bluuebunny/crossref_metadata_2025 huggingface dataset:
Research Priorities for Plasma and Platelet Transfusion Strategies in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding
Authors: Nellis Marianne E. , Remy Kenneth E. , Lacroix Jacques , Cholette Jill M. , Bembea Melania M. , Russell Robert T. , Steiner Marie E. , Goobie Susan M. , Vogel Adam M. , Crighton Gemma , Valentine Stacey L. , Delaney Meghan , Parker Robert I. ,   for the Pediatric Critical Care Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding (TAXI-CAB), in collaboration with the Pediatric Critical Care Blood Research Network (BloodNet), and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
Published: January 2022

Objectives:

To present a list of high-priority research initiatives for the study of plasma and platelet transfusions in critically ill children from the Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding.

Design:

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

Setting:

Not applicable.

Patients:

Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions.

Interventions:

None.

Measurements and Main Results:

A panel of 13 experts developed research priorities for the study of plasma and platelet transfusions in critically ill children which were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding experts. The specific priorities focused on the following subpopulations: severe trauma, traumatic brain injury, intracranial hemorrhage, cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, oncologic diagnosis or stem cell transplantation, acute liver failure and/or liver transplantation, noncardiac surgery, invasive procedures outside of the operating room, and sepsis and/or disseminated intravascular coagulation. In addition, tests to guide plasma and platelet transfusion, as well as component selection and processing, were addressed. We developed four general overarching themes and 14 specific research priorities using modified Research and Development/University of California, Los Angeles methodology.

Conclusions:

Studies are needed to focus on the efficacy/harm, dosing, timing, and outcomes of critically ill children who receive plasma and/or platelet transfusions. The completion of these studies will facilitate the development of evidence-based recommendations.
Prevalence of and Associations With Avascular Necrosis After Pediatric Sepsis: A Single-Center Retrospective Study
Authors: Periasamy Uvaraj , Chilutti Marianne , Kaplan Summer L. , Hickey Christopher P. , Hayes Katie , Pennington Jeffrey W. , Balamuth Fran , Fitzgerald Julie C. , Weiss Scott L.
Published: January 2022

OBJECTIVES:

Avascular necrosis (AVN) is a rare, but serious, complication after sepsis in adults. We sought to determine if sepsis is associated with postillness diagnosis of AVN, as well as potential-associated risk factors for AVN in children with sepsis.

DESIGN:

Retrospective observational study.

SETTING:

Single academic children’s hospital.

PATIENTS:

Patients less than 18 years treated for sepsis or suspected bacterial infection from 2011 to 2017. Patients who developed AVN within 3 years after sepsis were compared with patients who developed AVN after suspected bacterial infection and with patients with sepsis who did not develop AVN.

INTERVENTION:

None.

MEASUREMENTS AND MAIN RESULTS:

AVN was determined using International Classification of Diseases, 9th Edition/10th Edition codes and confirmed by chart review. The prevalence of AVN after sepsis was 0.73% (21/2,883) and after suspected bacterial infection was 0.43% (53/12,276; risk difference, 0.30; 95% CI, 0.0–0.63; p = 0.05). Compared with 43 sepsis controls without AVN, AVN in the 21 sepsis cases was associated with being older, having sickle cell disease and malignancy, higher body mass index, unknown source of infection, and low platelet count in the first 7 days of sepsis. Half of sepsis patients were treated with corticosteroids, and higher median cumulative dose of steroids was associated with AVN (23.2 vs 5.4 mg/kg; p < 0.01). Older age at infection (odds ratio [OR], 1.3; 95% CI, 1.1–1.4), malignancy (OR, 8.8; 95% CI, 2.6–32.9), unknown site of infection (OR, 12.7; 95% CI, 3.3–48.6), and minimal platelet count less than 100,000/µL in first 7 days of sepsis (OR, 5.0; 95% CI, 1.6–15.4) were identified as potential risk factors for AVN after sepsis following adjustment for multiple comparisons.

CONCLUSIONS:

Although rare, sepsis was associated with a higher risk of subsequent AVN than suspected bacterial infection in children. Older age, malignancy, unknown site of infection, and minimum platelet count were potential risk factors for AVN after sepsis.
Agreement Between Peak Inspiratory Pressure in Decelerating-Flow Ventilation and Plateau Pressure in Square-Flow Ventilation in Pediatric Acute Respiratory Distress Syndrome*
Authors: Patel Bhavesh , Thomas Neal J. , Yehya Nadir
Published: January 2022

OBJECTIVES:

Acute respiratory distress syndrome guidelines suggest limiting plateau pressures to 28–30 cm H2O. Plateau pressure is most accurately measured in square-flow modes, such as volume control. In children, decelerating-flow modes, such as pressure-regulated volume control and pressure control, are more common. Consequently, plateau pressures are rarely obtained, and pressure limits are instead provided for peak inspiratory pressure. The degree to which peak inspiratory pressure in decelerating-flow overestimates plateau pressure is unknown. Therefore, we assessed the correlation and accuracy of peak inspiratory pressure in decelerating-flow ventilation for approximating plateau pressure during square-flow ventilation.

DESIGN:

Prospective, observational study.

SETTING:

Tertiary, academic PICU.

PATIENTS:

Fifty-two intubated children with acute respiratory distress syndrome enrolled between January 2020 and May 2021.

INTERVENTIONS:

Measurement of peak inspiratory pressure in decelerating-flow ventilation and plateau pressure after transition to square-flow ventilation.

