bluuebunny/crossref_metadata_2025 huggingface dataset:
Withholding Medical Interventions and Ageism During a Pandemic
Authors: Lowey Susan E.
Published: April 2021

Decisions surrounding withholding and withdrawing medical interventions are common within the palliative and hospice care community. The unexpected effects of the recent pandemic ignited conversations about scarcity of resources and withholding medical interventions, based on age, among providers with limited expertise in palliative care. Using a case study and literature review, the aim of this article was to examine the best ethical considerations for resource allocation decision making that minimizes the effects of ageism. Public health ethics differs from clinical ethics by giving priority to promoting the greatest good over the protection of individual autonomy. This divide in ethics sheds light on the dangers associated with ageism. Age is often a component within clinical instruments that guide clinicians with allocation decisions. Basing decisions solely on age without evaluating health and functional status is dangerous and further propagates the discriminatory practices that fuel ageism. Previous research identified using ethical principles to guide resource allocation decisions but that may not be enough to protect the rights of older adults. A new model to guide these decisions should include advance directives and goals of care, medical indicators instead of demographics, functionality, transparent medical team, and impact of social determinants of health.
Case Report: Double Intrastromal Corneal Ring Segment and Posterior Chamber Phakic Intraocular Lens Implantation
Authors: Bouza-Miguens Carmen , González-López Félix , Álvarez Gema , Gódia Rosa , Gutiérrez Jorge
Published: April 2021

SIGNIFICANCE

Keratoconus can manifest asymmetrically, affecting binocularity and becoming a refractive problem that is sometimes complex to solve. We propose a therapeutic approach for correction of keratoconus based on parallel implantation of a second intrastromal corneal ring segment (ICRS).

PURPOSE

This study aimed to improve the refractive status of a patient affected with advanced bilateral keratoconus using implantation of a second ICRS and a phakic intraocular lens.

CASE REPORT

A 44-year-old man came to our clinic requesting a refractive solution for his visual impairment. He had been diagnosed with bilateral severe keratoconus categorized by the Amsler-Krumeich classification scale as grade III (right eye) and grade II (left eye). He had previously undergone corneal cross-linking and implantation of ICRS (Intacs) in both eyes. Significant anisometropia was present between the eyes, and the patient also complained of poor quality of vision. We decided to implant a posterior chamber phakic collamer lens in his right eye and to insert a new ICRS (Keraring) deep and parallel to the previous one in his left eye. We aimed to prevent anisometropia in his right eye and to further regularize the affected cornea in his left eye. Refractive symmetry was achieved, and vision was optimized after surgery.

CONCLUSIONS

In a patient with keratoconus, refractive surgery should be performed from a bilateral perspective. Specific cases of keratoconus can be managed by parallel implantation of a second ICRS.
Visual and Ocular Conditions among a Homeless Adult Population of Boston
Authors: Russo Diane , Bass Olivia
Published: April 2021

SIGNIFICANCE

The eye care needs of the homeless population in the United States are not well known. This study elucidates those needs for health care for the homeless programs and eye care practitioners. This information could result in an increase in the provision of necessary eye care services.

PURPOSE

The purpose of this study was to assess the extent of visual and ocular conditions, the frequency of eyeglass orders and receipt of eyeglasses, and the frequency of ophthalmology referrals and receipt of ophthalmological care in an adult homeless population in Boston.

METHODS

A cross-sectional retrospective chart review was conducted for patients of the Boston Health Care for the Homeless Program's Pine Street Inn eye clinic from September 26, 2016, to December 31, 2017. Data on sociodemographics, medical history, comprehensive eye examination findings, glasses orders and receipt, and ophthalmology referrals and receipt of care were collected and analyzed.

RESULTS

A total of 424 patients were included in the study. The mean age of the study population was 52.7 (interquartile range, 46 to 60), and the majority were male (74%). The most common systemic conditions were hypertension (40.6%) and diabetes (23.8%). The most common refractive error was presbyopia (67.7%), followed by astigmatism (38.9%), hyperopia (34.0%), and myopia (30.7%). The most common ocular conditions were dry eye (28.6%), visually or clinically significant cataract (20%), and glaucoma/glaucoma suspicion (13.9%). Refractive correction was indicated for 356 patients (84%), but 82 (29%) did not receive ordered eyeglasses. Ophthalmology referrals were placed for 61 patients (14.4%), yet only 20 (32.8%) of those referrals were completed.

CONCLUSIONS

A significant need for refractive correction and a large gap for ophthalmological care were found among the study population. Health care for the homeless programs and eye care practitioners should be aware of the visual and ocular needs of this patient population so as to better meet their needs.
Engaging Patients in the Use of Real-Time Electronic Clinical Data to Improve the Safety and Reliability of Their Own Care
Authors: Schnock Kumiko , Roulier Stephanie , Butler Jorie , Dykes Patricia , Fiskio Julie , Gibson Bryan , Lipsitz Stuart , Miller Susanne , Shaykevich Shimon , Bates David , Classen David
Published: April 2021

Objectives

There is considerable evidence that providing patients with access to their health information is beneficial, but there is limited evidence regarding the effect of providing real-time patient safety–related information on health outcomes. The aim of this study was to evaluate the association between use of an electronic patient safety dashboard (Safety Advisor) and health outcomes.

