bluuebunny/crossref_metadata_2025 huggingface dataset:
Therapeutic Overview of Neuromuscular Signaling Responses in Myasthenia Gravis Patients following Surgical vs Non‐Surgical Treatment
Authors: Sainvil Frantz , Tulp Orien Lee , Einstein George P.
Published: April 2020

Myasthenia gravis (MG) is one of the most common disorder of neuromuscular signaling, where it has a reported prevalence of between13 to 21 patients per 100,000 population, representing 37,000 to 61,000 confirmed cases in the USA. There is no single approach to treat the condition, and currently no cures are known. The purpose of this study was to review two of the primary therapeutic protocols for treating MG by Meta Analysis, in an attempt to determine which of the leading two protocols (thymectomy vs. neostigmine bromide (NBR)) was associated with the most optimistic outcome. The symptoms commonly experienced by people with MG include muscle weakness and generalized fatigue. In healthy patients, the presynaptic terminals release acetylcholine (ACh) from the motor nerve terminal in quanta. The ACh quanta diffuse across the synaptic cleft and impinge on ACh receptors on the post synaptic membrane of the muscle that causes depolarization from the neuromuscular cleft, and which results in a contractile event in the affected muscle. In MG patients, the post synaptic membrane (ACh receptors) are typically damaged at least in part due to immunological or sometimes genetic abnormalities.. Tumors of the thymus gland are also commonly observed in patients with MG. In MG, B‐cells interact with helper T‐cells to produce anti‐ACh receptor antibodies. The destruction of the thymus’ tolerance can thus result in an immunologic attack on the post‐synaptic ACh receptors. MG can be treated with cholinesterase inhibitors such as NBR or extended transsternal thymectomy. This study utilized a Meta‐analysis approach for data interpretation of surgical vs NBR in order to compare neuromuscular signaling on MG’s patients who are treated with cholinesterase inhibitors versus those who are treated surgically. The results of this study concluded that neuromuscular signaling in MG patients who have had surgical interventions have better and more successful outcomes that those patients that received the NBR treatment only.

Support or Funding Information

Supported by Institutional Resources of USAT Montserrat and the Einstein Medical Institute

Support or Funding Information

Supported by Institutional Resources of USAT Montserrat, the University of Health and Humanities Virgin Islands and the Einstein Medical Institute
Discriminative Stimulus Effects of Mu Opioid Receptor Agonists in Rats Discriminating Fentanyl: Differential Antagonism by Naltrexone
Authors: Flynn Shawn , France Charles
Published: April 2020

The opioid crisis continues despite the availability of medications that are effective in some patients. A significant number of deaths caused by opioids involve fentanyl and/or one of its very potent analogues (e.g., carfentanil). Many fentanyl analogs have not been studied extensively in vivo. The current study compared the discriminative stimulus effects of fentanyl and carfentanil and their antagonism by naltrexone. Seven male Sprague‐Dawley rats were trained to discriminate a 0.01 mg/kg fentanyl from saline while responding under a fixed‐ratio 10 schedule of food presentation. Dose effect curves were determined for the opioid receptor agonists alone: fentanyl (0.001–0.1 mg/kg) and carfentanil (0.0001–0.0032 mg/kg). Dose effect curves for fentanyl and carfentanil were then redetermined following a 15‐minute pretreatment with 0.1 mg/kg naltrexone. All drugs were delivered intraperitoneally. Fentanyl and carfentanil dosedependently increased responding on the fentanyl‐associated lever and at larger doses decreased the rate of lever pressing. Carfentanil was approximately 10‐fold more potent than fentanyl at eliciting >90% responding on the fentanyl‐associated lever. Pretreatment with 0.1 mg/kg naltrexone shifted the fentanyl dose‐effect curve 10‐fold rightward whereas the same dose of naltrexone shifted the carfentanil curve only 3‐fold rightward. Differences in the effectiveness of naltrexone to attenuate the discriminative stimulus effects of fentanyl and carfentanil suggests that there may be differences in how fentanyl and carfentanil exert their discriminative stimulus effects. Further evaluation of potential pharmacological and behavioral differences between fentanyl and carfentanil is needed and might provide important insights regarding the apparently increased toxicity of carfentanil, compared with other opioids, in humans.

Support or Funding Information

AQ‐0039 from the Welch Foundation
Flexible Intramedullary Nailing of Femoral Shaft Fractures in Children Weighing ≥40 kg: A Systematic Review and Meta-analysis
Authors: Makarewich Christopher A. , Talwar Divya , Baldwin Keith D. , Swarup Ishaan
Published: April 2020

Background:

Pediatric femur fractures are commonly treated with flexible intramedullary nails (FIN). However, there is controversy regarding the effect of patient weight on outcomes and complications. The purpose of this meta-analysis was to review the literature and describe implant choice, analyze complication, and reoperation rates; as well as the report clinical and radiographic outcomes of FIN in pediatric patients weighing ≥40 kg with femoral shaft fractures.

Methods:

A systematic review was performed of all retrospective and prospective studies focusing on the use of FIN in heavy children in Medline, Cochrane, and Web of Science databases. Data extraction was performed and summarized using descriptive statistics. Quality assessment was performed using the Newcastle-Ottawa Scale. Meta-analysis was performed for complications using pooled data from included studies.