MEASUREMENTS AND MAIN RESULTS:

Peak inspiratory pressure in decelerating-flow was highly correlated (r
2 = 0.99; p < 0.001) with plateau pressure in square-flow. Peak inspiratory pressure was 1.0 ± 0.6 cm H2O higher than plateau pressure, with 96% of values within 2 cm H2O. The single outlier had coexistent asthma and inspiratory flows that did not reach zero.

CONCLUSIONS:

Peak inspiratory pressure measured during decelerating-flow ventilation may be an adequate surrogate of plateau pressure in pediatric acute respiratory distress syndrome when inspiratory flow approaches zero. Practitioners should be aware that peak inspiratory pressures in decelerating-flow may not be substantially higher than plateau pressures.
Anti-NMDA Receptor Encephalitis Associated With an Ovarian Teratoma Presenting as First-episode Psychosis: A Case Report
Authors: Câmara-Pestana Pedro , Magalhães Andreia D. , Mendes Tiago , Levy Pedro , Coentre Ricardo
Published: January 2022

We report an unusual case of a 27-year-old previously healthy female who presented with a 15-day history of psychotic, cognitive, and unspecified somatic symptoms. She was admitted to the psychiatric ward of an early intervention in psychosis team and medicated with aripiprazole. The young age of onset, the rapid onset, the absent history of psychiatric disease, and the persistence of a marked memory deficit after the psychotic symptoms remitted strongly suggested a nonpsychiatric etiology and led us to hypothesize autoimmune encephalitis as the most probable diagnosis. An investigation was carried out for anti-N-methyl-D-aspartate (anti-NMDA) receptor antibodies in the patient’s serum and cerebrospinal fluid, and both tests were positive. The patient was transferred to the neurology ward, where an endovaginal ultrasound showed an ovarian teratoma in her right ovary. She underwent laparoscopic surgery without complications. She was initially treated with intravenous immunoglobulin and methylprednisolone for 5 days, which resulted in marked improvement of her memory and attention performance. Anti-NMDA receptor encephalitis, first described in 2007 by Dalmau and colleagues, is a form of auto-immune encephalitis with prominent neuropsychiatric manifestations, particularly psychotic symptoms. At symptom onset, distinguishing the disease from a primary psychiatric disorder is challenging. This case report highlights the importance of early psychosis treatment teams considering the diagnosis of anti-NMDA receptor encephalitis when evaluating new referrals with a potential diagnosis of first-episode psychosis, particularly when young patients with no relevant personal or familial psychiatric history present with neuropsychiatric symptoms and a distinctive pattern of symptom fluctuation over time.
Anti-NMDA Receptor Encephalitis Masquerades as Psychosis: A Case Report
Authors: Giri Yam R. , Korie Ijendu , Hashmi Seema , Parrill Allison , Ayed Nisrin
Published: January 2022

A 28-year-old male patient with an unclear history of psychosis was admitted to the inpatient psychiatric unit. He presented with auditory hallucinations, agitation, and bizarre and disorganized behavior. He was treated with antipsychotic medications without improvement. Magnetic resonance imaging of the brain showed hyperintensities throughout the brain parenchyma. Investigations for infectious, metabolic, autoimmune, and malignant etiologies were negative. Anti–N-methyl-D-aspartate (NMDA) receptor encephalitis was suspected. Cerebrospinal fluid (CSF) and serum NMDA receptor antibody testing were performed. Both tests were positive, confirming anti-NMDA receptor encephalitis. The patient was treated with intravenous immunoglobulin and methylprednisolone, which resulted in the resolution of his psychosis. In the case of unexplained psychosis associated with seizures, early screening using serum and CSF testing for anti-NMDA receptor antibodies and brain magnetic resonance imaging may be an important diagnostic tool for detecting anti-NMDA receptor encephalitis. Detailed investigations of CSF and serum should be performed to rule out infectious, metabolic, and autoimmune causes. Imaging studies should also be performed to identify any tumors such as a teratoma. This approach may help identify patients with anti-NMDA receptor encephalitis masquerading as psychosis. Early diagnosis and treatment including intravenous steroids, immunosuppressants, plasmapheresis, and removal of any teratoma if present in patients with anti-NMDA receptor encephalitis can improve the overall outcome.
Patients‘ Rights and the Texas Mental Health Law
Authors: Truong Thanh Thuy , Matorin Anu , David Elizabeth
Published: January 2022

A series of court cases between the 1960s and the 1980s focusing on patient autonomy changed the approach to mental health treatment in the United States. The process of involuntary psychiatric treatment can vary greatly between states; thus, all mental health practitioners need to have a strong grasp of their respective state and institutional policies. In this article, we examine the Texas mental health law regarding consent to psychoactive medications and involuntary medications. The Texas Health and Safety Code requires the use of a legally authorized representative to consent to psychoactive medications when patients lack capacity due to a mental illness. We argue that the use of a legally authorized representative is ethical and improves psychosocial outcomes. Using a case example, we explore the interplay among patient rights to treatment, autonomy, ethics, and the law. Consistent application of this process will facilitate treatment according to the current standard of practice.
First Use of Clozapine Point of Care Testing in Acute Inpatient Psychiatry: Preliminary Report
Authors: Boland Xavier , Dratcu Luiz
Published: January 2022

