Multimodality Monitoring: Informatics,Integration Data Display and Analysis

The goal of multimodality neuromonitoring is to provide continuous, real-time assessment of brain physiology to prevent, detect, and attenuate secondary brain injury. Clinical informatics deals with biomedical data, information, and knowledge including their acquisition, storage, retrieval, and optimal use for clinical decision-making. An electronic literature search was conducted for English language articles describing the use of informatics in the intensive care unit setting from January 1990 to August 2013. A total of 64 studies were included in this review. Clinical informatics infrastructure should be adopted that enables a wide range of linear and nonlinear analytical methods be applied to patient data. Specific time epochs of clinical interest should be reviewable. Analysis strategies of monitor alarms may help address alarm fatigue. Ergonomic data display that present results from analyses with clinical information in a sensible uncomplicated manner improve clinical decision-making. Collecting and archiving the highest resolution physiologic and phenotypic data in a comprehensive open format data warehouse is a crucial first step toward information management and two-way translational research for multimodality monitoring. The infrastructure required is largely the same as that needed for telemedicine intensive care applications, which under the right circumstances improves care quality while reducing cost.     

PKCbeta regulates ischemia/reperfusion injury in the lung

Activation of PKCbetaII is associated with the response to ischemia/reperfusion (I/R), though its role, either pathogenic or protective, has not been determined. In a murine model of single-lung I/R, evidence linking PKCbeta to maladaptive responses is shown in the following studies. Homozygous PKCbeta-null mice and WT mice fed the PKCbeta inhibitor ruboxistaurin subjected to I/R displayed increased survival compared with controls. In PKCbeta-null mice, phosphorylation of extracellular signal-regulated protein kinase-1 and -2 (ERK1/2), JNK, and p38 MAPK was suppressed in I/R. Expression of the immediate early gene, early growth response-1 (Egr-1), and its downstream target genes was significantly increased in WT mice in I/R, particularly in mononuclear phagocytes (MPs), whereas this expression was attenuated in PKCbeta-null mice or WT mice fed ruboxistaurin. In vitro, hypoxia/reoxygenation-mediated induction of Egr-1 in MPs was suppressed by inhibition of PKCbeta, ERK1/2, and JNK, but not by inhibition of p38 MAPK. These findings elucidate key roles for PKCbetaII activation in I/R by coordinated activation of MAPKs (ERK1/2, JNK) and Egr-1.     

Perioperative blood transfusion does not decrease survival after surgical treatment of spinal metastases

Purpose

To assess whether perioperative allogenic blood transfusions in patients undergoing surgical treatment for spinal metastases independently influence patient survival.

Methods

A retrospective study including 170 consecutive patients undergoing surgical treatment for spinal metastases in 2009 and 2010 at a tertiary referral center. Variables related to postoperative survival were all included in the same multivariable logistic regression analysis with either 3- or 12-month survival as the dependent variable. The independent variables were: transfusion of allogenic red blood cells, age at surgery, gender, preoperative hemoglobin, revised Tokuhashi score and no. of instrumented levels.

Results

Perioperative allogenic blood transfusion of 1–2 units was associated with increased 12-month survival [p = 0.049, odds ratio 2.619 (confidence interval 1.004–6.831)], but not with 3-month survival. Larger transfusion volumes did not significantly influence survival.

Conclusion

The results of the present study support that perioperative blood transfusion of <5 units does not decrease survival in patients operated for spinal metastases. Transfusion of 1–2 units seems to be associated with increased 12-month survival. Future studies should assess if a liberal transfusion regime can be applied to this group of patients; thereby, prioritizing early postoperative mobilization.     

General in-situation safety behaviors are uniquely associated with post-event processing

Background and objectives

Research suggests that state anxiety and in-situation safety behaviors are associated with post-event processing (PEP) in social anxiety. Past research has obtained mixed results on whether one or both factors contribute to PEP. The current investigation evaluated state anxiety and in-situation safety behaviors (including subtypes of in-situation safety behaviors) simultaneously to determine their relative contributions to PEP.

Methods

A prospective study assessed social anxiety, state anxiety, in-situation safety behaviors, PEP, and depression in the context of a speech stressor.

Results

Consistent with theory, in-situation safety behaviors were uniquely associated with greater PEP. State anxiety was not uniquely associated with PEP. Furthermore, restricting and active subtypes of in-situation safety behaviors showed specificity to PEP.

Limitations

Limitations of the present study include the use of a nonclinical analog sample and retrospective reporting of PEP.

Conclusions

These findings highlight the importance of research on in-situation safety behaviors as a potential contributor to PEP.     

Case Manager as Therapy Extender for Cognitive Behavior Therapy of Serious Mental Illness: A Case Report

Cognitive behavior therapy (CBT) is an evidence-based intervention for individuals with serious mental illness and potentiates standard medication management. Americans receiving publicly funded treatment for serious mental illnesses have limited access to CBT and hence we need to devise innovative ways of providing access to this important intervention. We present a case of a man who had severe disability, was medication resistant, and diagnosed with Obsessive Compulsive Disorder and Major Depressive Disorder. After being home bound for many years he was provided CBT utilizing his existing case manager as a therapy extender. The specific roles of the primary therapist and case manager as well as the improvement in quality of life of the individual are delineated. This case report opens up the possibility of further studying case managers as therapy extenders for treating serious mental illnesses.     