Methods

The Safety Advisor was implemented in 6 adult medicine units at one hospital in the United States. Study participants were asked to use the Safety Advisor, which provides real-time patient safety–related information through a Web-based portal. The primary outcome was the association between the application usage and health outcomes (readmission rate and mortality rate) per 3 different usage groups, and the secondary outcome was the association of Patient Activation Measure (PAM) scores with use.

Results

One hundred eighty-one participants were included for the data analysis. Approximately 90% of users accessed the application during the first 4 days of enrollment: 51.6% of users only accessed it on 1 day, whereas 5.8% used it more than 3 days. Patients who used the application more had lower 30-day readmission rates (P = 0.01) compared with the lower-usage group. The PAM scores for users of Safety Advisor (71.8) were higher than the nonpatient portal users (60.8, P < 0.0001).

Conclusions

We found an association between the use of Safety Advisor and health outcomes. Differences in PAM scores between groups were statistically significant. A larger-scale randomized control trial is warranted to evaluate the impact on patient outcomes among a high-risk patient population.
An Analysis of Judicial Cases Concerning Analgesic-Related Medication Errors in the Republic of Korea
Authors: Yoon Susie , Cho Soo Ick , Shin SuHwan , Lee Wonjong , Ko Youkang , Moon Jee Youn , Lee Ho-Jin
Published: April 2021

Objectives

Analgesic-related medication errors can be a threat to patient safety. This study aimed to identify and describe medication errors that can cause serious adverse drug events (ADEs) related to analgesic use.

Methods

This retrospective, observational, medicolegal study analyzed closed cases concerning complications induced by medication errors involving 3 commonly used analgesics: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen (AAP). Cases closed between 1994 and 2019 that were available in the Korean Supreme Court judgment database system were included. Medication errors were categorized using a classification system (developed by our group) based on the stage of drug administration. Clinical characteristics and judgment statuses were analyzed.

Results

A total of 71 cases were included in the final analysis (opioids, n = 30; NSAIDs, n = 35; AAP, n = 6). Among them, 43 claims (60.6%) resulted in payments to the plaintiffs, with a median payment of $86,607 (interquartile range, $34,554–$193,782). The severity of ADEs was high (National Association of Insurance Commissioners scale ≥6) in 88.7% (n = 63) of claims, with a total of 44 (62%) deaths. The most common types of ADEs associated with opioid, NSAID, and AAP use were respiratory depression, anaphylactic shock, and fulminant hepatitis, respectively. The most common recognized medication errors associated with opioid, NSAIDs, and AAP were inappropriate patient monitoring (n = 10; 33.3%), improper analgesic choice (n = 15; 42.9%), and inappropriate treatment after ADEs (n = 3; 50%), respectively.

Conclusions

Our findings indicate that efforts should be made to reduce medication errors related to analgesic use to prevent permanent injury and potential malpractice claims.
Primary Care Physicians’, Psychiatrists’, and Oncologists’ Coordination While Prescribing Medications for Patients With Multiple Chronic Conditions
Authors: McDaniel Cassidi C. , Chou Chiahung , Camp Christina , Hohmann Natalie S. , Hastings Tessa J. , Maciejewski Matthew L. , Farley Joel F. , Domino Marisa Elena , Hansen Richard A.
Published: April 2021

Objectives

Coordination of medication prescribing is important in the care of patients with multiple chronic conditions (MCC) given the involvement of multiple providers and multiple medications used to manage MCC. The objective of this study was to identify physician and practice factors associated with physicians’ coordination of prescribing for complex patients with MCC.

Methods

Our cross-sectional study used a 33-item anonymous, online survey to assess physicians’ coordination practices while prescribing for patients with MCC. We sampled primary care physicians (PCPs), psychiatrists, and oncologists across the United States. Coordination of medication prescribing was measured on a 7-point Likert-type scale. χ2, Fisher exact test, and binomial logistic regression, adjusted for factors and covariates, were used to determine differences in coordination of prescribing. Average marginal effects were calculated for factors.

Results

A total of 50 PCPs, 50 psychiatrists, and 50 oncologists participated. Most psychiatrists (56%) and oncologists (52%) reported frequently coordinating prescribing with other physicians, whereas less than half of the PCPs (42%) reported frequently coordinating prescribing. Female physicians were 25% points more likely to report coordinating prescribing than male physicians (P = 0.0186), and physicians not using electronic medical records were 30% points more likely to report coordinating prescribing than physicians using electronic medical records (P = 0.0230). Four additional factors were associated with lower likelihood of coordinating prescribing.

Conclusions

Physician and practice factors may influence differences in coordination of medication prescribing, despite physician specialty. These factors can provide a foundation for developing interventions to improve coordination of prescribing practices for MCC.
Bedside Clinicians’ Perceptions on the Contributing Role of Diagnostic Errors in Acutely Ill Patient Presentation: A Survey of Academic and Community Practice
Authors: Huang Chanyan , Barwise Amelia , Soleimani Jalal , Dong Yue , Svetlana Herasevich , Khan Syed Anjum , Gavin Anne , Helgeson Scott A. , Moreno-Franco Pablo , Pinevich Yuliya , Kashyap Rahul , Herasevich Vitaly , Gajic Ognjen , Pickering Brian W.
Published: April 2021

Objectives

This study aimed to explore clinicians’ perceptions of the occurrence of and factors associated with diagnostic errors in patients evaluated during a rapid response team (RRT) activation or unplanned admission to the intensive care unit (ICU).