Clozapine is the antipsychotic of choice in treatment-resistant schizophrenia. Serum clozapine concentration testing is essential to monitor adherence, adjust dosing, and ensure treatment safety. However, patients who are acutely unwell are frequently reluctant to undergo blood testing requiring venipuncture. Also, conventional laboratory-based measurement of clozapine plasma levels can take days, thus contributing to the suboptimal use of clozapine when it is most needed. We pioneered clozapine whole-blood point of care (POC) testing in the acute inpatient setting in the treatment of a group of actively psychotic patients receiving clozapine during the outbreak of the COVID-19 pandemic. POC clozapine testing using automated homogenous immunoassay requires only finger prick blood sampling and is more acceptable to patients. As it produces results in minutes, clozapine POC testing serves to promptly ascertain adherence with treatment and inform therapeutic dosing. POC testing offered a more practical, less invasive, and quicker alternative to conventional methods of monitoring clozapine levels. Near immediate availability of clozapine levels expedited clinical decisions and helped ensure safe clozapine prescribing to our severely psychotic patients in a time of crisis. By facilitating patients’ early safe discharge from the hospital, clozapine POC testing also reduced length of hospitalization.
Quantification of Pneumothorax Volume on Chest X-Ray
Authors: Aguinagalde Borja , Zabaleta Jon , López Iker , Izquierdo Jose M. , Mendoza Mikel , Garmendia Eñaut , Fernandez-Monge Arantza , Lizarbe Jon A.
Published: January 2022

Purpose:

Owing to the extent of lung collapse estimated on chest radiograph it is still the complementary test most commonly used in the management of patients with pneumothorax. There are several indices to assess the extent of lung collapse. The objective of this study was to develop a more accurate index, using the 3D printing technology.

Materials and Methods:

We created physical hemithorax models using 3D printing. In this way, we obtained simple radiographs of models for which the lung volume was known accurately. In the first part of the study, we estimated the intraobserver and interobserver agreement as well as the agreement between methods. We created 2 new indices and the results obtained with these; the Light index and the Collins method were compared with data on real lung volume loss using linear regression analysis and by calculating the coefficient of determination (r
2). In the second part of the study, we validated the 4 equations, comparing the Light index, the Collins method, and the 2 new indices using regression analysis. For this analysis, we used STATA V14.

Results:

Both intraobserver and interobserver agreements were very high (<0.9). The agreement between the Collins method and the Light index was poor, with a mean difference of 18.6%. The equation that best represented real lung collapse was the new equation 2.

Conclusions:

This study demonstrates the poor agreement between the Light index and Collins method for measuring the extent of lung collapse in pneumothorax and proposes a more accurate equation for this measurement based on a simple chest radiograph.
Socioeconomic disadvantage is associated with greater mortality after high-risk emergency general surgery
Authors: Cain Brian T. , Horns Joshua J. , Huang Lyen C. , McCrum Marta L.
Published: January 2022

BACKGROUND

Socioeconomic disadvantage is associated with worse outcomes after elective surgery, but the effect on emergency general surgery (EGS) remains unclear. We examined the association of socioeconomic disadvantage and outcomes after EGS procedures and investigated whether admission to hospitals with comprehensive clinical and social resources mitigated this effect.

METHODS

Adults undergoing 1 of the 10 most burdensome high- and low-risk EGS procedures were identified in six 2014 State Inpatient Databases. Socioeconomic disadvantage was assessed using Area Deprivation Index (ADI) of patient residence. Multivariable logistic regression models adjusting for patient and hospital factors were used to evaluate the association between ADI quartile (high >75 percentile vs. low <25 percentile), and 30-day readmission, in-hospital mortality, and discharge disposition. Effect modification between ADI and (a) level 1 trauma center and (b) safety-net hospital status was tested.

RESULTS

A total of 103,749 patients were analyzed: 72,711 low-risk (70.1%) and 31,038 high-risk procedures (29.9%). Patients from neighborhoods with high socioeconomic disadvantage had a higher proportion with ≥3 comorbidities (41.9% vs. 32.0%), minority race/ethnicity (66.3% vs. 42.4%), and Medicaid (28.8% vs. 14.7%) and were less likely to be treated at level 1 trauma centers (18.3% vs. 27.7%; p < 0.001 for all). Adjusting for competing factors, high socioeconomic disadvantage was associated with increased in-hospital mortality after high-risk procedures (odd ratio, 1.30; 95% confidence interval, 1.01–1.66; p = 0.04) and higher odds of non–home discharge (odd ratio, 1.15; 95% confidence interval, 1.02–1.30; p = 0.03) for low-risk procedures. Socioeconomic disadvantage was not associated with 30-day readmission for either procedure group. Level 1 trauma status and safety-net hospital did not meaningfully mitigate effect of ADI for any outcome.

CONCLUSION

Socioeconomic disadvantage is associated with increased mortality after high-risk procedures and higher odds of non–home discharge after low-risk procedures. This effect was not mitigated by either level 1 trauma or safety-net hospitals. Interventions that specifically address the needs of socially vulnerable communities will be required to significantly improve EGS outcomes for this population.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, level III.
Can blood loss be assessed by echocardiography? An experimental study on a controlled hemorrhagic shock model in piglets
Authors: Grau-Mercier Laura , Coisy Fabien , Markarian Thibaut , Muller Laurent , Roger Claire , Lefrant Jean-Yves , Claret Pierre-Géraud , Bobbia Xavier
Published: January 2022

BACKGROUND

Assessment of the volemic loss is a major challenge during the management of hemorrhagic shock. Echocardiography is an increasingly used noninvasive tool for hemodynamic assessment. In mechanically ventilated patients, some studies suggest that respiratory variations of mean subaortic time-velocity integral (∆VTI) would be predictive of fluid filling response. An experimental model of controlled hemorrhagic shock provides a precise approach to study correlation between blood volume and cardiac ultrasonographic parameters.