Results:

The initial search strategy yielded 177 references, and after exclusions, 5 studies were included. The majority of studies were retrospective, and the most commonly used implants in heavier patients were titanium FIN and stainless steel Enders FIN. There were higher rates of radiographic nonunion and malunion, complications, and reoperations for refracture; and nonunion in heavier children treated with FIN. Meta-analysis performed on 4 applicable studies showed the overall complication rate was higher in the heavier patients compared with lighter patients (30.6% vs. 11.1%) with a relative risk of 1.20 [95% confidence interval (CI), 1.02-1.41]. Heavier patients also had higher rates of major complications (relative risk, 1.32; 95% CI, 1.03-1.69) but similar minor complications (relative risk, 1.13; 95% CI, 0.90-1.41).

Conclusions:

Heavier children have worse radiographic outcomes and higher complication rates with the use of FIN for femoral shaft fractures. Additional research is needed to determine the effect of FIN material on clinical outcomes in heavier children, and the relationship between weight and other known risk factors for poor outcome in FIN, such as length stability.

Level of Evidence:

Level III—systematic review of level-III studies.
Impact of Bilateral Infiltrates on Inflammatory Biomarker Levels and Clinical Outcomes of Children With Oxygenation Defect
Authors: Kohne Joseph G. , Dahmer Mary K. , Weeks Heidi M. , Kaciroti Niko , Quasney Michael W. , Sapru Anil , Curley Martha A. Q. , Matthay Michael , Flori Heidi
Published: April 2020

Objectives:

The 2015 definition for pediatric acute respiratory distress syndrome did not require the presence of bilateral infiltrates. We tested the hypothesis that pediatric patients meeting oxygenation criteria for pediatric acute respiratory distress syndrome but without bilateral infiltrates would have different inflammatory biomarker levels and clinical outcomes than those with bilateral infiltrates.

Design:

Secondary analysis of a prospective cohort study.

Setting:

Twenty-two PICUs.

Patients:

Four-hundred forty-six patients age 2 weeks to 17 years intubated for respiratory failure with oxygenation index greater than or equal to 4 or oxygenation saturation index greater than or equal to 5 on the day of intubation or the day after.

Interventions:

None.

Measurements and Main Results:

Patients with bilateral infiltrates, either on the day of intubation or within the following 2 days, were compared with children who never developed bilateral infiltrates. Two analyses were performed to test 1) whether bilateral infiltrates are associated with elevated interleukin-1 receptor antagonist or interleukin-8 and 2) whether bilateral infiltrates are associated with worse clinical outcomes. Patients with bilateral infiltrates more often had a primary diagnosis of pneumonia (41% vs 28%; p = 0.02) and less often asthma (8% vs 23%; p < 0.01). After controlling for age, gender, and primary diagnosis, interleukin-1 receptor antagonist was higher on study days 1 and 2 in patients with bilateral infiltrates. There was no difference in interleukin-8 levels. After adjusting for age, gender, Pediatric Risk of Mortality score, and severity of oxygenation defect, presence of bilateral infiltrates was associated with longer duration of mechanical ventilation in survivors (hazard ratio, 0.64; 95% CI, 0.49–0.82; p < 0.01); this association was independent of primary diagnosis. Overall mortality was 9%; mortality was higher in those without bilateral infiltrates (14% vs 8%; p = 0.04).

Conclusions:

Children meeting pediatric acute respiratory distress syndrome oxygenation criteria with bilateral infiltrates on chest radiograph experience a more intense early inflammatory response. Bilateral infiltrates are associated with longer time on the ventilator independent of oxygenation defect severity.
Association Between Arterial Carbon Dioxide Tension and Clinical Outcomes in Venoarterial Extracorporeal Membrane Oxygenation*
Authors: Diehl Arne , Burrell Aidan J. C. , Udy Andrew A. , Alexander Peta M. A. , Rycus Peter T. , Barbaro Ryan P. , Pellegrino Vincent A. , Pilcher David V.
Published: April 2020

Objectives:

The manipulation of arterial carbon dioxide tension is associated with differential mortality and neurologic injury in intensive care and cardiac arrest patients; however, few studies have investigated this relationship in patients on venoarterial extracorporeal membrane oxygenation. We investigated the association between the initial arterial carbon dioxide tension and change over 24 hours on mortality and neurologic injury in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiac arrest and refractory cardiogenic shock.

Design:

Retrospective cohort analysis of adult patients recorded in the international Extracorporeal Life Support Organization Registry.

Setting:

Data reported to the Extracorporeal Life Support Organization from all international extracorporeal membrane oxygenation centers during 2003-2016.

Patients:

Adult patients (≥ 18 yr old) supported with venoarterial extracorporeal membrane oxygenation.

Interventions:

None.

Measurements and Main Results:

A total of 7,168 patients had sufficient data for analysis at the initiation of venoarterial extracorporeal membrane oxygenation, 4,918 of these patients had arterial carbon dioxide tension data available at 24 hours on support. The overall in-hospital mortality rate was 59.9%. A U-shaped relationship between arterial carbon dioxide tension tension at extracorporeal membrane oxygenation initiation and in-hospital mortality was observed. Increased mortality was observed with a arterial carbon dioxide tension less than 30 mm Hg (odds ratio, 1.26; 95% CI, 1.08–1.47; p = 0.003) and greater than 60 mm Hg (odds ratio, 1.28; 95% CI, 1.10–1.50; p = 0.002). Large reductions (> 20 mm Hg) in arterial carbon dioxide tension over 24 hours were associated with important neurologic complications: intracranial hemorrhage, ischemic stroke, and/or brain death, as a composite outcome (odds ratio, 1.63; 95% CI, 1.03–2.59; p = 0.04), independent of the initial arterial carbon dioxide tension.