Methods

A multicenter prospective survey study was conducted among multiprofessional clinicians involved in the care of patients with RRT activations and/or unplanned ICU admissions (UIAs) at 2 academic hospitals and 1 community-based hospital between April 2019 and March 2020. A study investigator screened eligible patients every day. Within 24 hours of the event, a research coordinator administered the survey to clinicians, who were asked the following: whether diagnostic errors contributed to the reason for RRT/UIA, whether any new diagnosis was made after RRT/UIA, if there were any failures to communicate the diagnosis, and if involvement of specialists earlier would have benefited that patient. Patient clinical data were extracted from the electronic health record.

Results

A total of 1815 patients experienced RRT activations, and 1024 patients experienced UIA. Clinicians reported that 18.2% (95/522) of patients experienced diagnostic errors, 8.0% (42/522) experienced a failure of communication, and 16.7% (87/522) may have benefitted from earlier involvement of specialists. Compared with academic settings, clinicians in the community hospital were less likely to report diagnostic errors (7.0% versus 22.8%, P = 0.002).

Conclusions

Clinicians report a high rate of diagnostic errors in patients they evaluate during RRT or UIAs.
Utilization of Coronary Artery Disease Reporting and Data System: A Survey of Cardiovascular Imaging Societies
Authors: Whalen Hallie , Hossain Rydhwana , Jeudy Jean , White Charles S.
Published: April 2021

Objective

This survey was performed to determine the extent of utilization of Coronary Artery Disease Reporting and Data System (CAD-RADS) since its introduction in 2016 among members of cardiovascular imaging societies.

Methods

A survey regarding use of CAD-RADS was distributed to members of North American Society for Cardiovascular Imaging and Society for Cardiovascular Computed Tomography.

Results

A total of 246 surveys were completed, and results show that, although most respondents are familiar with CAD-RADS (95%), less than half (45%) report using CAD-RADS for all coronary CTA. Rates of CAD-RADS utilization were similar among physicians who work in a variety of settings. Years of clinical experience did not affect the rates of CAD-RADS utilization; however, a higher weekly volume of cardiac computed tomography was associated with higher rates of CAD-RADS utilization.

Conclusions

Four years after the introduction of CAD-RADS, the reporting system is used by less than half of surveyed members of North American Society for Cardiovascular Imaging and Society for Cardiovascular Computed Tomography regardless of practice model and range of practice experience with cardiac computed tomography.
Magnetic Resonance Imaging Characteristics of Poroma and Porocarcinoma
Authors: Kawaguchi Masaya , Kato Hiroki , Imada Hiroki , Miyazaki Tatsuhiko , Matsuyama Kanako , Seishima Mariko , Matsuo Masayuki
Published: April 2021

Purpose

The purpose of this study was to evaluate magnetic resonance (MR) imaging findings of poroma and porocarcinoma.

Methods

Six patients (3 male, 3 female; age range, 40–84 years; mean age, 61 years) with histologically confirmed skin appendage tumors with apocrine and eccrine differentiation (2 poromas and 4 porocarcinomas) were enrolled. All patients underwent preoperative MR imaging and the MR images were retrospectively reviewed.

Results

The configurations were classified as pedunculated solid in 5 lesions and subcutaneous cystic with mural nodules in 1. Well-demarcated deep tumor margins and smooth skin surfaces were observed in all 6 lesions, and peritumoral fat stranding was observed in 2. In all 5 pedunculated solid lesions, T2-hyperintense foci, T1 hyperintensity, and homogeneous solid components were observed within the lesions.

Conclusions

Poroma and porocarcinoma usually exhibited pedunculated solid homogeneous lesion. Intratumoral T2-hyperintense foci and T1 hyperintensity were observed in pedunculated solid lesions.
COVID-19: Abdominal and Pelvic Imaging Findings: A Primer for Radiologists
Authors: Palacios Sofía , Schiappacasse Giancarlo , Valdes Rosario , Maldonado Ignacio , Varela Cristian
Published: April 2021

The COVID-19 pandemic presents an ongoing global health threat. The SARS-CoV-2 is known to cause substantial pulmonary disease, and most of the current radiological publications are dedicated to describing and characterizing these findings. However, studies regarding imaging findings in the abdomen and pelvis of infected patients are still very limited. The aim of this review is to discuss the most frequent abdominal manifestations based on the current literature and representative images from our local experience.
RSNA-STR-ACR Consensus Statement for COVID-19 CT Patterns: Interreader Agreement in 240 Consecutive Patients and Association With RT-PCR Status
Authors: Silva Claudio F. , Alegria Julia , Ramos Cristobal , Verdugo Jaime , Diaz Juan-Carlos , Varela Cristian , Barbe Mario
Published: April 2021

Purpose

The aim of this study was to study interreader agreement of the RSNA-STR-ACR (Radiological Society of North America/Society of Thoracic Radiology/American College of Radiology) consensus statement on reporting chest computed tomography (CT) findings related to COVID-19 on a sample of consecutive patients confirmed with reverse transcriptase–polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2.

