Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP): a scoping review.

BACKGROUND: Numerous conditions are grouped under the generic term exercise-induced leg pain (EILP), yet clear diagnostic guidelines are lacking. This scoping review was conducted to clarify the definition and diagnostic criteria of nine commonly occurring EILP conditions. METHODS: Three online databases were searched from inception to April 2022 for any English language original manuscripts identifying, describing, or assessing the clinical presentation and diagnostic criteria of the nine most common conditions that cause EILP. We included manuscripts considering all adults with any reported diagnostic criteria for EILP in any setting. Methodological quality was assessed using the Mixed Method Appraisal tool. Condition definitions were identified and categorised during data charting. Twenty-five potential elements of the history, 24 symptoms, 41 physical signs, 21 investigative tools, and 26 overarching diagnostic criteria, were identified and coded as counts of recommendation per condition, alongside qualitative analysis of the clinical reasoning. Condition definitions were constructed with 11 standardised elements based on recent consensus exercises for other conditions. RESULTS: One hundred nineteen retained manuscripts, of which 18 studied multiple conditions, had a median quality of 2/5. A combination of the history, pain location, symptoms, physical findings, and investigative modalities were fundamental to identify each sub-diagnosis alongside excluding differentials. The details differed markedly for each sub-diagnosis. Fifty-nine manuscripts included data on chronic exertional compartment syndrome (CECS) revealing exertional pain (83% history), dull aching pain (76% symptoms), absence of physical signs (78% physical findings) and elevated intercompartment pressure (93% investigative modality). Twenty-one manuscripts included data on medial tibial stress syndrome (MTSS), revealing persistent pain upon discontinuation of activity (81% history), diffuse medial tibial pain (100% pain location), dull ache (86% symptoms), diffuse tenderness (95% physical findings) and MRI for exclusion of differentials (62% investigative modality). Similar analyses were performed for stress fractures (SF, n = 31), popliteal artery entrapment syndrome (PAES, n = 22), superficial peroneal nerve entrapment syndrome (SPNES, n = 15), lumbar radiculopathy (n = 7), accessory/low-lying soleus muscle syndrome (ALLSMS, n = 5), myofascial tears (n = 3), and McArdle's syndrome (n = 2). CONCLUSION: Initial diagnostic frameworks and definitions have been developed for each condition of the nine most common conditions that cause EILP, suitable for clinical consideration and consensus confirmation

Variation in Hospital-use and Outcomes Associated with Pulmonary Artery Catheterization in Heart Failure in the United States

Background There has been an increase in the use of pulmonary artery (PA) catheters in heart failure (HF) in the United States in recent years. However, patterns of hospital-use and trends in patient outcomes are not known. Methods and Results In the National Inpatient Sample 2001–2012, using ICD-9 codes we identified 11,888,525 adult (≥18 years) HF hospitalizations nationally, of which an estimated 75,209 (SE 0.6%) received a PA catheter. In 2001, the number of hospitals with ≥1 PA catheterization was 1753, decreasing to 1183 in 2011. The mean PA catheter use per hospital trended from 4.9/year in 2001 (limits 1–133) to 3.8/year in 2007 (limits 1–46), but increased to 5.5/year in 2011 (limits 1–70). During 2001–2006, PA catheterization declined across hospitals; however, in 2007–2012 there has been a disproportionate increase at hospitals with large bedsize, teaching programs, and advanced HF capabilities. The overall in-hospital mortality with PA catheter use was higher than without PA catheter use (13.1% vs. 3.4%, P<0.0001), however, in propensity-matched analysis, differences in mortality between these groups have attenuated over time – risk-adjusted odds ratio for mortality for PA-catheterization, 1.66 (95% CI 1.60–1.74) in 2001–2003 down to 1.04 (95% CI 0.97– 1.12) in 2010–2012. Conclusions There is substantial hospital-level variability in PA catheterization in HF along with increasing volume at fewer hospitals overrepresented by large, academic hospitals with advanced HF capabilities. This is accompanied by a decline in excess mortality associated with PA catheterization