Conclusions:

Initial arterial carbon dioxide tension tension was independently associated with mortality in this cohort of venoarterial extracorporeal membrane oxygenation patients. Reductions in arterial carbon dioxide tension (> 20 mm Hg) from the initiation of extracorporeal membrane oxygenation were associated with neurologic complications. Further prospective studies testing these associations are warranted.
Utility of Driving Pressure and Mechanical Power to Guide Protective Ventilator Settings in Two Cohorts of Adult and Pediatric Patients With Acute Respiratory Distress Syndrome: A Computational Investigation
Authors: Saffaran Sina , Das Anup , Laffey John G. , Hardman Jonathan G. , Yehya Nadir , Bates Declan G.
Published: April 2020

Objectives:

Mechanical power and driving pressure have been proposed as indicators, and possibly drivers, of ventilator-induced lung injury. We tested the utility of these different measures as targets to derive maximally protective ventilator settings.

Design:

A high-fidelity computational simulator was matched to individual patient data and used to identify strategies that minimize driving pressure, mechanical power, and a modified mechanical power that removes the direct linear, positive dependence between mechanical power and positive end-expiratory pressure.

Setting:

Interdisciplinary Collaboration in Systems Medicine Research Network.

Subjects:

Data were collected from a prospective observational cohort of pediatric acute respiratory distress syndrome from the Children’s Hospital of Philadelphia (n = 77) and from the low tidal volume arm of the Acute Respiratory Distress Syndrome Network tidal volume trial (n = 100).

Interventions:

Global optimization algorithms evaluated more than 26.7 million changes to ventilator settings (approximately 150,000 per patient) to identify strategies that minimize driving pressure, mechanical power, or modified mechanical power.

Measurements and Main Results:

Large average reductions in driving pressure (pediatric: 23%, adult: 23%), mechanical power (pediatric: 44%, adult: 66%), and modified mechanical power (pediatric: 61%, adult: 67%) were achievable in both cohorts when oxygenation and ventilation were allowed to vary within prespecified ranges. Reductions in driving pressure (pediatric: 12%, adult: 2%), mechanical power (pediatric: 24%, adult: 46%), and modified mechanical power (pediatric: 44%, adult: 46%) were achievable even when no deterioration in gas exchange was allowed. Minimization of mechanical power and modified mechanical power was achieved by increasing tidal volume and decreasing respiratory rate. In the pediatric cohort, minimum driving pressure was achieved by reducing tidal volume and increasing respiratory rate and positive end-expiratory pressure. The Acute Respiratory Distress Syndrome Network dataset had limited scope for further reducing tidal volume, but driving pressure was still significantly reduced by increasing positive end-expiratory pressure.

Conclusions:

Our analysis identified different strategies that minimized driving pressure or mechanical power consistently across pediatric and adult datasets. Minimizing standard and alternative formulations of mechanical power led to significant increases in tidal volume. Targeting driving pressure for minimization resulted in ventilator settings that also reduced mechanical power and modified mechanical power, but not vice versa.
Abrupt and Severe Obsessive-Compulsive Disorder in an 11-Year-Old Girl—PANDAS/PANS Syndrome: An Entity to be Considered—Management Implications : “[RETRACTED]”
Authors: Khodayar-Pardo Parisá , Álvarez-Bravos Laura
Published: April 2020

CASE:

An 11-year-old preadolescent girl was taken to the pediatric emergency room by her parents because of emotional overload.

Her clinical history started 3 weeks before the visit, coinciding with a self-limited gastrointestinal infection affecting the whole family. Her obsessive behavior first appeared in the school setting; she tried to write perfectly, needing to make repeated corrections and ripping out multiple sheets from her notebooks when she made mistakes. She quickly developed new obsessions in diverse areas that progressively took over her life. When crossing the street, she initially avoided stepping on the zebra crossing lines, which recently progressed to needing to be carried across the pedestrian crossings, becoming greatly distressed if her parents refused. She also developed symmetry compulsions, requiring others to participate in them to avoid frustrating her, for example, asking anyone who touched her clothes to repeat the action for a similar length of time on the opposite side with a perfect symmetry, adopting the same position like a mirror image. There were no superstitions or psychotic features associated with these behaviors. The rituals progressively affected all areas of life (school, family, and friends) and had become highly maladaptive. Being aware of the peculiarity of her symptoms, at school, she tried unsuccessfully to hide them, feeling increasingly anxious.