OBJECTIVES

The main objective was to analyze the ∆VTI changes during hemorrhage in an anesthetized-piglet model of controlled hemorrhagic shock. The secondary objective was to evaluate ∆VTI during the resuscitation process after hemorrhage and other echocardiographic parameters changes during the whole protocol.

METHODS

Twenty-four anesthetized and ventilated piglets were bled until mean arterial pressure reached 40 mm Hg. Controlled hemorrhage was maintained for 30 minutes before randomizing the piglets to two resuscitation groups: fluid filling group resuscitated with saline solution and noradrenaline group resuscitated with saline solution and noradrenaline. Echocardiography and hemodynamic measures, including pulsed pressure variations (PPV), were performed at different stages of the protocol.

RESULTS

The correlation coefficient between ΔVTI and PPV with the volume of bleeding during the hemorrhagic phase were respectively 0.24 (95% confidence interval, 0.08–0.39; p < 0.01) and 0.57 (95% CI, 0.44–0.67; p < 0.01). Two parameters had a moderate correlation coefficient with hemorrhage volume (over 0.5): mean subaortic time-velocity index (VTI) and mitral annulus diastolic tissular velocity (E′).

CONCLUSION

In this hemorrhagic shock model, ΔVTI had a low correlation with the volume of bleeding, but VTI and E′ had a correlation with blood volume comparable to that of PPV.
Risk factors for stroke in penetrating carotid trauma—An analysis from the PROOVIT Registry
Authors: O'Banion Leigh Ann , Dirks Rachel C. , Siada Sammy S. , Dubose Joseph J. , Inaba Kenji , Byerly Saskya , Rajani Ravi R. , Morrison Jonathan J. , Lucero Leah , Magee Gregory A.
Published: January 2022

BACKGROUND

Penetrating carotid injuries are associated with an up to 20% risk of stroke. This study evaluated patients in the American Association for Surgery of Trauma PROspective Observational Vascular Injury Trial, with the aim of determining factors associated with stroke and stroke or death.

METHODS

Penetrating extracranial carotid injuries in the American Association for Surgery of Trauma PROspective Observational Vascular Injury Trial registry from 2012 to 2020 were queried. Isolated external carotid injuries were excluded. Patients with documented postinjury in-hospital stroke were compared with those without. Significant predictors (p < 0.1) for stroke and stroke or death on univariate analysis were included in multivariate analyses.

RESULTS

One hundred two patients from 17 institutions were included. Mean age was 35 ± 18 years, and 80% were male. Average Glasgow Coma Scale (GCS) score on presentation was 9 ± 5, with an Injury Severity Score [ISS] of 22 ± 13. Operative management occurred in 51% of patients who were significantly more hypotensive (systolic blood pressure: 109 vs. 131 mm Hg; p = 0.015) with a lower initial pH (7.17 vs. 7.31; p = 0.001) and presented with hard signs of vascular injury (74% vs. 26%; p < 0.001). Overall stroke rate was 17% (23% operative vs. 10% nonoperative, p = 0.076). Rate of stroke or death was 27% (64% operative and 36% nonoperative). On multivariate analysis, lower GCS (p = 0.05) and completion angiography (p = 0.04) were associated with stroke. Likewise lower GCS (p = 0.015) and ISS (p = 0.04) were associated with stroke or death.

CONCLUSION

Penetrating carotid trauma undergoing operative management had a stroke rate of 23%. Low GCS on arrival and need for completion angiography are independently associated with postinjury in-hospital stroke, whereas low GCS on arrival and ISS were associated with stroke or death. The ideal treatment strategy remains elusive, thus a dedicated multicenter study may help to achieve higher fidelity data on this rare but devastating injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological, Level III.
Screening tools for predicting posttraumatic stress disorder in acutely injured adult trauma patients: A systematic review
Authors: Jensen Stephanie Marie , Abrahamsen Imani , Baumgarten Mark , Gallaher Jared , Feltner Cynthia
Published: January 2022

BACKGROUND

Adult trauma patients are at risk of developing posttraumatic stress disorder (PTSD). Early intervention reduces the development of PTSD, but few trauma patients seek and obtain care. Valid and reliable screening tools are needed to identify patients at risk of developing PTSD. The objective of this review is to identify existing screening tools and evaluate their accuracy for predicting PTSD outcomes.

METHODS

PubMed, PsychInfo, and ClinicalTrials.gov were searched for studies evaluating the predictive accuracy of PTSD screening tools among traumatically injured adult civilians. Eligible studies assessed patients during acute hospitalization and at least 1 month following injury to measure PTSD outcome. Eligible outcomes included measures of predictive accuracy, such as sensitivity and specificity. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess the risk of bias of each study, and the strength of evidence was assessed following the Agency for Healthcare Research and Quality guidelines.