Materials and Methods

This institutional review board–approved retrospective study included 240 cases with a mean age of 47.6 ± 15.9 years, ranging from 20 to 90 years, who had a chest CT and RT-PCR performed. Computed tomography images were independently analyzed by 2 thoracic radiologists to identify patterns defined by the RSNA-STR-ACR consensus statement, and concordance was determined with weighted κ tests. Also, CT findings and CT severity scores were tabulated and compared.

Results

Of the 240 cases, 118 had findings on CT. The most frequent on the RT-PCR–positive group were areas of ground-glass opacities (80.5%), crazy-paving pattern (32.2%), and rounded pseudonodular ground-glass opacities (22.9%). Regarding the CT patterns, the most frequent in the RT-PCR–positive group was typical in 75.9%, followed by negative in 17.1%. The interreader agreement was 0.90 (95% confidence interval, 0.80–0.96) in this group. The CT severity score had a mean difference of −0.07 (95% confidence interval, −0.48 to 0.34) among the readers, showing no significant differences regarding visual estimation.

Conclusions

The RSNA-STR-ACR consensus statement on reporting chest CT patterns for COVID-19 presents a high interreader agreement, with the typical pattern being more frequently associated with RT-PCR–positive examinations.
A Rare Case of Metastatic Solitary Fibrous Tumor (Hemangiopericytoma) of the Dura on 18F-FDG PET/CT
Authors: Grünig Hannes , Skawran Stephan , Stolzmann Paul , Messerli Michael , Huellner Martin W.
Published: April 2021

Solitary fibrous tumor is a rare neoplasm of mesenchymal origin. It can arise in various locations, most commonly in the pleura. It encompasses a heterogeneous group of histological patterns with different biological behavior. In some cases, metastases occur, sometimes years after the initial diagnosis. We report a case of metastatic meningeal hemangiopericytoma, also called solitary fibrous tumor of the dura, exhibiting liver metastases and muscle metastases 5 years after resection and adjuvant radiotherapy of the primary tumor.
Paraneoplastic Limbic Encephalitis Secondary to SCLC on 18F-FDG PET/CT
Authors: Verçosa Alinne Fernanda Amaral , Mota Isabella Araújo , Flamini Maria Eduarda Duarte de Mello , Flamini Rodrigo de Carvalho
Published: April 2021

A 67-year-old man with rapidly neurologic deterioration and 15 kg weight loss in 2 months was extensively evaluated by several medical specialties and conventional image examinations, with no diagnostic definition. 18F-FDG PET/CT was performed, showing glycolytic hypermetabolism in the hippocampus, cerebral hypometabolism with posterior temporoparietal pattern, multiple cervical and supraclavicular lymph nodes, and mediastinal hypermetabolic and enlarged lymph nodes, suggesting paraneoplastic limbic encephalitis, Alzheimer dementia, and lymphoma. Lymph node biopsy resulted in small cell lung carcinoma. The patient presented rapid clinical deterioration and died.
A Systematic Review of Fecal Microbiota Transplantation Versus Vancomycin for Treatment of Recurrent Clostridioides difficile Infection
Authors: Leung Jane , Pham Stacey
Published: April 2021

Clostridioides difficile infection is a major clinical challenge, which may be associated with severe complications. Clostridioides difficile infection may result in repeated episodes of diarrhea, abdominal pain, and dehydration, leading to an increased risk of mortality. Increasingly high rates of recurrent Clostridioides difficile-associated diarrhea, refractory to antibiotic therapy, are difficult to treat. The suboptimal response to antibiotic therapy has led to the need for fecal microbiota transplantation in addition to the more commonly prescribed antibiotic, vancomycin. This systematic review aims to evaluate the effectiveness of fecal microbiota transplantation in the resolution of recurrent Clostridioides difficile infection in adults, compared with an oral vancomycin regimen alone. A systematic literature search was performed, resulting in three randomized control studies. Results from the studies are conflicting, with different variations of study outcomes. In two of the three randomized control trials, fecal microbiota transplantation was statistically significant in effectively resolving Clostridioides difficile infection, but not significant in the third. Although fecal microbiota transplantation results are promising, there are many different variables within the studies, and further research is recommended to explore the effects of these variables within larger sample sizes.
Validation of the Injured Trauma Survivor Screen: An American Association for the Surgery of Trauma multi-institutional trial
Authors: Hunt Joshua C. , Herrera-Hernandez Erick , Brandolino Amber , Jazinski-Chambers Kelley , Maher Kathryn , Jackson Brianna , Smith Randi N. , Lape Diane , Cook Mackenzie , Bergner Carisa , Schramm Andrew T. , Brasel Karen J. , de Moya Marc A. , deRoon-Cassini Terri A.
Published: April 2021

BACKGROUND

Psychological distress is common following a traumatic injury event. The Injured Trauma Survivor Screen (ITSS) was developed at a level 1 trauma center to assess for posttraumatic stress disorder (PTSD) and major depressive episode (MDE) following admission for a traumatic injury. The ITSS sensitivity and specificity were analyzed 1 to 3 and 6 to 9 months postinjury to test the validity across trauma centers.