On the day of the hospital visit, she felt so overwhelmed by distress and the need for rituals that she was unable to get out of bed to go to school, describing a compulsion to rearrange the sheets and pillows in a specific way that was impossible to achieve. Her concerned parents decided to take her to hospital.
Radiofrequency Treatment of Labia Minora and Majora: A Minimally Invasive Approach to Vulva Restoration
Authors: Dayan Erez , Ramirez Henry , Theodorou Spero
Published: April 2020

Labiaplasty has rapidly increased in popularity over the past 5 years.Traditional labiaplasty is associated with potential complications, such as dehiscence, hematoma, flap necrosis, narrowed introitus, pain, and asymmetry. Minimally invasive techniques such as radiofrequency (RF) have emerged as viable alternatives to traditional labiaplasty through a temperature-controlled bipolar mechanism to heat tissues to target temperatures of 40°C–45°C. This controlled energy delivery leads to an inflammatory cascade initiating neocollagenesis, angiogenesis, and elastogenesis over the coming 3–4 months. A single surgeon series of labia minora and majora treatment by RF (InMode, Lake Forrest, Calif.) was reviewed between April 2018–October 2018. Demographic data were collected as well grade of hypertrophy (pre/posttreatment), number of vaginal deliveries, and reason for treatment. Procedural parameters were recorded, including internal/external temperatures, total energy used, and time of treatment. All adverse events were recorded. Objective and subjective data points were obtained in the form of patient surveys and photographic evaluation by lay persons as well as plastic surgeons objective to the treatment. Ten consecutive patients were treated with bipolar RF (InMode, Lake Forrest, Calif.) between April 2018–October 2018. Mean age was 44 (29–54). Average number of pregnancies was 2 (STD 1.1). Three patients were treated for aesthetic concerns, 3 for functional complaints, and 4 desired improvement in both. Overall graded improvement in labia size/contour was +50% (STD ±15.3). Patient satisfaction scale data demonstrated 9.5/10 (±1.7). All patients (10/10) stated that they would undergo treatment again. In all cases, the surgeon observed tightening of the clitoral hood, introitus, forchett, as well as improved distribution of dark pigmentation of the labia minora. There were no significant complications and no need for additional procedures. Average recovery time was 14 days (STD 2.2). Treatment of labia hyperplasia and laxity with bipolar RF may potentially fill a treatment gap of women seeking aesthetic and functional improvements without surgical labiaplasty. A powered prospective randomized double-blinded study is needed to further elucidate the role of this technology.
Does Realism Matter? A Randomized Controlled Trial Comparing Models for Medical Student Suture Education
Authors: Blau Jared A. , Shammas Ronnie L. , Anolik Rachel A. , Avashia Yash J. , Krucoff Kate B. , Zenn Michael R.
Published: April 2020

Background:

We hypothesized that medical students trained in suturing using high-fidelity models (cadaveric tissue) would demonstrate greater proficiency when compared with those trained using low-fidelity models (synthetic tissue).

Methods:

Forty-three medical students were randomized into 2 groups. Group 1 consisted of students taught to perform simple interrupted sutures using synthetic tissue, and group 2 consisted of those taught using human cadaveric tissue. Suturing proficiency was measured pre- and postinstruction using the Global Rating Scale and by measuring suture accuracy. Perceived confidence in suturing was measured on a scale of 0–100.

Results:

Perceived confidence was measured as an average of 8.26 out of 100 pretraining and significantly improved after training (56.91 out of 100); however, there was no significant difference when comparing confidence between groups posttraining (57.65 cadaveric versus 56.05 synthetic; P = 0.78), nor in the measured confidence change pre- and posttraining (P = 0.53). Posttraining, participants displayed a significant improvement in the number of adequately placed sutures; however, there was no significant difference posttraining when comparing groups (2.43 cadaveric versus 2.75 synthetic; P = 0.48). The change in adequate suture placement pre- and posttraining did not reach statistical significance between groups (P = 0.27). After instruction, participants demonstrated a significant improvement in total suture performance scores; however, there was no significant difference when comparing groups (30.04 cadaveric versus 29.80 synthetic; P = 0.90), nor in the total change pre- and posttraining (P = 0.74).

Conclusions:

Training medium fidelity (tissue versus synthetic) does not significantly influence a student’s overall suturing performance. However, formal instruction significantly improves objective competence and perceived confidence. Regardless of the model, surgical departments should emphasize medical student exposure to basic surgical skills education.
Intraoperative Near-infrared Spectroscopy Correlates with Skin Flap Necrosis: A Prospective Cohort Study
Authors: Hill William F. , Webb Carmen , Monument Michael , McKinnon Gregory , Hayward Victoria , Temple-Oberle Claire
Published: April 2020

Background:

Skin flap necrosis (SFN) is a morbid complication that is disfiguring, leads to acute and chronic wound issues, often requires further surgery, and can delay adjuvant chemotherapy. Although most surgeons rely on the clinical examination, near-infrared (NIR) spectroscopy can extrapolate tissue oxygenation and may serve as an important tool to assess flap perfusion intraoperatively. This cohort study was undertaken to evaluate the capacity of NIR spectroscopy to detect clinically relevant differences in tissue perfusion intraoperatively.

Methods:

Patients undergoing oncologic resection of breast cancer, sarcomas, and cutaneous tumors requiring flap reconstruction (local, regional, or free) between January 2018 and January 2019 were analyzed in this study. Clinicians were blinded to device tissue oxygen saturation (StO2) measurements taken intraoperatively after closure and at follow-up appointments in the first 30 days. Measurements were categorized as (1) control areas not affected by the procedure, (2) areas at risk, and (3) areas of necrosis. These areas were retrospectively demarcated by 2 blinded assessors on follow-up images and transposed onto anatomically correlated intraoperative StO2 measurements. Mean StO2 values were compared using a single-sample t test and analysis of variance (ANOVA) to determine differences in oxygenation.

