, and (3) socio-environmental factors, with a total of 11 themes: personal belief, emotions, the burden on others, timing, responsiveness, relationship, family dynamics, experience, person taking the lead, culture, and support. SIGNIFICANCE OF RESULTS: Patients, families, and healthcare professionals are the essential stakeholders of ACP in healthcare settings. Factors are interweaved among the intrapersonal, interpersonal, and socio-environmental dimensions. Research is warranted to examine the dynamic interactions of the 3 essential stakeholders from a multidimensional perspective, and the mechanism of the interweaving of factors.

Pyroglutamic Acidosis - An Underrecognised Entity Associated with Acetaminophen Use.

Pyroglutamic acidosis (PGA) is an underrecognized entity characterised by raised anion gap metabolic acidosis (RAGMA) and urinary hyper-excretion of pyroglutamic acid. It is frequently associated with chronic acetaminophen (APAP) ingestion. We report the case of a 73-year-old man with invasive pulmonary aspergillosis treated with voriconazole and APAP for analgesia with a cumulative dose of 160 g over 40 days. PGA was suspected as he developed severe RAGMA and common causes were excluded. Diagnosis was confirmed via urinary organic acid analysis which showed significant hyper-excretion of pyroglutamic acid. APAP was discontinued, and N-acetylcysteine (NAC) was administered. His RAGMA rapidly resolved following treatment.

Impact of COVID-19 on Mental Health of Palliative Care Professionals and Services: A Mixed-Methods Survey Study.

INTRODUCTION: This study aimed to examine the mental health of palliative care professionals in Hong Kong during the COVID-19 pandemic, the relationship of mental health with socio-demographic factors, and the impact of the pandemic on palliative care services. METHODS: A total of 142 palliative care professionals in Hong Kong participated in an online survey. The questionnaire includes measurements on depression, anxiety, perceived stress, post-traumatic stress, professional quality of life, items that measure the effect of COVID-19 on palliative care services, and one open-ended question for describing how the services were affected. Descriptive and multivariate regression analyses were conducted. Quantitative and qualitative data about the impact of COVID-19 on palliative care services were analyzed and triangulated using a mixed-methods approach. RESULTS: Up to 82%, 43%, and 42% of the participants felt moderately to highly stressed, anxious, and depressed, respectively, during the pandemic. Younger participants tended to have poorer mental health and professional quality of life. Around 82% felt stressed when communicating with patients and family members under the no-visiting policy during the pandemic. More than three-quarters of participants showed lack of confidence in the anti-epidemic policy of the government. Qualitative findings identified 3 themes affecting the provision of palliative care: 1. the tightening of restrictions on visitors; 2. the limited provision of services; and 3. staff deployment. CONCLUSIONS: Appropriate responses are required to give extra support to palliative care professionals during the pandemic and facilitate their coping with the impact of COVID-19 on the provision of palliative care.

Knowledge gaps for functional outcomes after multilobar resective and disconnective pediatric epilepsy surgery: Conference Proceedings of the Patient-Centered Stakeholder Meeting 2019.

For children with medication-resistant epilepsy who undergo multilobar or hemispheric surgery, the goal of achieving seizure freedom is met with a variety of potential functional consequences, both favorable and unfavorable. However, there is a paucity of literature that comprehensively addresses the cognitive, medical, behavioral, orthopedic, and sensory outcomes across the lifespan following large epilepsy surgeries in childhood, leaving all stakeholders underinformed with regard to counseling and expectations. Through collaboration between clinicians, researchers, and patient/caregiver stakeholders, the "Functional Impacts of Large Resective or Disconnective Pediatric Epilepsy Surgery: Identifying Gaps and Setting PCOR Priorities" meeting was convened on July 18, 2019, to identify gaps in knowledge and inform various patient-centered research initiatives. Clinicians and researchers with content expertise presented the best available data in each functional domain which is summarized here. As a result of the meeting, the top three consensus priorities included research focused on postoperative: (1) hydrocephalus; (2) mental health issues; and (3) literacy and other educational outcomes. The proceedings of this meeting mark the first time research on functional outcomes after resective and disconnective pediatric epilepsy surgery has been codified and shared among multidisciplinary stakeholders. This joint initiative promotes continued collaboration in the field and ensures that advancements align with actual patient and family needs and experiences. Collaboration around common objectives will lead to better informed counseling around postoperative expectations and management for children undergoing epilepsy surgery.

Monitoring the Burden of Seizures and Highly Epileptiform Patterns in Critical Care with a Novel Machine Learning Method.