METHOD

Four level 1 trauma centers from the East, Midwest, South, and West in the United States recruited 375 eligible adult inpatients (excluded participants included those with moderate or severe traumatic brain injury, whose injury was self-inflicted, were noncommunicative, or were non-English speaking). Baseline sample (White/Caucasian, 63.2%; male, 62.4%; mean (SD) age, 45 (17.11) years; injured by motor vehicle collision, 42.4%) measurements were conducted during index hospitalization. At first follow-up, 69.6% (n = 261) were retained; at second follow-up, 61.3% (n = 230) were retained. Measurements included the ITSS, PTSD Checklist for DSM-5, Center for Epidemiologic Studies Depression Scale—Revised, and Clinician-Administered PTSD Scaled for DSM 5.

RESULTS

At follow-up 1, the ITSS PTSD subscale had a sensitivity of 75% and specificity of 78.8%, and the MDE subscale had a sensitivity of 80.4% and specificity of 65.6%. At follow-up 2, the PTSD subscale had a sensitivity of 72.7% and specificity of 83.1%, and the MDE subscale had a sensitivity of 76.1% and specificity of 68.3%. A combined risk group using two symptom based measures administered at baseline produced increased specificity.

CONCLUSION

The nine-item ITSS continues to be an efficient and effective risk screen for PTSD and MDE following traumatic injury requiring hospitalization. This multi-institutional validation study creates a solid foundation for further exploration of the generalizability of this screen’s psychometric properties in distinct populations.

LEVEL OF EVIDENCE

Prognostic study, level III
Use of the spatial access ratio to measure geospatial access to emergency general surgery services in California
Authors: McCrum Marta L. , Wan Neng , Lizotte Steven L. , Han Jiuying , Varghese Thomas , Nirula Raminder
Published: April 2021

BACKGROUND

Emergency general surgery (EGS) encompasses a spectrum of time-sensitive and resource-intensive conditions, which require adequate and timely access to surgical care. Developing metrics to accurately quantify spatial access to care is critical for this field. We sought to evaluate the ability of the spatial access ratio (SPAR), which incorporates travel time, hospital capacity, and population demand in its ability to measure spatial access to EGS care and delineate disparities.

METHODS

We constructed a geographic information science platform for EGS-capable hospitals in California and mapped population location, race, and socioeconomic characteristics. We compared the SPAR to the shortest travel time model in its ability to identify disparities in spatial access overall and for vulnerable populations. Reduced spatial access was defined as >60 minutes travel time or lowest three classes of SPAR.

RESULTS

A total of 283 EGS-capable hospitals were identified, of which 142 (50%) had advanced resources. Using shortest travel time, only 166,950 persons (0.4% of total population) experienced prolonged (>60 minutes) travel time to any EGS-capable hospital, which increased to 1.05 million (2.7%) for advanced-resource centers. Using SPAR, 11.5 million (29.5%) had reduced spatial access to any EGS hospital, and 13.9 million (35.7%) for advanced-resource centers. Rural residents had significantly decreased access for both overall and advanced EGS services when assessed by SPAR despite travel times within the 60-minute threshold.

CONCLUSION

While travel time and SPAR showed similar overall geographic patterns of spatial access to EGS hospitals, SPAR identified a greater a greater proportion of the population as having limited access to care. Nearly one third of California residents experience reduced spatial access to EGS hospitals when assessed by SPAR. Metrics that incorporate measures of population demand and hospital capacity in addition to travel time may be useful when assessing spatial access to surgical services.

LEVEL OF EVIDENCE

Cross-sectional study, level VI.
Temporal profile of the pro- and anti-inflammatory responses to severe hemorrhage in patients with venous thromboembolism: Findings from the PROPPR trial
Authors: McCully Belinda H. , Wade Charlie E. , Fox Erin E. , Inaba Kenji , Cohen Mitchell J. , Holcomb John B. , Schreiber Martin A. ,   the PROPPR study group
Published: April 2021

BACKGROUND

The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial showed that 15% of patients developed venous thromboembolism (VTE) following hemorrhage, but the mechanisms are unknown. Since inflammation is associated with hypercoagulability and thrombosis, our goal was to compare the temporal inflammatory profile following hemorrhagic shock in patients with and without VTE.

STUDY DESIGN

Secondary analysis was performed on data collected from PROPPR. Blood samples collected at 0 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours following admission were assayed on a 27-target cytokine panel, and compared between VTE (n = 83) and non-VTE (n = 475) patients. p < 0.05 indicated significance.

RESULTS

Over time, both groups exhibited elevations in proinflammatory mediators interleukin (IL)-6, IL-8, IL-10, granulocyte colony-stimulating factor 57, monocyte chemoattractant protein 1 and macrophage inflammatory protein 1β, and anti-inflammatory mediators IL-1ra and IL-10 (p < 0.05 vs. admission). Venous thromboembolism patients showed amplified responses for IL-6 (6–72 hours) and IL-8 (6–24 hours), which peaked at later time points, and granulocyte colony-stimulating factor 57 (12–24 hours), monocyte chemoattractant protein 1 (6–72 hours), and macrophage inflammatory protein-1 β (2–12 hours) (p < 0.05 vs. non-VTE per time point) that peaked at similar time points to non-VTE patients. The anti-inflammatory responses were similar between groups, but the interleukin-mediated proinflammatory responses continued to rise after the peak anti-inflammatory response in the VTE group. The occurrence rate of adverse events was higher in VTE (97%) versus non-VTE (87%, p = 0.009) and was associated with higher inflammation.