Results:

Forty-two patients were enrolled, and 51 images were included in the analysis. Oncologic procedures were predominantly breast (22), postextirpative melanoma (13), and sarcoma (3) reconstructions. Flap reconstruction involved 30 regional skin flaps, 3 pedicled flaps, and 3 free flaps. Nine patients (20.9%) and 11 surgical sites developed SFN. Mean intraoperative StO2 measurements for control areas, areas at risk, and areas of SFN were 74.9%, 71.1%, and 58.3%, respectively. Relative to control areas, mean intraoperative StO2 measurements were lower by 17.5% (P = 0.01) in ultimate areas of SFN and in areas at risk by 5.8% (P = 0.003). Relative to areas at risk, mean StO2 measurements from areas of ultimate SFN were lower by 8.3% (P = 0.04).

Conclusion:

These preliminary data suggest that measuring skin flap tissue oxygenation intraoperatively, with NIR spectroscopy, can differentiate objective variations in perfusion that are associated with clinical outcomes.
African Americans have a distinct clinical and histologic profile with lower prevalence of NASH and advanced fibrosis relative to Caucasians
Authors: Satapathy Sanjaya K. , Marella Hemnishil K. , Heda Rajiv P. , Ganguli Surosree , Kirthi Reddy Yala , Podila Pradeep S.B. , Clark Ian , Maliakkal Benedict
Published: April 2020

Background and Aims

Racial/ethnic disparities have been reported in the prevalence of nonalcoholic fatty liver disease (NAFLD). Thus, we aimed to understand the inter-ethnic clinical, biochemical, and histological differences in a large cohort of Caucasians and African-Americans (AA).

Methods

Laboratory and liver biopsy data of 942 NAFLD patients were retrospectively analyzed. Nine hundred seven patients were included in the analysis: 677 (74.6%) Caucasians and 230 (25.3%) AA.

Results

AA had higher mean BMI compared to Caucasians (42.6 ± 9.5 vs. 39 ± 8.6 kg/m2). The prevalence of nonalcoholic steatohepatitis (NASH), defined by NAFLD activity score (NAS . 5), was higher in the Caucasians (n = 67) compared to AA (n = 7) (9.8% vs. 3%, P = 0.0007). One hundred fifteen patients (12.8%) had advanced fibrosis: 109 (16.2%) Caucasians and six (2.6%) AA. No AA patients had stage 4 fibrosis or cirrhosis. Multivariate logistic regression analysis revealed advanced fibrosis was significantly associated with age at liver biopsy (OR 1.03, 95% CI 1.0.1.1, P = 0.017, lower platelet count (OR 0.99, 95% CI 0.98.0.99, P = <0.0001), AST/ALT ratio (OR 5.19, 95% CI 2.9.9.2, P <0.0001) and Caucasian race (OR 7.49, 95% CI 2.53.22.2, P = 0.0003). Advanced fibrosis in AA was predicted by lower platelet count and AST/ALT ratio. Whereas Advanced fibrosis in Caucasians was predicted by age at biopsy, lower platelet count and AST/ALT ratio.

Conclusion

The AA have a distinct clinical and histologic phenotype. Caucasians have a significantly greater proportion of
NASH and are eight times more likely to develop advanced fibrosis than AA.
The suspected SARS-Cov-2 infection in a Charcot-Marie-Tooth patient undergoing postsurgical rehabilitation: the value of telerehabilitation for evaluation and continuing treatment
Authors: Prada Valeria , Bellone Emilia , Schenone Angelo , Grandis Marina
Published: April 2020

We report, to the best of our knowledge, the first case of a probable COVID-19 infection in a 28-year-old man with Charcot-Marie-Tooth disease. The diagnosis was established through a remote interaction with the patient after early discharge from outpatient therapy due to upcoming traveling restrictions. The COVID-19 disease appeared mild, without major respiratory problems, and no obvious neuromuscular deterioration was reported or observed. Telerehabilitation provided an opportunity to continue with hand rehabilitation after tendon transfer surgery, perform an ad-hoc online evaluation, and advise the patient how to prevent the spread of infection and cope with restrictions limiting outpatient visits. This experience seems valuable for further development of telerehabilitation in anticipation of future pandemics or adversarial events since it allows reaching out to patients unable to travel and overcomes the need for regular outpatient visits.
The Value of Nursing Research
Authors: Ives Erickson Jeanette , Pappas Sharon
Published: April 2020

Innovations in patient care, nursing, and the practice environment are hallmarks of organizations receiving American Nurses Credentialing Center (ANCC) Magnet Recognition®. In this month's “Magnet® Perspectives” column, the chair and vice-chair of ANCC's Commission on Magnet Recognition examine the growing importance of nursing research on patient care and outcomes and the role of Magnet hospitals as research pacesetters for the nursing profession. The authors discuss the critical difference between research and evidence-based practice, why both are important, and how organizations can develop the structures and processes to inspire and advance a robust culture of clinical inquiry.
Promoting Direct Care Nurse Engagement in Research in Magnet Hospitals
Authors: Patton Lindsey , Montgomery Kathleen , Coyne Kelly , Slaven Abigail , Arthur Megan , Hockenberry Marilyn
Published: April 2020