INTRODUCTION: Current electroencephalography (EEG) practice relies on interpretation by expert neurologists, which introduces diagnostic and therapeutic delays that can impact patients' clinical outcomes. As EEG practice expands, these experts are becoming increasingly limited resources. A highly sensitive and specific automated seizure detection system would streamline practice and expedite appropriate management for patients with possible nonconvulsive seizures. We aimed to test the performance of a recently FDA-cleared machine learning method (Claritγ, Ceribell Inc.) that measures the burden of seizure activity in real time and generates bedside alerts for possible status epilepticus (SE). METHODS: We retrospectively identified adult patients (n = 353) who underwent evaluation of possible seizures with Rapid Response EEG system (Rapid-EEG, Ceribell Inc.). Automated detection of seizure activity and seizure burden throughout a recording (calculated as the percentage of ten-second epochs with seizure activity in any 5-min EEG segment) was performed with Claritγ, and various thresholds of seizure burden were tested (≥ 10% indicating ≥ 30 s of seizure activity in the last 5 min, ≥ 50% indicating ≥ 2.5 min of seizure activity, and ≥ 90% indicating ≥ 4.5 min of seizure activity and triggering a SE alert). The sensitivity and specificity of Claritγ's real-time seizure burden measurements and SE alerts were compared to the majority consensus of at least two expert neurologists. RESULTS: Majority consensus of neurologists labeled the 353 EEGs as normal or slow activity (n = 249), highly epileptiform patterns (HEP, n = 87), or seizures [n = 17, nine longer than 5 min (e.g., SE), and eight shorter than 5 min]. The algorithm generated a SE alert (≥ 90% seizure burden) with 100% sensitivity and 93% specificity. The sensitivity and specificity of various thresholds for seizure burden during EEG recordings for detecting patients with seizures were 100% and 82% for ≥ 50% seizure burden and 88% and 60% for ≥ 10% seizure burden. Of the 179 EEG recordings in which the algorithm detected no seizures, seizures were identified by the expert reviewers in only two cases, indicating a negative predictive value of 99%. DISCUSSION: Claritγ detected SE events with high sensitivity and specificity, and it demonstrated a high negative predictive value for distinguishing nonepileptiform activity from seizure and highly epileptiform activity. CONCLUSIONS: Ruling out seizures accurately in a large proportion of cases can help prevent unnecessary or aggressive over-treatment in critical care settings, where empiric treatment with antiseizure medications is currently prevalent. Claritγ's high sensitivity for SE and high negative predictive value for cases without epileptiform activity make it a useful tool for triaging treatment and the need for urgent neurological consultation.

Comparing the quality of signals recorded with a rapid response EEG and conventional clinical EEG systems.

OBJECTIVES: To compare the quality of electroencephalography (EEG) signals recorded with a rapid response EEG system and the signals recorded with conventional clinical EEG recordings. METHODS: We studied the differences between EEG recordings taken with a rapid response EEG system (Ceribell) compared to conventional EEG through two separate set of studies. First, we conducted simultaneous recording on a healthy subject in an experimental laboratory setting where the rapid response EEG and two conventional EEG recording systems (Nihon Kohden and Natus) were used at the same time on the same subject using separate but adjacently placed electrodes. The rapid response EEG was applied by a user without prior training in EEG set up while two separate sets of conventional EEG electrodes were placed by a trained EEG technologist. The correlation between each of the recordings was calculated and quantitatively compared. In the second study, we performed a set of consecutive recordings on 22 patients in an ICU environment. The rapid response EEG system was applied by clinical ICU fellows without prior training in EEG set up while waiting for the conventional EEG system to arrive, after which the rapid response EEG was stopped and the conventional EEG was applied by a trained EEG technologist. We measured and compared several metrics of EEG quality using comparative metrics. RESULTS: For the simultaneous recording performed in a laboratory environment, the tested rapid response EEG and conventional EEG recordings showed agreement when aligned and visually compared in the time domain, all EEG waveform features were distinguishable in both recordings. The correlation between each pair of recordings also showed that the correlation between the rapid response EEG recording and each of the two conventional recordings was statistically the same as the correlation between the two conventional recordings. For the consecutive recordings performed in real life clinical ICU environment, Hjorth parameters, spike count, baseline wander, and kurtosis measures were statistically similar (p > 0.05, Wilcoxon signed rank test) for the rapid response EEG and conventional clinical EEG recordings. The rapid response EEG data had significantly lower 60 Hz noise compared to recordings made with the conventional systems both in laboratory and ICU settings. Lastly, the clinical information obtained with the rapid response EEG system was concordant with the diagnostic information obtained with the conventional EEG recordings in the ICU setting. CONCLUSIONS: Our findings show that the tested rapid response EEG system provides EEG recording quality that is equivalent to conventional EEG systems and even better when it comes to 60 Hz noise level. The concordance between the rapid response EEG and conventional EEG systems was demonstrated both in a controlled laboratory environment as well as in the noisy environment of a hospital ICU on patients with altered mental status. SIGNIFICANCE: Our findings clearly confirm that the tested rapid response EEG system provides EEG data that is equivalent in quality to the recordings made using conventional EEG systems despite the fact that the rapid response system can be applied within few minutes and with no reliance on specialized technologists. This can be important for urgent situations where the use of conventional EEG systems is hindered by the lengthy setup time and limited availability of EEG technologists.

Does postural instability affect the initiation of human gait?

During gait initiation (GI), decoupling of the center of mass and center of pressure allows the center of mass to fall forwards. Subjects initiated gait rapidly before and after tibial nerve block of the tibial nerve. Static single limb stability, stance limb ground reaction forces, electromyogram and temporal data were measured. It was hypothesized that postural stability would decrease post-block and that this would affect the kinetic and temporal properties of GI. Subjects had significantly decreased postural stability post-block and changes in normal gait kinetics, however, no changes were noted in ground reaction forces or relative temporal data of the GI task. The finding that GI was unaffected by diminished single leg postural instability suggests that GI is a pre-programmed task.