bluuebunny/crossref_metadata_2025 huggingface dataset:
Posttraumatic Stress Disorder Symptom Trajectories in ICU Family Caregivers
Authors: Wendlandt Blair , Chen Yi Tang , Lin Feng-Chang , Toles Mark , Gaynes Bradley , Hanson Laura , Carson Shannon
Published: April 2021

Objectives:

To use latent class growth analysis to identify posttraumatic stress disorder symptom trajectories in ICU family caregivers.

Design:

Prospective cohort study.

Setting:

The medical ICU at a tertiary-care center in the United States.

Participants:

Adult patients experiencing acute cardiorespiratory failure (defined as requiring at least one of the following: 1) vasopressors, 2) noninvasive positive pressure ventilation, 3) high-flow nasal cannula, or 4) mechanical ventilation) were enrolled in a pair with their primary family caregivers.

Measurements and Main Results:

Participants were enrolled within the first 48 hours of ICU admission. Family caregiver posttraumatic stress disorder symptoms were measured using the Impact of Events Scale-Revised at four time points: at enrollment, shortly after ICU discharge, and at 3 and 6 months after ICU discharge. The data were examined using latent class growth analysis to identify posttraumatic stress disorder symptom trajectories. Two distinct symptom trajectories were identified: a persistently high trajectory, characterized by high posttraumatic stress disorder symptoms at initial assessment, which remained elevated over time, and a persistently low trajectory, characterized by low posttraumatic stress disorder symptoms at initial assessment, which remained low over time. Approximately two-thirds of caregivers belonged to the persistently high trajectory, and one-third of caregivers belonged to the persistently low trajectory.

Conclusions:

Using latent class growth analysis to measure 6-month ICU family caregiver posttraumatic stress disorder symptom trajectories, we identified two distinct trajectories (persistently low and persistently high). A larger cohort study is warranted to further delineate posttraumatic stress disorder trajectories in this population, with the ultimate goal of targeting high-risk caregivers for interventions to reduce psychologic distress and improve long-term caregiver outcomes.
Frugal Innovation: Enabling Mechanical Ventilation During Coronavirus Disease 2019 Pandemic in Resource-Limited Settings
Authors: Dave Chintan , Cameron Paul , Basmaji John , Campbell Gordon , Buga Edward , Slessarev Marat
Published: April 2021

ICUs worldwide are facing resource shortages including increased need for provision of invasive mechanical ventilation during the current coronavirus disease 2019 pandemic. Fearing shortage of ventilators, many private companies and public institutions have focused on building new inexpensive, open-source ventilators. However, designing and building new ventilators is not sufficient for addressing invasive mechanical ventilation needs in resource-limited settings. In this commentary, we highlight additional interdependent constraints that should be considered and provide a framework for addressing these constraints to ensure that the increasing stockpile of open-source ventilators are easily deployable and sustainable for use in resource-limited settings.
Determining Cause of Death During Coronavirus Disease 2019 Pandemic
Authors: Nada Khaled M. , Hsu En-shuo , Seashore Justin , Zaidan Mohammed , Nishi Shawn P. , Duarte Alexander , Sharma Gulshan
Published: April 2021

Objectives:

Controversy exists whether the cause of death due to severe acute respiratory syndrome coronavirus 2 is directly related to the infection or to underlying conditions. The purpose of this study is to assess the relationship of severe acute respiratory syndrome coronavirus 2 infection with the cause of death in hospitalized patients.

Design:

Retrospective observational study; deidentified discharge summaries of deceased patients were reviewed by two intensivists and classified as coronavirus disease 2019–related (caused by severe acute respiratory syndrome coronavirus 2) or coronavirus disease 2019–unrelated (not caused by severe acute respiratory syndrome coronavirus 2 or indeterminate) deaths. For classification disagreement, a separate group of three intensivists reviewed the discharge summaries and arbitrated to determine the cause of death.

Setting:

Single-center study performed at the University of Texas Medical Branch.