RESULTS

Forty-nine studies were included evaluating the predictive accuracy of 38 screening tools. Most tools were assessed in a single study. Questionnaire-style tools had more favorable predictive ability than diagnostic interview assessments. The Injured Trauma Survivor Screen, Posttraumatic Adjustment Screen, the PTSD Checklist for DSM-5, and the Richmond et al. tool demonstrated the most favorable predictive accuracy, with high sensitivity (75–100%) and specificity (67–94%). Common sources of bias were selection bias due to high attrition rate and using nondiagnostic tools to assess PTSD symptoms at follow-up.

CONCLUSION

Although sensitivity and specificity of PTSD predictive tools varied widely, several emerged with favorable predictive accuracy. Further research is needed to define the ability of screening and intervention to prevent PTSD in injured trauma survivors. The results of this review can inform screening tool options for screening programs and future intervention studies.

LEVEL OF EVIDENCE

Systematic review, level III.
Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis
Authors: McDonogh Jack M. , Lewis Daniel P. , Tarrant Seth M. , Balogh Zsolt J.
Published: January 2022

BACKGROUND

Hemodynamically unstable pelvic fracture patients are challenging to manage. Preperitoneal packing (PPP) and angioembolization (AE) are two interventions commonly used to help gain hemorrhage control. Recently, there has been a tendency to support PPP in hemodynamically unstable pelvic fracture seemingly in direct comparison with AE. However, it seems that key differences between published cohorts exist that limits a comparison between these two modalities.

METHODS

A systematic literature search of the MEDLINE, CINAHL, and EMBASE databases was conducted. Prospective and retrospective studies were eligible. No limitation was placed on publication date, with only manuscripts printed in English eligible (PROSPERO CRD42021236219). Included studies were retrospective and prospective cohort studies and a quasirandomized control trial. Studies reported demographic and outcome data on hemodynamically unstable patients with pelvis fractures that had either PPP or AE as their initial hemorrhage control intervention. The primary outcome was in-hospital mortality rate. Eighteen studies were included totaling 579 patients, of which 402 were treated with PPP and 177 with AE.

RESULTS

Significant differences were found between AE and PPP in regard to age, presence of arterial hemorrhage, Injury Severity Score, and time to intervention. The crude mortality rate for PPP was 23%, and for AE, it was 32% (p = 0.001). Analysis of dual-arm studies showed no significant difference in mortality. Interestingly, 27% of patients treated with PPP did not get adequate hemorrhage control and required subsequent AE.

CONCLUSION

Because of bias, heterogeneity, and inadequate reporting of physiological data, a conclusive comparison between modalities is impossible. In addition, in more than a quarter of the cases treated with PPP, the patients did not achieve hemorrhage control until subsequent AE was performed. This systematic review highlights the need for standardized reporting in this high-risk group of trauma patients.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.
Length of stay and trauma center finances: A disparity of payer source at a Level I trauma center
Authors: Chavez Marin A. , Bogert James N. , Soe-Lin Hahn , Jacobs Jordan V. , Chapple Kristina M. , Weinberg Jordan A.
Published: January 2022

BACKGROUND

In an effort to reduce costs, hospitals focus efforts on reducing length of stay (LOS) and often benchmark LOS against the geometric LOS (GMLOS) as predicted by the assigned diagnosis-related group (DRG) used by the Centers for Medicare and Medicaid Services. The objective of this cross-sectional study was to evaluate the impact of exceeding GMLOS on hospital profit/loss with respect to payer source.

METHODS

Contribution margin for each insured patient admitted to a Level I trauma center between July 1, 2016, and June 30, 2019, was determined. Age, ethnicity, race, DRG weight, DRG version, injury severity, intensive care unit admission status, mechanical ventilation, payer, exceeding GMLOS, and the interaction between payer and exceeding the GMLOS were regressed on contribution margin to determine significant predictors of positive contribution margin.

RESULTS

Among 2,449 insured trauma patients, the distribution of payers was Medicaid (54.6%), Medicare (24.0%), and commercial (21.4%). Thirty-five percent (n = 867) of patient LOS exceeded GMLOS. Exceeding GMLOS by 10 or more days was significantly more likely for Medicaid and Medicare patients in stepwise fashion (commercial, 2.7%; Medicaid, 4.5%; Medicare, 6.0%; p = 0.030). Median contribution margin was positive for commercially insured patients ($16,913) and negative for Medicaid (−$8,979) and Medicare (−$2,145) patients. Adjusted multivariate modeling demonstrated that when exceeding GMLOS, Medicare and Medicaid cases were less likely than commercial payers to have a positive contribution margin (p < 0.001 and p < 0.001).

CONCLUSION

Government-insured patients, despite having a payer source, are a financial burden to a trauma center. Excess LOS among government insured patients, but not the commercially insured, exacerbates financial loss. A shift toward a greater proportion of government insured patients may result in a significant fiscal liability for a trauma center.