CONCLUSION

Patients with VTE following hemorrhagic shock exhibited a prolonged and amplified proinflammatory responses mediated by select interleukin, chemotactic, and glycoprotein cytokines that are not antagonized by anti-inflammatory mediators. This response is not related to randomization group, injury severity or degree of shock, but may be linked to adverse events.

LEVEL OF EVIDENCE

Prognostic, level III
Epidemiology and management of isolated blunt renal artery injuries
Authors: Owattanapanich Natthida , Benjamin Elizabeth , Lewis Meghan , Cai Jie , Demetriades Demetrios
Published: April 2021

BACKGROUND

Isolated blunt renal artery injury (BRAI) is uncommon. Treatment options include observation, nephrectomy, surgical reconstruction and endovascular stenting. Over the last decade, there has been an increasing use of angiointervention techniques in vascular trauma. Previous studies reported underutilization of endovascular stenting in BRAI, in favor of observation. The aim of this study was to examine the epidemiology and assess changes in the management of isolated BRAI over the last decade.

METHODS

Patients with BRAI identified from the National Trauma Data Bank (2016–2017). Deaths in the emergency department, transferral from outside hospital, and those with associated high-grade kidney injuries were excluded. Demographics, type of renal artery injury, and renal artery management were analyzed. Multivariate analysis was used to identify independent factors associated with isolated BRAI.

RESULTS

During the study period, there were 1,708,076 patients with blunt trauma and 873 (0.05%) of them had BRAI. After exclusions, 563 patients with isolated BRAI who met the criteria for inclusion in the analysis. Auto versus pedestrian mechanism and male sex were associated with the highest risk for isolated BRAI. Comorbidities, such as hypertension or diabetes, were not associated with an increased risk of BRAI. Seatbelt use had a protective effect against BRAI. In the majority of patients (534, 95%), the renal artery injury was treated with observation, 23 (4%) with nephrectomy, 5 (0.9%) with endovascular stent and 1 (0.2%) with open renal artery repair. Among the 103 patients with isolated major renal artery laceration, 91.2% were treated with observation, 7.8% with nephrectomy and 1% with stenting.

CONCLUSION

Isolated blunt renal artery trauma is rare. The vast majority of patients with BRAI is managed with observation with only a small number undergoing endovascular intervention. Endovascular stenting utilization has remained very low and has not changed in the last decade.
Development of a field artificial intelligence triage tool: Confidence in the prediction of shock, transfusion, and definitive surgical therapy in patients with truncal gunshot wounds
Authors: Nederpelt Charlie J. , Mokhtari Ava K. , Alser Osaid , Tsiligkaridis Theodoros , Roberts Jay , Cha Miriam , Fawley Jason A. , Parks Jonathan J. , Mendoza April E. , Fagenholz Peter J. , Kaafarani Haytham M.A. , King David R. , Velmahos George C. , Saillant Noelle
Published: April 2021

BACKGROUND

In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury.

METHODS

Using an American College of Surgeons Trauma Quality Improvement Program–derived database of truncal and junctional gunshot wound (GSW) patients (aged 16–60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0–1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables.

RESULTS

A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery.

CONCLUSION

Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings.

LEVEL OF EVIDENCE

Prognostic, Level III.
Prehospital continuous vital signs predict need for resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy prehospital continuous vital signs predict resuscitative endovascular balloon occlusion of the aorta
Authors: Zeineddin Ahmad , Hu Peter , Yang Shiming , Floccare Douglas , Lin Chien-Yu , Scalea Thomas M. , Kozar Rosemary A.
Published: April 2021

BACKGROUND

Rapid triage and intervention to control hemorrhage are key to survival following traumatic injury. Patients presenting in hemorrhagic shock may undergo resuscitative thoracotomy (RT) or resuscitative endovascular balloon occlusion of the aorta (REBOA) as adjuncts to rapidly control bleeding. We hypothesized that machine learning along with automated calculation of continuously measured vital signs in the prehospital setting would accurately predict need for REBOA/RT and inform rapid lifesaving decisions.

METHODS

Prehospital and admission data from 1,396 patients transported from the scene of injury to a Level I trauma center via helicopter were analyzed. Utilizing machine learning and prehospital autonomous vital signs, a Bleeding Risk Index (BRI) based on features from pulse oximetry and electrocardiography waveforms and blood pressure (BP) trends was calculated. Demographics, Injury Severity Score and BRI were compared using Mann-Whitney-Wilcox test. Area under the receiver operating characteristic curve (AUC) was calculated and AUC of different scores compared using DeLong’s method.