Patients:

All adult patients (> 18 yr) admitted from March 10, 2020, to October 22, 2020, with positive severe acute respiratory syndrome coronavirus 2 test results who expired during their hospitalization were identified.

Interventions:

None.

Measurements and Main Results:

Patient demographics, comorbidities, prescribed medications, and ventilatory support data were collected. Comparison between groups was performed using t test and chi-square test. During the study period, 1,052 patients were admitted within 14 days of severe acute respiratory syndrome coronavirus 2–positive test results, of whom 100 expired during the hospitalization. Deceased patients were predominantly male and older than 65 years. Obesity (body mass index ≥ 30 kg/m2) was present in 41%, and common comorbidities included hypertension (47%), diabetes (30%), and heart failure (20%). Death was classified as directly caused by severe acute respiratory syndrome coronavirus 2 in 85% and not caused by severe acute respiratory syndrome coronavirus 2 in 5%. An indeterminate cause of death in 10% was due to insufficient information or an atypical presentation. The observed interrater agreement on the cause of death classification was 81%.

Conclusions:

In this single-center study, the majority of deaths in severe acute respiratory syndrome coronavirus 2–positive hospitalized patients were related to a typical or atypical presentation of coronavirus disease 2019 disease.
A case of hyperprolactinaemia in a patient with metastatic melanoma
Authors: Manning Annie , Rassie Kate , Rivalland Gareth
Published: April 2021

Ectopic prolactin production from a malignancy is infrequently reported. We report here a 60-year-old gentleman who presented with hyperprolactinaemia (9100 mIU/L) causing expressible galactorrhoea, decreased libido and fatigue thought to be due to ectopic prolactin secretion from a metastatic melanoma. Upon initiation of pembrolizumab, the patient’s symptoms resolved and he became normoprolactinaemic. This corresponded with a partial response on radiological imaging. Although the core biopsy of the metastatic melanoma did not exhibit immunostaining for prolactin, we believe that only a subset of the tumour cells possesses prolactin-secreting capacity. This case illustrates the need to consider ectopic prolactin production for a solid malignant tumour as a rare cause of hyperprolactinaemia in patients with a normal pituitary MRI, in the absence of other causes.
Genetic variants predictive of reproductive aging are associated with vasomotor symptoms in a multiracial/ethnic cohort
Authors: Zhao Wei , Smith Jennifer A. , Yu Miao , Crandall Carolyn J. , Thurston Rebecca C. , Hood Michelle M. , Ruiz-Narvaez Edward , Peyser Patricia A. , Kardia Sharon L.R. , Harlow Sioban D.
Published: April 2021

Objective:

Vasomotor symptoms (VMS), hot flashes, and night sweats are cardinal symptoms of the menopausal transition. Little is known about genetic influences on VMS. This study evaluated whether previously identified genetic factors predictive of VMS, age at menarche, and age at menopause were associated with VMS in a multiracial/ethnic cohort.

Methods:

For 702 White, 306 Black, 126 Chinese, and 129 Japanese women from the Study of Women's Health Across the Nation (SWAN) Genomic Substudy, we created polygenic risk scores (PRSs) from genome-wide association studies of VMS and ages at menarche and menopause. PRSs and single nucleotide polymorphisms (SNPs) from a previously identified VMS locus (tachykinin receptor 3 [TACR3]) were evaluated for associations with frequent VMS (VMS ≥6 days in the past 2 weeks at any visit) and with VMS trajectories (persistently low, early onset, final menstrual period onset, persistently high).