Use of mechanical circulatory support devices among patients with acute myocardial infarction complicated by cardiogenic shock

Importance: Mechanical circulatory support (MCS) devices, including intravascular microaxial left ventricular assist devices (LVADs) and intra-aortic balloon pumps (IABPs), are used in patients who undergo percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock despite limited evidence of their clinical benefit. Objective: To examine trends in the use of MCS devices among patients who underwent PCI for AMI with cardiogenic shock, hospital-level use variation, and factors associated with use. Design, Setting, and Participants: This cross-sectional study used the CathPCI and Chest Pain-MI Registries of the American College of Cardiology National Cardiovascular Data Registry. Patients who underwent PCI for AMI complicated by cardiogenic shock between October 1, 2015, and December 31, 2017, were identified from both registries. Data were analyzed from October 2018 to August 2020. Exposures: Therapies to provide hemodynamic support were categorized as intravascular microaxial LVAD, IABP, TandemHeart, extracorporeal membrane oxygenation, LVAD, other devices, combined IABP and intravascular microaxial LVAD, combined IABP and other device (defined as TandemHeart, extracorporeal membrane oxygenation, LVAD, or another MCS device), or medical therapy only. Main Outcomes and Measures: Use of MCS devices overall and specific MCS devices, including intravascular microaxial LVAD, at both patient and hospital levels and variables associated with use. Results: Among the 28 304 patients included in the study, the mean (SD) age was 65.4 (12.6) years and 18 968 were men (67.0%). The overall MCS device use was constant from the fourth quarter of 2015 to the fourth quarter of 2017, although use of intravascular microaxial LVADs significantly increased (from 4.1% to 9.8%; P \u3c .001), whereas use of IABPs significantly decreased (from 34.8% to 30.0%; P \u3c .001). A significant hospital-level variation in MCS device use was found. The median (interquartile range [IQR]) proportion of patients who received MCS devices was 42% (30%-54%), and the median proportion of patients who received intravascular microaxial LVADs was 1% (0%-10%). In multivariable analyses, cardiac arrest at first medical contact or during hospitalization (odds ratio [OR], 1.82; 95% CI, 1.58-2.09) and severe left main and/or proximal left anterior descending coronary artery stenosis (OR, 1.36; 95% CI, 1.20-1.54) were patient characteristics that were associated with higher odds of receiving intravascular microaxial LVADs only compared with IABPs only. Conclusions and Relevance: This study found that, among patients who underwent PCI for AMI complicated by cardiogenic shock, overall use of MCS devices was constant, and a 2.5-fold increase in intravascular microaxial LVAD use was found along with a corresponding decrease in IABP use and a significant hospital-level variation in MCS device use. These trends were observed despite limited clinical trial evidence of improved outcomes associated with device use

Increasing survival after admission to UK critical care units following cardiopulmonary resuscitation

© 2016 The Author(s). Background: In recent years there have been many developments in post-resuscitation care. We have investigated trends in patient characteristics and outcome following admission to UK critical care units following cardiopulmonary resuscitation (CPR) for the period 2004-2014. Our hypothesis is that there has been a reduction in risk-adjusted mortality during this period. Methods: We undertook a prospectively defined, retrospective analysis of the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database (CMPD) for the period 1 January 2004 to 31 December 2014. Admissions, mechanically ventilated in the first 24 hours in the critical care unit and admitted following CPR, defined as the delivery of chest compressions in the 24 hours before admission, were identified. Case mix, withdrawal, outcome and activity were described annually for all admissions identified as post-cardiac arrest admissions, and separately for out-of-hospital cardiac arrest and in-hospital cardiac arrest. To assess whether in-hospital mortality had improved over time, hierarchical multivariate logistic regression models were constructed, with in-hospital mortality as the dependent variable, year of admission as the main exposure variable and intensive care unit (ICU) as a random effect. All analyses were repeated using only the data from those ICUs contributing data throughout the study period. Results: During the period 2004-2014 survivors of cardiac arrest accounted for an increasing proportion of mechanically ventilated admissions to ICUs in the ICNARC CMPD (9.0 % in 2004 increasing to 12.2 % in 2014). Risk-adjusted hospital mortality following admission to ICU after cardiac arrest has decreased significantly during this period (OR 0.96 per year). Over this time, the ICU length of stay and time to treatment withdrawal has increased significantly. Re-analysis including only those 116 ICUs contributing data throughout the study period confirmed all the results of the primary analysis. Conclusions: Risk-adjusted hospital mortality following admission to ICU after cardiac arrest has decreased significantly during the period 2004-2014. Over the same period the ICU length of stay and time to treatment withdrawal has increased significantly