RESULTS

Of the 1,396 patients, median age was 45 years and 68% were men. Patients who underwent REBOA/RT were more likely to have a penetrating injury (24% vs. 7%, p < 0.001), higher Injury Severity Score (25 vs. 10, p < 0.001) and higher mortality (44% vs. 7%, p < 0.001). Prehospital they had lower BP (96 [70–130] vs. 134 [117–152], p < 0.001) and higher heart rate (106 [82–118] vs. 90 [76–106], p < 0.001). Bleeding risk index calculated using the entire prehospital period was 10× higher in patients undergoing REBOA/RT (0.5 [0.42–0.63] vs. 0.05 [0.02–0.21], p < 0.001) with an AUC of 0.93 (95% confidence interval [95% CI], 0.90–0.97). This was similarly predictive when calculated from shorter periods of transport: BRI initial 10 minutes prehospital AUC of 0.89 (95% CI, 0.83–0.94) and initial 5 minutes AUC of 0.90 (95% CI, 0.85–0.94).

CONCLUSION

Automated prehospital calculations based on vital sign features and trends accurately predict the need for the emergent REBOA/RT. This information can provide essential time for team preparedness and guide trauma triage and disaster management.

LEVEL OF EVIDENCE

Therapeutic/care management, Level IV.
Pediatric age-adjusted shock index as a tool for predicting outcomes in children with or without traumatic brain injury
Authors: Reppucci Marina L. , Phillips Ryan , Meier Maxene , Acker Shannon N. , Stevens Jenny , Moulton Steven L. , Bensard Denis
Published: April 2021

BACKGROUND

The pediatric age-adjusted shock index (SIPA) accurately identifies severely injured children following trauma without accounting for neurological status. Understanding how the presence of traumatic brain injury (TBI) affects the generalizability of SIPA as a bedside triage tool is important given high rates of TBI in the pediatric trauma population. We hypothesized that SIPA combined with TBI (SIPAB+) would more accurately identify severely injured children.

METHODS

Patients (1–18 years old) in the American College of Surgeons Pediatric Trauma Quality Improvement Program database (2014–2017) with an elevated SIPA upon arrival to a pediatric trauma center were included. Pediatric age-adjusted shock index combined with TBI was defined as elevated SIPA with Glasgow Coma Scale score of ≤8. Pediatric age-adjusted shock index without TBI (SIPAB−) was defined as elevated SIPA with Glasgow Coma Scale score of >9. Patients were stratified into SIPAB+ and SIPAB−. A subanalysis of patients with isolated brain injury and those with brain injury and multisystem injuries was also performed. Data were compared through univariate models and three separate logistic regression models.

RESULTS

Overall, 25,068 had an elevated SIPA, with 12.3% classified as SIPAB+ and the remainder SIPAB−. Patients classified as SIPAB+ received more blood transfusions within 4 hours of injury and had higher mortality rates. On logistic regression, SIPAB+ patients had significantly higher odds of early blood transfusion and a combination of both. Mortality and early blood transfusion were also higher in SIPAB+ patients on subanalysis for patients with isolated TBI and those with multisystem injuries.

CONCLUSION

The use of SIPAB+ as a bedside triage tool accurately identifies traumatically injured children at high risk for early blood transfusion and/or death while incorporating the presence of neurological injury. This is true for patients with isolated TBI and those with multisystem injury, indicating its utility in predicting outcomes for TBI patients with elevated SIPA regardless of presence of concomitant injuries. Incorporation of this as a triage tool should be considered to better predict resources in this population.

LEVEL OF EVIDENCE

Prognostic, level III.
Ruxolitinib for the Treatment of Chronic GVHD and Overlap Syndrome in Children and Young Adults
Authors: Wang YunZu Michele , Teusink-Cross Ashley , Elborai Yasser , Krupski M. Christa , Nelson Adam S. , Grimley Michael S. , Flannery Amanda , Mehta Parinda A. , Bleesing Jacob J. , Chandra Sharat , Kumar Ashish R. , Myers Kasiani C. , Davies Stella M. , Khandelwal Pooja
Published: April 2021

Background.

Ruxolitinib, a JAK1/2 inhibitor, is used to treat chronic graft versus host disease (cGVHD) in adult allogeneic hematopoietic stem cell transplant patients, but experience in children is limited, perhaps because of lack of pediatric dosing information. In this report, we describe our pediatric and young adult dosing strategy experience in cGVHD.

Methods.

Ruxolitinib was administered orally at 5 mg twice daily for children ≥25 kg or 2.5 mg twice daily if <25 kg. The dose was halved with concurrent azole administration and increased to a maximum of 10 mg twice daily if tolerated. Responses were evaluated using the 2014 NIH consensus criteria. Phosphorylation of lymphocyte STAT5 following dosing, a surrogate of JAK inhibition, was evaluated by flow cytometry.

Results.

Twenty patients with a median age 14.6 y (range 5–26 y) received ruxolitinib for severe (n = 9) and moderate (n = 11) cGVHD. Median steroid dose was 0.5 mg/kg/d (range 0.08–1.5 mg/kg/d) at ruxolitinib initiation. Two patients with moderate cGVHD achieved a complete response (CR), while 12 patients achieved a partial response (PR) at a median of 48 d (range 17–98 d) from the first ruxolitinib dose, for an overall response rate of 70%. Eleven patients are maintaining their PRs. pSTAT5 on lymphocytes was absent or decreased (0%–6% events) in 5 evaluated patients, suggesting adequate inhibition. Three patients discontinued ruxolitinib because of neutropenia, thrombocytopenia, or elevated alanine aminotransferase. Four patients developed bacterial infections, and 3 experienced symptomatic viral infections. Two patients died from complications related to progressive severe cGVHD.