Results:

The C-allele of rs74827081 in TACR3 was associated with reduced likelihood of frequent VMS in White women (odds ratio [OR] = 0.49 [95% CI, 0.29-0.83]). With higher menarche PRS (later menarche), Black women were less likely (OR = 0.55 [95% CI, 0.38-0.78]) to report frequent VMS. With higher PRS for age at menarche, Black women were also less likely to have a persistently high VMS trajectory (OR = 0.55 [95% CI, 0.34-0.91]), whereas White women (OR = 0.75 [95% CI, 0.58-0.98]) were less likely to have a final menstrual period onset trajectory (vs persistently low). Chinese women with higher menopause PRS were more likely to have frequent VMS (OR = 2.29 [95% CI, 1.39-3.78]). Associations were substantively similar after excluding rs74827081 C-allele carriers.

Conclusions:

Genetic factors predictive of reproductive aging are also associated with VMS, suggesting that VMS have a polygenic architecture. Further study in this area may help to identify new targets for novel VMS therapies.

Video Summary:
http://links.lww.com/MENO/A761.
An Evidenced-based Approach to Stress Urinary Incontinence in Women: What's New?
Authors: WINKELMAN WILLIAM D. , ELKADRY EMAN
Published: April 2021

Stress urinary incontinence is a common condition in women potentially affecting women of any age including young women who have not yet completed childbearing. It is important to consider the impact on quality of life and offer treatment to those experiencing bother. There are several effective nonsurgical treatments for women before considering more invasive or definitive intervention. There is good data on lifestyle and behavioral changes which are often first-line recommendations. Data is also strong for pelvic muscle training and strengthening. Pessary supportive devices also play a role. Additional options also exist for limited indications.
Ibrutinib Has Time-dependent On- and Off-target Effects on Plasma Biomarkers and Immune Cells in Chronic Lymphocytic Leukemia
Authors: Mulder Tom A. , Peña-Pérez Lucía , Berglöf Anna , Meinke Stephan , Estupiñán H. Yesid , Heimersson Kia , Zain Rula , Månsson Robert , Smith C. I. Edvard , Palma Marzia
Published: April 2021

Ibrutinib is a covalently binding inhibitor of the B-cell receptor signaling-mediator Bruton’s tyrosine kinase (BTK) with great efficacy in chronic lymphocytic leukemia (CLL). Common side effects like atrial fibrillation (AF), bleeding and infections might be caused by ibrutinib’s inhibition of other kinases in non-B cells. Five-year follow-up of plasma biomarkers by proximity extension assay and immune cell numbers by flow cytometry during ibrutinib treatment revealed that 86 of the 265 investigated plasma biomarkers significantly changed during treatment, 74 of which decreased. Among the 12 markers that increased, 6 are associated with cardiovascular diseases and therefore potentially involved in ibrutinib-induced AF. Comparison between healthy donors and X-linked agammaglobulinemia (XLA) patients, who have nonfunctional BTK and essentially lack B cells, showed indicative changes in 53 of the 265 biomarkers while none differed significantly. Hence, neither B cells nor BTK-dependent pathways in other cells seem to influence the levels of the studied plasma biomarkers in healthy donors. Regarding immune cells, the absolute number of T cells, including subsets, decreased, paralleling the decreasing tumor burden. T helper 1 (Th1) cell numbers dropped strongly, while Th2 cells remained relatively stable, causing Th2-skewing. Thus, long-term ibrutinib treatment has a profound impact on the plasma proteome and immune cells in patients with CLL.
COVID-19 as a Cause of Acute Neonatal Encephalitis and Cerebral Cytotoxic Edema
Authors: Fragoso Diego Cardoso , Marx Catherine , Dutra Bruna Garbugio , da Silva Carlos Jorge , da Silva Pollyanna Martins , Martins Maia Junior Antônio Carlos , Tobara Mariana Crema , Silva Camila de Almeida , Dias Livio , Polycarpo Angela Cristina , Richtmann Rosana
Published: April 2021

The majority of coronavirus disease 2019 (COVID-19) have been confirmed in adults, with only a few reported cases in children. In the pediatric population, COVID-19 infection appears to be often unremarkable or associated with mild respiratory symptoms. Little is known about neurologic complications related to COVID-19 in newborns. We present a case of severe encephalitis with cytotoxic brain edema in a newborn with COVID-19.
Opportunistic Illnesses in Children With HIV Infection in the United States, 1997–2016
Authors: Nesheim Steven R. , Balaji Alexandra , Hu Xiaohong , Lampe Margaret , Dominguez Kenneth L.
Published: April 2021

Background:

Among children with HIV infection, opportunistic illness (OI) rates decreased after introduction of highly active antiretroviral therapy (ART) in 1997. We evaluated whether such decreases have continued.