Multisite study participation provides an opportunity for hospitals to gain access to the resources required to facilitate nursing research. The nurse-led Parent Educational Discharge Support Strategies for children newly diagnosed with cancer (PEDSS) multisite study engaged direct care nurses for successful implementation across 16 Magnet®-designated hospitals. This article addresses strategies to overcome barriers to nursing research demonstrated through the PEDSS experience.
Controlled Avalanche – A Regulated Voluntary Exposure Approach for Addressing Covid-19
Authors: Klement Eyal , Klement Alon , Chinitz David , Harel Alon , Fattal Eyal , Klausner Ziv
Published: April 2020

Background

The ongoing Covid-19 pandemic has driven many countries to take radical suppression measures. While reducing mortality, these measures result in severe economic repercussions, and inhibit the development of herd immunity. Until an effective vaccine will be available, we propose an alternative approach, akin to avalanche control at ski resorts, a practice which intentionally triggers small avalanches in order to prevent a singular catastrophic one. Its main goal is to approach herd immunity faster than the current alternatives, with lower mortality rates and lower demand for critical health-care resources. According to this approach, individuals whose probability of developing serious health conditions is low (i.e. 20-49 years old with no comorbidities) will be offered the option to be voluntarily exposed to the virus under controlled supervision, and will then be issued ‘immunity certificates’ if they are confirmed to have developed SARS-CoV-2 antibodies.

Methods

Using a compartmental model we examine the implications of the controlled avalanche (CA) strategy over the population in Israel. We compare four scenarios: in two scenarios the CA program is applied to the low-risk population (with the rest of the population subject to mitigation measures), followed by mitigation for the entire population or by uncontrolled spread. These are compared to mitigated and uncontrolled scenarios without the CA program. We discuss the economic, ethical and public health implications of the CA strategy.

Findings

We show that compared to mitigation of the entire population, the CA strategy reduces the overall mortality by 43%, reduces the maximum number of people in need for ICUs by 62% and decreases the time required for release of 50% of the low-risk population by more than 2 months.

Interpretation

This study suggests an ethically acceptable practice, that enables reaching herd immunity faster than the current alternatives, with low mortality and minimal economic damage.
The Contribution of Age Structure to the Number of Deaths from Covid-19 in the UK by Geographical Units
Authors: Kulu Hill , Dorey Peter
Published: April 2020

This study investigates the contribution of population age structure to mortality from Covid-19 in the UK by geographical units. We project death rates at various spatial scales by applying data on age-specific fatality rates to the area’s population by age and sex. Our analysis shows a significant variation in the projected death rates between the constituent countries of the UK, between its regions and within regions. First, Scotland and Wales have higher projected fatality levels from Covid-19 than England, whereas Northern Ireland has lower rate. Second, the infection fatality rates are projected to be substantially higher in small towns and rural areas than those in large urban areas. Third, our analysis shows that within urban regions there are also ‘pockets’ of high projected death rates. Overall, the areas with high and low fatality rates tend to cluster because of the high residential separation of different population age-groups in the UK. Our analysis also reveals that the Welsh-, Gaelic- and Cornish-speaking communities with relatively old populations are likely to experience heavy population losses if the virus spreads widely across the UK.
A Novel Heuristic Global Algorithm to Predict the COVID-19 Pandemic Trend
Authors: Asteris Panagiotis G. , Douvika Maria , Karamani Christina , Skentou Athanasia , Daras Tryfon , Cavaleri Liborio , Armaghani Danial Jahed , Chlichlia Katerina , Zaoutis Theoklis E.
Published: April 2020

Mathematical models are useful tools to predict the course of an epidemic. A heuristic global Gaussian-function-based algorithm for predicting the COVID-19 pandemic trend is proposed for estimating how the temporal evolution of the pandemic develops by predicting daily COVID-19 deaths, for up to 10 days, starting with the day the prediction is made. The validity of the proposed heuristic global algorithm was tested in the case of China (at different temporal stages of the pandemic). The algorithm was used to obtain predictions in six different locations: California, New York, Iran, Sweden, the United Kingdom, and the entire United States, and in all cases the prediction was confirmed. Our findings show that this algorithm offers a robust and reliable method for revealing the temporal dynamics and disease trends of SARS-CoV-2, and could be a useful tool for the relevant authorities in settings worldwide.
Evaluating the different control policies for COVID-19 between mainland China and European countries by a mathematical model in the confirmed cases
Authors: Lin Feng , Huang Yi , Zhang Huifang , He Xu , Yin Yonghua , Liu Jiaxin
Published: April 2020

This study focuses on evaluating the different policies of controlling the outbreak of COVID-19 in mainland China and in some European countries. The study is based on mathematical model which is a modified susceptible-infected-recovered (SIR) model. The model takes death and recovery into consideration which in convenience is called the susceptible-infected-recovered-death (SIRD) model. The criterion for the recovered patients is assumed by COVID-19 nucleic acid testing negative. The mathematical model is constructed by retrospective study. Determination of the parameters in the model is based on the epidemic bulletin supplied by the Chinese Center for Disease Control and Prevention (CDC) and National Health Commission of the People’s Republic of China (NHC) from Jan 16 2020 to Mar 5 2020. The data cover the date when the epidemic situation is reported and the data showed that the epidemic situation is almost under control in China. The mathematical model mainly simulates the active cases and the deaths during the outbreak of COVID-19. Then apply the mathematical model to simulate the epidemic situations in Italy and Spain, which are suffering the outbreak of COVID-19 in Europe. The determination of the parameters for the 2 European countries is based on the data supplied by Worldometers. By comparing the difference of the parameters based on the same mathematical model, it is possible to evaluate the different policies in different countries. It turns out that the relatively easing control policies might lead to rapid spread of the disease.
The proportion of deaths cases in confirmed patients of COVID-19 is still increasing for cumulative cases reported up to 25 April 2020
Authors: Scheuerl Thomas
Published: April 2020