LEVEL OF EVIDENCE

Economic and Value-Based Evaluation, Level III.
The Governance of Pandemics in Primary Health Care: The Governance Strategies Adopted by Health Facility Governing Committees in Times of COVID Pandemic in Tanzania
Authors: Kesale Anosisye Mwandulusya , Mahonge Christopher , Muhanga Mikidadi
Published: January 2022

The governance of COVID 19 in Lower and Middle-Income Countries (LMICs) is very critical for curbing its effects. However, it is unknown what governance strategies are adopted by Health Facility Governing Committees (HFGCs) s as a response to the pandemic. We employed an exploratory qualitative design to study the governance strategies adopted by HFGCs during the COVID19. Since COVID 19 is new, an inductive approach was used as it involves analyzing collected data with little or no predetermined theory for the study. A purposive sampling technique was employed in which multistage clustered sampling was used to select regions, councils, health facilities and respondents. In-depth interviews with HFGCs chairpersons and Focus Group Discussions with members of HFGCs were used to collect data. The data were analyzed based on the themes which emerged during data collection. We found five governance strategies that were found to be commonly adopted by many HFGCs which are financial allocation, re-planing, mobilization of resources, community sensitization and mobilization of stakeholders. however, these governance structures were not all adopted by all HFGCs. The HFGCs slowly adopted governance strategies in the times of COVID 19 pandemics because were unprepared. Despite being empowered by the Direct Health Facility Financing, still, the newest of the COVID 19 has been a challenge to many HFGCs. This calls for urgent capacity building for governance institutions on how to deal will pandemics in primary health facilities.
T cell reactivity to the SARS-CoV-2 Omicron variant is preserved in most but not all prior infected and vaccinated individuals
Authors: Naranbhai Vivek , Nathan Anusha , Kaseke Clarety , Berrios Cristhian , Khatri Ashok , Choi Shawn , Getz Matthew A. , Tano-Menka Rhoda , Ofoman Onosereme , Gayton Alton , Senjobe Fernando , Denis Kerri J. St , Lam Evan C. , Garcia-Beltran Wilfredo F. , Balazs Alejandro B. , Walker Bruce D. , Iafrate A. John , Gaiha Gaurav D.
Published: January 2022

The SARS-CoV-2 Omicron variant (B.1.1.529) contains mutations that mediate escape from infection and vaccine-induced antibody responses, although the extent to which these substitutions in spike and non-spike proteins affect T cell recognition is unknown. Here we show that T cell responses in individuals with prior infection, vaccination, both prior infection and vaccination, and boosted vaccination are largely preserved to Omicron spike and non-spike proteins. However, we also identify a subset of individuals (∼21%) with a >50% reduction in T cell reactivity to the Omicron spike. Evaluation of functional CD4+and CD8+memory T cell responses confirmed these findings and reveal that reduced recognition to Omicron spike is primarily observed within the CD8+T cell compartment. Booster vaccination substantially enhanced T cell responses to Omicron spike. In contrast to neutralizing immunity, these findings suggest preservation of T cell responses to the Omicron variant, although with reduced reactivity in some individuals.
Modern lineages of Mycobacterium tuberculosis were recently introduced in western India and demonstrate increased transmissibility
Authors: Dixit Avika , Kagal Anju , Ektefaie Yasha , Freschi Luca , Karyakarte Rajesh , Lokhande Rahul , Groschel Matthias , Tornheim Jeffrey A , Gupte Nikhil , Pradhan Neeta N , Paradkar Mandar S , Deshmukh Sona , Kadam Dileep , Schito Marco , Engelthaler David M. , Gupta Amita , Golub Jonathan , Mave Vidya , Farhat Maha
Published: January 2022

Background

Mycobacterium tuberculosis (Mtb) transmissibility may vary between lineages (or variants) and this may contribute to the slow decline of tuberculosis (TB) incidence. The objective of our study was to compare transmissibility across four major lineages (L1-4) of Mtb among participants from two cohort studies in Pune, India.

Methods

We performed whole-genome sequencing (WGS) of Mtb sputum culture-positive isolates from participants in two prospective cohort studies of adults with pulmonary TB seeking care at public treatment centers in Pune, Maharashtra. We performed genotypic susceptibility prediction for both first- and second-line drugs using a previously validated random forest model. We used single nucleotide substitutions (SNS) and maximum likelihood estimation to build isolate phylogenies by lineage. We used Bayesian molecular dating to estimate ancestral node ages and compared tree characteristics using a two-sample Kolmogorov-Smirnov (KS) test.

Results

Of the 642 isolates from distinct study participants that underwent WGS, 612 met sequence quality criteria. The median age of the 612 participants was 31 years (IQR 24.4-44.2), the majority were male (64.7%) and sputum smear-positive (83.3%), and 6.7% had co-infection with HIV. Most isolates belonged to L3 (44.6%). The majority (61.1%) of multidrug-resistant isolates (MDR, resistant to isoniazid and rifampin) belonged to L2 (P < 0.001 [Fisher’s Exact]). There was no significant difference in host characteristics between participants infected with the four major lineages. In phylogenetic analysis, we measured shorter terminal branch lengths in the L2 tree compared to L1 and L3 trees indicating less time elapsing between transmission and sampling and higher transmissibility (median branch lengths: L2 - 3.3, L3 - 7.8, p <0.001). Branching times for L2 and L4 were more recent than L1 and L3 indicating recent introduction into the region (p < 0.01 [KS test]).