Methods:

Data from the Centers for Disease Control and Prevention’s National HIV Surveillance System for children with HIV living in the US during 1997–2016 was used to enumerate infants experiencing the first OI by birth year and OIs among all children <13 years of age (stratified by natality). We calculated the time to first OI among infants using Kaplan-Meier methods.

Results:

Among infants born during 1997–2016, 711 first OIs were diagnosed. The percentage of the first OIs diagnosed in successive 5-year birth periods was: 60.0% (1997–2001), 24.6% (2002–2006), 11.3% (2007–2011), and 3.4% (2012–2016). For every OI, the number of first cases decreased nearly annually. Time to first OI increased in successive birth periods. Among children <13 years of age, 2083 OI were diagnosed, including Pneumocystis jiroveci pneumonia, candidiasis, recurrent bacterial infection, wasting syndrome, cytomegalovirus, lymphocytic interstitial pneumonitis, tuberculosis, nontuberculous mycobacteriosis and herpes simplex virus. The rate (#/1000 person-years) decreased overall (60–7.2) and for all individual OIs. Earlier during 1997–2016, rates for all OIs were higher among foreign-born than US-born children but later became similar for all OIs except tuberculosis.

Conclusions:

Among children with HIV in the US, numbers and rates of all OIs decreased during 1997–2016. Earlier, OI rates were highest among non-US-born children but were later comparable with those among US-born children for all OIs except tuberculosis.
Patient Characteristics and Acute PT and OT Utilization During the Initial Surge of COVID-19
Authors: Myszenski Adele , Bello Romina , Melican Cynthia , Pfitzenmaier Nanette
Published: April 2021

Objective:

To describe the characteristics of patients and investigate the utilization of physical (PT) and occupational therapy (OT) intervention for those with a positive coronavirus disease-2019 (COVID-19) diagnosis compared with other patient populations during the first 6 weeks of the novel coronavirus pandemic.

Methods:

A retrospective, observational study of adult inpatients with a length of stay of 1 or more days at an urban hospital in Detroit, Michigan. Individuals with a COVID-19 diagnosis were compared with a cohort within similar diagnostic categories (respiratory, fever, and sepsis) but without COVID-19. Outcome measures included PT or OT intervention on 1 or more days, the timing of initial PT or OT visit, the average number of visits and units per patient, length of stay, discharge to home, and readmission within 30 days.

Results:

Individuals with COVID-19 had lower rates of discharge to home (P = .001), higher rates of readmission within 30 days of hospital discharge (P = .01), increased hospital length of stay (P = .001), and waited an average of 3.1 days longer for therapy evaluations than subjects in the comparison group (P = .001). The percentage of subjects who had one or more PT or OT visits during their hospital stays was comparable between groups. Once therapy was initiated, the average number of visits per patient and dosing of units in 15-minute increments were similar between the 2 groups.

Conclusions:

Patients acutely ill with COVID-19 hospitalized with the virus during the first 6 weeks of the pandemic remained in the intensive care unit and hospital longer than their counterparts without COVID-19 and had a delay in initiation of PT and OT intervention. PT and OT are important members of the care team for patients with the novel coronavirus. Understanding the descriptive characteristics of patients and therapy services during the initial surge could help improve utilization and patient outcomes.
Active Rehabilitation in a Patient During and After Venovenous Extracorporeal Membrane Oxygenation With a Diagnosis of COVID-19: A Case Report
Authors: Andersen Eric M. , Kelly Tara L. , Sharp Amanda , Keller-Ross Manda L. , Brunsvold Melissa E.
Published: April 2021