In this work I analyse how proportions of fatal cases after COVID-19 infection change since outbreak of the disease. Using publicity available data I model the change in deaths probability from day 30 of outbreak until 25 April 2020. The global trend is that the proportion of fatal cases is still increasing and that many countries have not yet reached the maximum deaths proportion. However, there are visual differences between countries and in some countries the proportions are clearly below or above the global trend. A positive correlation between deaths cases and recorded infections indicates that a higher infection number results in increased mortality numbers.
The current COVID-19 wave will likely be mitigated in the second-line European countries
Authors: Soubeyrand S. , Ribaud M. , Baudrot V. , Allard D. , Pommeret D. , Roques L.
Published: April 2020

Objective

Countries presently apply different strategies to control the COVID-19 outbreak. Differences in population structures, decision making, health systems and numerous other factors result in various trajectories in terms of mortality at country scale. Our objective in this manuscript is to disentangle the future ofsecond-lineEuropean countries (i.e. countries that present, today, a moderate death rate) with respect to the current COVID-19 wave.

Method

We propose a data-driven approach, grounded on a mixture model, to forecast the dynamics of the number of deaths from COVID-19 in a given focal country using data from countries that areahead in timein terms of COVID-19-induced mortality. In this approach, the mortality curves of ahead-in-time countries are used to build predictors, which are then used as the components of the mixture model. This approach was applied to eight second-line European countries (Austria, Denmark, Germany, Ireland, Poland, Portugal, Romania and Sweden), using Belgium, France, Italy, Netherlands, Spain, Switzerland, United Kingdom as well as the Hubei province in China to build predictors. For this analysis, we used data pooled by the Johns Hopkins University Center for Systems Science and Engineering.

Results

In general, the second-line European countries tend to follow relatively mild mortality curves (typically, those of Switzerland and Hubei) rather than fast and severe ones (typically, those of Spain, Italy, Belgium, France and the United Kingdom). From a methodological viewpoint, the performance of our forecasting approach is about 80% up to 8 days in the future, as soon as the focal country has accumulated at least two hundreds of deaths.

Discussion

Our results suggest that the continuation of the current COVID-19 wave across Europe will likely be mitigated, and not as strong as it was in most of the front-line countries first impacted by the wave.
Why does COVID-19 case fatality rate vary among countries?
Authors: Sorci Gabriele , Faivre Bruno , Morand Serge
Published: April 2020

Background

While the epidemic of SARS-CoV-2 is spreading worldwide, there is much concern over the mortality rate that the infection induces. Available data suggest that COVID-19 case fatality rate varies temporally (as the epidemic progresses) and spatially (among countries). Here, we attempted to identify key factors possibly explaining the variability in case fatality rate across countries.

Methods

We used data on the temporal trajectory of case fatality rate provided by the European Center for Disease Prevention and Control, and country-specific data on different metrics describing the incidence of known comorbidity factors associated with an increased risk of COVID-19 mortality at the individual level (Institute for Health Metrics and Evaluation). We also compiled data on demography, economy and political regimes for each country.

Findings

We first showed that temporal trajectories of case fatality rate greatly vary among countries. We found no evidence for association between comorbidities and case fatality rate at the country level. Case fatality rate was negatively associated with number of hospital beds x1,000 inhabitants. We also report evidence suggesting an association between case fatality rate and the political regime, with democracies suffering from the highest mortality burden, compared to autocratic regimes. However, most of the among-country variance in case fatality rate remained unexplained.

Interpretation

Overall, these results emphasize the role of socio-economic and political factors as possible drivers of COVID-19 case fatality rate at the country level.

Funding

None.
Effects of COVID-19 infection during pregnancy and neonatal prognosis: what is the evidence?
Authors: Sousa Álvaro Francisco Lopes , de Carvalho Herica Emilia Félix , de Oliveira Layze Braz , Schneider Guilherme , Camargo Emerson Lucas Silva , Watanabe Evandro , de Andrade Denise , Fernandes Ana Fátima Carvalho , Mendes Isabel Amélia Costa , Fronteira Inês
Published: April 2020

Background

Little is known about how COVID-19 infection affects pregnant women, as well as about the possibility of vertical transmission or complications in childbirth. This study’s aims to assess the current evidence presented in the literature regarding the potential risks of COVID-19 infection among pregnant women and consequent fetal transmission.

Methods

a systematic literature review assessing papers published in the most comprehensive databases in the field of health, intended to answer the question: “What are the effects of COVID-19 infection during pregnancy and what is the neonatal prognosis?”

Results

42 papers published in 2020 were eligible. Were included 19 case reports (45%), 15 cross-sectional descriptive studies (35%), 6 cross-sectional analytical studies (14%), one case-control study (3%) and one cohort study (3%), presenting low levels of evidence. A total of 650 pregnant women and 511 infants were assessed. More than half of pregnant women having cesarean deliveries (324/64%). Only 410 (80%) infants were tested for SARS-CoV-2, of which 8 (2%) were positive, however, based on what was assessed that there is no evidence of vertical transmission so far, as there are gaps concerning the care taken during and after delivery, and biological sample proper for testing the SARS-CoV-2.