Tumour-derived PGD2 and NKp30-B7H6 engagement drives an immunosuppressive ILC2-MDSC axis.

Group 2 innate lymphoid cells (ILC2s) are involved in human diseases, such as allergy, atopic dermatitis and nasal polyposis, but their function in human cancer remains unclear. Here we show that, in acute promyelocytic leukaemia (APL), ILC2s are increased and hyper-activated through the interaction of CRTH2 and NKp30 with elevated tumour-derived PGD2 and B7H6, respectively. ILC2s, in turn, activate monocytic myeloid-derived suppressor cells (M-MDSCs) via IL-13 secretion. Upon treating APL with all-trans retinoic acid and achieving complete remission, the levels of PGD2, NKp30, ILC2s, IL-13 and M-MDSCs are restored. Similarly, disruption of this tumour immunosuppressive axis by specifically blocking PGD2, IL-13 and NKp30 partially restores ILC2 and M-MDSC levels and results in increased survival. Thus, using APL as a model, we uncover a tolerogenic pathway that may represent a relevant immunosuppressive, therapeutic targetable, mechanism operating in various human tumour types, as supported by our observations in prostate cancer.Group 2 innate lymphoid cells (ILC2s) modulate inflammatory and allergic responses, but their function in cancer immunity is still unclear. Here the authors show that, in acute promyelocytic leukaemia, tumour-activated ILC2s secrete IL-13 to induce myeloid-derived suppressor cells and support tumour growth

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial

Objective: To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA). Methods: We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge. Results: One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones. Conclusion: Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge

Embracing open innovation to acquire external ideas and technologies and to transfer internal ideas and technologies outside

The objective of this dissertation is to increase understanding of how organizations can embrace open innovation in order to acquire external ideas and technologies from outside the organization, and to transfer internal ideas and technologies to outside the organization. The objective encompasses six sub-objectives, each addressed in one or more substudies. Altogether, the dissertation consists of nine substudies and a compendium summarizing the substudies. An extensive literature review was conducted on open innovation and crowdsourcing literature (substudies 1–4). In the subsequent empirical substudies, both qualitative research methods (substudies 5–7) and quantitative research methods (substudies 8–9) were applied. The four literature review substudies provided insights on the body of knowledge on open innovation and crowdsourcing. These substudies unveiled most of the influential articles, authors, and journals of open innovation and crowdsourcing disciplines. Moreover, they identified research gaps in the current literature. The empirical substudies offer several insightful findings. Substudy 5 shows how non-core ideas and technologies of a large firm can become valuable, especially for small firms. Intermediary platforms can find solutions to many pressing problems of large organizations by engaging renowned scientists from all over world (substudy 6). Intermediary platforms can also bring breakthrough innovations with novel mechanisms (substudy 7). Large firms are not only able to garner ideas by engaging their customers through crowdsourcing but they can also build long-lasting relations with their customers (substudies 8 and 9). Embracing open innovation brings challenges for firms too. Firms need to change their organizational structures in order to be able to fully benefit from open innovation. When crowdsourcing is successful, it produces a very large number of new ideas. This has the consequence that firms need to allocate a significant amount of resources in order to identify the most promising ideas. In an idea contest, customarily, only one or a few best ideas are rewarded (substudy 7). Sometimes, no reward is provided for the selected idea (substudies 8 and 9). Most of the ideas that are received are not implemented in practice