Conclusions.

Ruxolitinib using our dosing strategy demonstrates promise for treating cGVHD in children.
Cancer Screening in Solid Organ Transplant Recipients: A Focus on Screening Liver, Lung, and Kidney Recipients for Cancers Related to the Transplanted Organ
Authors: Dharia Atit , Boulet Jacinthe , Sridhar Vikas S. , Kitchlu Abhijat
Published: April 2021

Over the last few decades, the life expectancy of solid organ transplant recipients (SOTRs) has improved significantly. With SOTRs living longer, more recipients are dying from cancer. There is a reported 2- to 3-fold increased risk of cancer-specific mortality in SOTRs compared with the general population. Cancer in an SOTR can be de novo, recurrent, or donor-derived. Cancer screening in this population is crucial, as early detection and treatment may improve outcomes. In the absence of randomized controlled trials dedicated to SOTRs, clinicians rely on clinical practice guidelines from regional and national transplant societies; however, these may vary considerably across jurisdictions and transplanted organ. At present, no widely accepted consensus exists for cancer screening protocols in SOTRs, particularly with regard to screening for malignancy related to transplanted organ. Some SOTRs may be at higher risk of malignancies within the allograft. This is particularly the case in lung and liver recipients, though less common in kidney recipients who are at increased risk of developing renal cell cancer in their native kidneys. This increased risk has not been uniformly incorporated into screening recommendations for SOTRs. In this review, we summarize the cancer screening recommendations for SOTRs from various transplant organizations based on transplanted organ. This review also discusses the complexity and controversies surrounding screening of cancer in the allograft and future avenues to improve cancer detection in this context. More studies specific to SOTRs are required to form generalizable and evidence-based cancer screening guidelines, particularly with respect to cancer screening in the allograft.
Intravenous Lacosamide in Seizure Clusters: Dose and Efficacy
Authors: Eilam Anda , Khmeliov Nadejda , Penker Delit , Gilad Ronit
Published: April 2021

Purpose

The objective of our study was to evaluate the relationship between the loading dose and efficacy of lacosamide (LCM), when used in seizure clusters (SCs).

Methods

A cohort of patients with SC treated with intravenous (IV)-LCM between September 2017 and September 2019 was retrospectively examined. Demographic data, type of seizure emergency, etiology, response rate, previous oral antiepileptic drugs used, total LCM loading dose, and side effects were reviewed.

Results

Thirty-nine cases of epileptic emergencies treated with IV LCM were collected. The mean age was 59.25 years (18–88 years), and the median loading dose was 136.5 mg (100–300 mg) with a response rate in the whole population of 29.2%. Nine patients received a loading dose of 200 to 300 mg, and their response rate was 89%. Common side effects (drowsiness and dizziness) were mild. No electrocardiogram changes or other cardiovascular side effects, or unexpected side effects were seen.

Conclusions

In adults with SC, a loading dose of IV LCM of 200 mg or more achieved 89% response rate in this cohort. Loading doses of less than 300 mg caused mild side effects only.
Oseltamivir-Induced Mania in a Patient With Influenza A
Authors: Ferahkaya Eda
Published: April 2021

Oseltamivir is an antiviral drug often preferred in treating viral infections. Its use has increased owing to annual influenza outbreaks and the COVID-19 pandemic. Although its adverse effects are often seen in the gastrointestinal system, it has other adverse effects that can prevent its use, for example, neuropsychiatric events. In this case report, we present a manic episode case caused by the use of oseltamivir.
Electroconvulsive Therapy in Children and Adolescents
Authors: Døssing Erik , Pagsberg Anne Katrine
Published: April 2021

There is a lack of studies regarding the efficacy of electroconvulsive therapy (ECT) in children and adolescents. In this study, we aimed to assess benefits and harms of ECT in children and adolescents with major psychiatric diseases. We conducted a systematic search in PubMed, EMBASE, and PsycINFO for peer-reviewed articles written in English regarding the use of ECT as treatment for major psychiatric diseases in children and adolescents. This study consists of 192 articles, mostly case studies (n = 50), reviews and overview articles (n = 52), and retrospective studies (n = 30). We present an overview of evidence for ECT in children and adolescents with mood disorders, catatonia, schizophrenia, intellectual disability, self-injurious behavior, and other indications. This article is also a summary of international guidelines regarding the use of ECT in children and adolescents. We evaluated the overall quality of evidence by using Grading of Recommendations, Assessment, Development and Evaluations and found the overall level of evidence to be of low quality. There are no absolute contra indications for ECT in children and adolescents. Fears regarding cognitive dysfunction have not been reproduced in studies. Electroconvulsive therapy should be considered in severe, treatment-resistant mood disorders, catatonia, and schizophrenia, especially in older adolescents. High-quality studies are warranted to assess the efficacy of ECT, especially in these potentially life-threatening diseases.