An initial investigation of the relationships between hoarding and smoking

Cigarette smokers have increased rates of mood and anxiety-related conditions. Hoarding is another anxiety-related condition that has yet to be examined in relation to smoking behavior. The current investigation sought to examine smoking rates among a sample of individuals with hoarding disorder and individuals with non-hoarding obsessive–compulsive disorder (OCD). Additionally, we examined the relationship between hoarding symptoms and reasons for smoking. Participants in Study 1 consisted of 57 individuals with non-hoarding OCD or hoarding disorder. Participants in Study 2 consisted of 661 adult daily smokers. Results revealed that a significantly greater proportion of individuals diagnosed with hoarding were current smokers compared to the non-hoarding OCD group. Additionally, hoarding severity was associated with negative affect reduction expectancies. These results provide important information regarding smoking behaviors within hoarding disorder. Given the poor treatment outcomes and negative health risks associated with hoarding, this information could inform future research and treatment programs.     

Rehabilitation therapy for patients with long-term spinal cord injuries

The functional effects of three types of therapy for subjects with long-term incomplete cervical spinal cord injuries were investigated. Men and women, aged 18 to 45 years, were assigned to one of four groups using a restricted randomization process. The training period was divided into two consecutive eight-week time blocks where subjects received either (1) supervised physical exercise therapy (PET), (2) neuromuscular stimulation (NMS), or (3) electromyographic (EMG) biofeedback. Group 1 received EMG biofeedback followed by PET; Group 2 received EMG biofeedback followed by NMS; Group 3 received NMS followed by PET; and Group 4 received 16 weeks of PET. Dependent measures (manual muscle tests, self-care scores, mobility measures, and voluntary EMG activity) were assessed before training, at eight weeks, and after 16 weeks of training. A significant improvement (p less than .05) across time was found on all dependent measures except voluntary EMG. No difference was found on comparisons between groups.     

23Na-magnetic resonance imaging of the human lumbar vertebral discs: in vivo measurements at 3.0 T in healthy volunteers and patients with low back pain

Background context¹H magnetic resonance imaging (MRI) of the spine can rule out common causes of low back pain (LBP), such as disc protrusions or nerve root compression; however, no significant causal relation exists between morphology and the extent of symptoms. Functional MRI techniques, such as ²³Na, may provide additional information, allowing indirect assessment of vertebral glycosaminoglycan concentrations, decreases in which are associated with early degenerative changes.PurposeTo evaluate ²³Na-MRI of asymptomatic healthy volunteers and symptomatic patients with LPB and correlate the results to the Pfirrmann classification of MRI disc morphology.Study designRetrospective cohort study at an academic medical center.Patient sampleTwo groups were studied: (1) 55 healthy volunteers (31 men, 24 women; mean age 28.8 years) and (2) 12 patients (6 men, 6 women; mean age: 35.3 years) with a recent history of LBP.MethodsLumbar spines of the aforementioned groups were examined on a 3.0 T MRI scanner with morphological ¹H and ²³Na imaging. Intervertebral disc (IVD) ²³Na at each level was normalized (²³Na_norm). Distribution and differences between mean ²³Na_norm corresponding to each Pfirrmann classification were evaluated in the two study groups (analysis of variance). Linear correlations between ²³Na_norm, body mass index (BMI), and age were assessed (Pearson correlation coefficient). Gender-dependent differences were evaluated (paired t test).Outcome measuresPhysiological measure: IVD ²³Na_norm as determined by ²³Na-MRI.ResultsA normal distribution of ²³Na_norm was confirmed for both groups (p=.072 and p=.073, respectively). The mean Pfirrmann score statistically significantly differed between them (p<.0001). ²³Na_norm was statistically significantly reduced in degenerated IVDs (Pfirrmann scores 4+5) (p<.0001). No statistically significant differences were seen for the mean ²³Na_norm of IVDs with the same Pfirrmann score in healthy volunteers and patients (.469<p<.967). Age (0.007<R²<0.202) and BMI (0.074<R²<0.288) showed either weak or no correlation to ²³Na_norm. Mean ²³Na_norm was significantly (p=.0002) greater in women relative to men.ConclusionsThe results underline the feasibility and robustness of ²³Na-MRI of human IVDs and affirm, in a large cohort, decreases in ²³Na IVD content seen with disc degeneration.     

Qualitätssicherung an der Schnittstelle zwischen Anästhesie und Transfusionsmedizin

Background

The current situation in hospitals is characterized by financial limitations and simultaneously by increasing demands on quality and safety. The operative interface between anesthesia and transfusion medicine affects both factors.

Aim

A detailed analysis was performed to evaluate the process quality at this operative interface at the University Hospital of Göttingen. The aim of the project was to revise und develop the structures and responsibilities at this interface, to dispose of weak points and to realize the optimization potential in the supply of blood products.

Material and methods

A databank-based electronic data processing solution was established with the clear definition of responsibilities for the various workflow procedures and the written documentation of these definitions in standard operating protocols. In order to guarantee the necessary transparency a routine reporting system to the department of surgery was established. In addition, a continuous further development of the blood supply standard based on electronic report data was implemented.

Results

By implementing the above named measures the rate of supplied to transfused blood products could be increased from 43.1?% to 55.7?%. The compliance with the blood supply standard improved continually over the first 18 months from 60.3?% to 92.3?%. The rate of supplied blood product deliveries without subsequent operation could be reduced from 9.0?% to 4.6??%. As a result of this optimization the supply costs in the internal cost allocation were reduced from 9,406 € to 3,544 €.

Conclusion

The measures described are appropriate to cost-effectively improve quality and patient safety. The optimization measures presented in this article can be implemented in other hospitals to increase quality and safety after individual adjustment to the local circumstances.