Conclusion

Modern Mtb lineages (L2 and L4) were more recently introduced in western India, compared to older lineages (L1 and L3). L2 shows a higher frequency of drug-resistance and higher transmissibility. Our findings highlight the need for contact tracing around cases of TB due to L2, and heightened surveillance of TB antibiotic resistance in India.
Statistical learning in patients in the minimally conscious state
Authors: Xu Chuan , Gao Jian , Gao Jiaxin , Li Lingling , He Fangping , Yu Jie , Ling Yi , Li Hangcheng , Li Jingqi , Melloni Lucia , Luo Benyan , Ding Nai
Published: January 2022

When listening to an unknown language, listeners could learn the transitional probability between syllables and group frequently co-occurred syllables into a whole unit. Such statistical learning ability has been demonstrated for both pre-verbal infants and adults, even during passive listening. Here, we investigated whether statistical learning occurred in patients in minimally conscious state (MCS) and patients emerged from the minimally conscious state (EMCS) using electroencephalography (EEG). We presented to participants an isochronous sequence of syllables, which were composed of either 2-word real phrases or 2-word artificial phrases that were defined by the transitional probability between words. An inter-trial phase coherence (ITPC) analysis revealed that the phrase-rate EEG response was weakened in EMCS patients compared with healthy individuals, and was even more severely weakened in MCS patients. Although weak, the phrase-rate response or its harmonics remained statistically significant in MCS patients, suggesting that the statistical learning ability was preserved in MCS patients. The word-rate response was also weakened with a decreased level of consciousness. The harmonics of the word-rate response, however, were more salient in MCS than EMCS patients in the alpha and beta bands. Together with previous studies, the current results suggest that MCS patients retain residual learning ability, which can potentially be harnessed to induce neural plasticity, and that different frequency bands are differentially related to the consciousness level.
Breast milk exposure is associated with cortical maturation in preterm infants
Authors: Sullivan Gemma , Vaher Kadi , Blesa Manuel , Galdi Paola , Stoye David Q. , Quigley Alan J. , Thrippleton Michael J. , Bastin Mark E. , Boardman James P.
Published: January 2022

Objective

Breast milk exposure is associated with improved neurocognitive outcomes following preterm birth but the neural substrates linking nutrition with outcome are uncertain. By combining nutritional data with brain MRI, we tested the hypothesis that high versus low breast milk exposure in preterm infants during neonatal care results in a cortical morphology that more closely resembles that of infants born at term.

Methods

We studied 135 preterm (mean gestational age 30+2 weeks, range 22+1 to 32+6) and 77 term-born infants (mean gestational age 39+4 weeks, range 36+3 to 42+1). Nutritional data was collected from birth until hospital discharge to identify the proportion of days preterm infants received exclusive breast milk. Structural and diffusion MRI were performed at term-equivalent age. Cortical indices (volume, thickness, surface area, gyrification index, sulcal depth, curvature) and water diffusion parameters (fractional anisotropy, mean diffusivity, radial diffusivity, axial diffusivity, neurite density index, orientation dispersion index) were compared between preterm infants who received exclusive breast milk for <75% of inpatient days (n=68), preterm infants who received exclusive breast milk for ≥75% of inpatient days (n=67) and term-born controls (n=77).

Results

High breast milk exposure was associated with reduced cortical gray matter volume (d=0.47, p=0.014), thickness (d=0.42, p=0.039) and radial diffusivity (d=0.38, p=0.039), and increased fractional anisotropy (d=0.38, p=0.037) after adjustment for age at MRI.

Interpretation

High versus low breast milk exposure in the weeks following preterm birth is associated with a cortical imaging phenotype that more closely resembles the brain morphology of healthy infants born at term.
Estimation of causal effects of a time-varying exposure at multiple time points through Multivariable Mendelian randomization
Authors: Sanderson Eleanor , Richardson Tom G , Morris Tim T , Tilling Kate , Smith George Davey
Published: January 2022

Mendelian Randomisation (MR) is a powerful tool in epidemiology to estimate the causal effect of an exposure on an outcome in the presence of unobserved confounding, by utilising genetic variants as instrumental variables (IVs) for the exposure. The effects obtained from MR studies are often interpreted as the lifetime effect of the exposure in question. However, the causal effects of many exposures are thought to vary throughout an individual’s lifetime and there may be periods during which an exposure has more of an effect on a particular outcome. Multivariable MR (MVMR) is an extension of MR that allows for multiple, potentially highly related, exposures to be included in an MR estimation. MVMR estimates the direct effect of each exposure on the outcome conditional on all of the other exposures included in the estimation. We explore the use of MVMR to estimate the direct effect of a single exposure at different time points in an individual’s lifetime on an outcome. We use simulations to illustrate the interpretation of the results from such analyses and the key assumptions required. We show that causal effects at different time periods can be estimated through MVMR when the association between the genetic variants used as instruments and the exposure measured at those time periods varies, however this estimation will not necessarily identify exact time periods over which an exposure has the most effect on the outcome. We illustrate the method through estimation of the causal effects of childhood and adult BMI on smoking behaviour.
Validation of a novel fluorescent lateral flow assay for rapid qualitative and quantitative assessment of total anti-SARS-CoV-2 S-RBD binding antibody units (BAU) from plasma or fingerstick whole-blood of COVID-19 vaccinees
Authors: Younes Nadin , Al-Sadeq Duaa W. , Shurrab Farah M. , Zidan Hadeel T. , Abou-Saleh Haissam , Halawa Bushra Y. Abo , AlHamaydeh Fatima M. , Elsharafi Amira E. , Daas Hanin I. , Thomas Swapna , Aboalmaaly Sahar , Farsi Afra Al , Al-Buainain Reeham , Ataelmannan Samar , Paul Jiji , Al Saadi Amana Salih , Yassine Hadi M. , Majdalawieh Amin F. , Ismail Ahmed , Abu-Raddad Laith J. , Nasrallah Gheyath K.
Published: January 2022

Background

Limited commercial LFA assays are available to provide a reliable quantitative measurement of the total binding antibody units (BAU/mL) against the receptor-binding domain of the SARS-CoV-2 spike protein (S-RBD).