Conclusions

health professionals cannot rule out a possible worsening of the clinical picture of the pregnant woman infected with SARS-CoV-2 because she is asymptomatic or does not have comorbidities related to gestation. Pregnant women and health professionals should be cautious and vigilant, as soon as their pregnancy is confirmed, with or without confirmed infection, as this review checks for infected pregnant women in all trimesters of pregnancy.
An 81 base-pair deletion in SARS-CoV-2 ORF7a identified from sentinel surveillance in Arizona (Jan-Mar 2020)
Authors: Holland LaRinda A. , Kaelin Emily A. , Maqsood Rabia , Estifanos Bereket , Wu Lily I. , Varsani Arvind , Halden Rolf U. , Hogue Brenda G. , Scotch Matthew , Lim Efrem S.
Published: April 2020

On January 26 2020, the first Coronavirus Disease 2019 (COVID-19) case was reported in Arizona of an individual with travel history (3rd case in the US) (1). Here, we report on early SARS-CoV-2 sentinel surveillance in Tempe, Arizona (USA). Genomic characterization identified an isolate encoding a 27 amino acid in-frame deletion in accessory protein ORF7a, the ortholog of SARS-CoV immune antagonist ORF7a/X4.
The role of corticosteroids in the management of critically ill patients with coronavirus disease 2019 (COVID-19): A meta-analysis
Authors: Gangopadhyay Kalyan Kumar , Mukherjee Jagat J , Sinha Binayak , Ghosal Samit
Published: April 2020

Objective

There are no controlled studies on the role of systemic corticosteroids (CS) in patients with coronavirus disease 2019 (COVID-19). In the absence of high-quality evidence, understandably the recommendations from various organizations are cautious. Several randomized controlled trials are underway but shall take time to conclude. We therefore undertook a meta-analysis to ascertain the role of CS in the management of critically ill patients with COVID-19.

Data Sources

Electronic databases, including Pubmed, Cochrane library and Embase, were searched, using the keywords of interest and the PICO search technique, from inception to 12th April 2020.

Study Selection

Studies highlighting the use of CS in coronavirus infection with severe acute respiratory syndrome (SARS), Middle East Respiratory Syndrome (MERS) and COVID-19 were selected based on pre-determined inclusion criteria.

Data extraction

Data was extracted into an excel sheet and transferred to comprehensive meta-analysis software version 3, Biostat Inc., Englewood, NJ, USA, for analysis.

Data synthesis

Five studies with SARS-CoV-2 infection were included in the meta-analysis. The rate ratio (RR) for mortality in patients with SARS-CoV-2 infection was 1.26 (95% CI: 0.96-1.65, I2: 74.46), indicating lack of benefit of CS therapy on mortality in critically ill patients with COVID-19. The RR for mortality on analysis of the three studies that particularly reported on patients with significant pulmonary compromise secondary to SARS-CoV-2 infection was neutral (RR: 0.91, 95% CI: 0.63-1.33, I2: 63.38).

Conclusions

The use of CS in critically ill patients with COVID-19 did not improve or worsen mortality. Pending further information from controlled studies, CS can be used in critically ill patients with COVID-19 with ‘critical illness related corticosteroid insufficiency’ and moderate to severe ARDS without the risk of increased mortality.
Estimating the impact of COVID-19 control measures using a Bayesian model of physical distancing
Authors: Anderson Sean C. , Edwards Andrew M. , Yerlanov Madi , Mulberry Nicola , Stockdale Jessica E. , Iyaniwura Sarafa A. , Falcao Rebeca C. , Otterstatter Michael C. , Irvine Michael A. , Janjua Naveed Z. , Coombs Daniel , Colijn Caroline
Published: April 2020

Extensive physical distancing measures are currently the primary intervention against coronavirus disease 2019 (COVID-19) worldwide. It is therefore urgent to estimate the impact such measures are having. We introduce a Bayesian epidemiological model in which a proportion of individuals are willing and able to participate in distancing measures, with the timing of these measures informed by survey data on attitudes to distancing and COVID-19. We fit our model to reported COVID-19 cases in British Columbia, Canada, using an observation model that accounts for both underestimation and the delay between symptom onset and reporting. We estimate the impact that physical distancing (also known as social distancing) has had on the contact rate and examine the projected impact of relaxing distancing measures. We find that distancing has had a strong impact, consistent with declines in reported cases and in hospitalization and intensive care unit numbers. We estimate that approximately 0.78 (0.66–0.89 90% CI) of contacts have been removed for individuals in British Columbia practising physical distancing and that this fraction is above the threshold of 0.45 at which prevalence is expected to grow. However, relaxing distancing measures beyond this threshold re-starts rapid exponential growth. Because the extent of underestimation is unknown, the data are consistent with a wide range in the prevalence of COVID-19 in the population; changes to testing criteria over time introduce additional uncertainty. Our projections indicate that intermittent distancing measures—if sufficiently strong and robustly followed— could control COVID-19 transmission, but that if distancing measures are relaxed too much, the epidemic curve would grow to high prevalence.