Aim

To evaluate the performance of FinecareTM2019-nCoV S-RBD LFA and its fluorescent reader (FinecareTM-FIA Meter) against the following reference methods (i) The FDA-approved Genscript surrogate virus-neutralizing assay (sVNT), and (ii) three highly performing automated immunoassays: BioMérieux VIDAS®3, Ortho VITROS®, and Mindray CL-900i®.

Methods

Plasma from 488 vaccinees were tested by all aforementioned assays. Fingerstick whole-blood samples from 156 vaccinees were also tested by FinecareTM.

Results and conclusions

FinecareTM showed 100% specificity as none of the pre-pandemic samples tested positive. Equivalent FinecareTM results were observed among the samples taken from fingerstick or plasma (Pearson correlationr=0.9, p<0.0001), suggesting that fingerstick samples are sufficient to quantitate the S-RBD BAU/mL. A moderate correlation was observed between FinecareTM and sVNT (r=0.5, p<0.0001), indicating that FinecareTM can be used for rapid prediction of the neutralization antibody post-vaccination. FinecareTM BAU results showed strong correlation with VIDAS®3 (r=0.6, p<0.0001), and moderate correlation with VITROS® (r=0.5, p<0.0001), and CL-900i® (r=0.4, p<0.0001), suggesting that FinecareTM be used as a surrogate for the advanced automated assays to measure S-RBD BAU/mL.
Heterologous immunization with inactivated vaccine followed by mRNA booster elicits strong humoral and cellular immune responses against the SARS-CoV-2 Omicron variant
Authors: Zuo Fanglei , Abolhassani Hassan , Du Likun , Piralla Antonio , Bertoglio Federico , de Campos-Mata Leire , Wan Hui , Schubert Maren , Wang Yating , Sun Rui , Cassaniti Irene , Vlachiotis Stelios , Kumagai-Braesch Makiko , Andréll Juni , Zhang Zhaoxia , Xue Yintong , Wenzel Esther Veronika , Calzolai Luigi , Varani Luca , Rezaei Nima , Chavoshzadeh Zahra , Baldanti Fausto , Hust Michael , Hammarström Lennart , Marcotte Harold , Pan-Hammarström Qiang
Published: January 2022

Background

There has been an unprecedented global effort to produce safe and effective vaccines against SARS-CoV-2. However, production challenges, supply shortages and unequal global reach, together with an increased number of breakthrough infections due to waning of immunity and the emergence of new variants of concern (VOC), have prolonged the pandemic. To boost the immune response, several heterologous vaccination regimes have been tested and have shown increased antibody responses compared to homologous vaccination. Here we evaluated the effect of mRNA vaccine booster on immunogenicity in individuals who had been vaccinated with two doses of inactivated vaccines.

Methods

The levels of specific antibodies against the receptor-binding domain (RBD) of the spike protein from wild-type virus and the Beta, Delta and Omicron variants were measured in healthy individuals who had received two doses of homologous inactivated (BBIBP-CorV or CoronoVac) or mRNA (BNT162b2 or mRNA-1273) vaccines, and in donors who were given an mRNA vaccine boost after two doses of either vaccine. Pre-vaccinated healthy donors, or individuals who had been infected and subsequently received the mRNA vaccine were also included as controls. In addition, specific memory B and T cell responses were measured in a subset of samples.

Results

A booster dose of an mRNA vaccine significantly increased the level of specific antibodies that bind to the RBD domain of the wild-type (6-fold) and VOCs including Delta (8-fold) and Omicron (14-fold), in individuals who had previously received two doses of inactivated vaccines. The level of specific antibodies in the heterologous vaccination group was furthermore similar to that in individuals receiving a third dose of homologous mRNA vaccines or boosted with mRNA vaccine after natural infection. Moreover, this heterologous vaccination regime significantly enhanced the specific memory B and T cell responses.

Conclusions

Heterologous prime-boost immunization with inactivated vaccine followed by an mRNA vaccine boost markedly increased the levels of specific antibodies and B and T cell responses and may thus increase protection against emerging SARS-CoV-2 variants including Omicron.
Containment of a multi-index B.1.1.7 outbreak on a university campus through a genomically-informed public health response
Authors: Martin Emily T. , Lauring Adam S. , Montgomery JoLynn P. , Valesano Andrew L. , Eisenberg Marisa C. , Sheen Danielle , Nord Jennifer , Ernst Robert D. , Mortenson Lindsey Y. , Valdez Riccardo , Niknafs Yashar , Conway Darryl , Rifat Sami F. , Bagdasarian Natasha , Lyon-Callo Sarah , Collins Jim , Blankenship Heather , Soehnlen Marty , Marquez Juan
Published: January 2022

The first cluster of SARS-CoV-2 cases with lineage B.1.1.7 in the state of Michigan was identified through intensive university-led surveillance sampling and targeted sequencing. A collaborative investigation and response was conducted by the local and state health departments, and the campus and athletic medicine COVID-19 response teams, using S-gene target failure screening and rapid genomic sequencing to inform containment strategies. A total of 50 cases of B.1.1.7-lineage SARS-CoV-2 were identified in this outbreak, which was due to three coincident introductions of B.1.1.7-lineage SARS-CoV-2, all of which were genetically distinct from lineages which later circulated in the broader community. This investigation demonstrates the successful implementation of a genomically-informed outbreak response which can be extended to university campuses and other settings at high risk for rapid emergence of new variants.