Purpose:

The coronavirus disease-2019 (COVID-19) pandemic has resulted in an influx of critically ill patients requiring mechanical ventilation, some receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO). The benefits of early mobility while undergoing ECMO have been previously documented. However, the COVID-19 pandemic has presented physical therapists with novel challenges, balancing the risk of a widespread shortage of personal protective equipment (PPE) with the benefits of early mobility for patients on ECMO. The purpose of this case study is to report the successful rehabilitation of a critically ill patient with COVID-19 undergoing VV ECMO.

Methods:

This is a case description of a 38-year-old man who presented to the hospital with COVID-19 and subsequent intubation and cannulation for VV ECMO. Physical therapy was initiated while the patient remained critically ill on VV ECMO. Focused coordination and education were employed to limit PPE usage by limiting the number of essential staff/therapists that entered the room as well as changing the frequency of therapy sessions dependent on how the patient was progressing functionally.

Results:

On VV ECMO day 11, he was able to sit up and perform a sit-to-stand. ECMO decannulation occurred on hospital day 14 with extubation on hospital day 18. The patient progressed functionally while quarantined in the room until he was discharged home with supplemental oxygen after spending 29 days in the hospital.

Conclusion:

This case study demonstrates the clinical decision-making used to provide physical therapy services for a critically ill patient with COVID-19. High-level team coordination resulted in limiting the use of PPE as well as reducing staff exposure frequency during rehabilitation. Despite his severe critical illness, the patient was successfully discharged home within 30 days.
The evolution of guideline-directed medical therapy among decompensated HFrEF patients in sacubitril/valsartan era: Medical expenses and clinical effectiveness
Authors: Liang Huai-Wen , Liao Chia-Te , Lin Wen-Yu , Chung Fa-Po , Huang Jin-Long , Lee Ying-Hsiang , Lin Po-Lin , Chiou Wei-Ru , Hsu Chien-Yi , Chang Hung-Yu
Published: April 2021

Background:

Over recent years, new evolution in guideline-directed medical therapy (GDMT) contributes to clinical benefits in patients with heart failure and reduced ejection fraction (HFrEF). The additional medical expenditure may be a concern due to the current financial constraint. This study aimed to investigate the medical costs and clinical effectiveness of contemporary GDMT in recently hospitalized HFrEF patients.

Methods:

Acutely decompensated hospitalized HFrEF patients from two multicenter cohorts of different periods were retrospectively analyzed. A propensity score matching was performed to adjust the baseline characteristics. Annual medication costs, risks of mortality, and recurrent heart failure hospitalizations (HFH) were compared.

Results:

Following 1:2 propensity score matching, there were 426 patients from the 2017-2018 cohort using sacubitril/valsartan, while 852 patients from 2013 to 2014 did not use so at discharge. Baseline characteristics were similar, whereas the sacubitril/valsartan users were more likely to receive beta-blockers, ivabradine and mineralocorticoid receptor antagonists at discharge (79.3% vs 60.4%, 23.2% vs 0%, and 64.1% vs 49.8%, p < 0.001). The 2017-2018 cohort produced more medication costs by 1277 United States dollar (USD) per person per year, while it resulted in lower rates of HFH and all-cause mortality (10.3 vs 20.3 and 48.8 vs 79.9 per 100 person-year, p < 0.001). Costs of preventing a mortality event and a HFH event with contemporary treatments were 15 758 USD (95% confidence interval [CI] 10 436-29 244) and 5317 USD (95% CI 3388-10 098), respectively.

Conclusion:

The higher adoption of GDMT was associated with greater medical expenses but better clinical outcomes in recently decompensated HFrEF patients.
Sleep Insufficiency and Baseline Preseason Concussion-Like Symptom Reporting in Youth Athletes
Authors: Terry Douglas P. , Jurick Sarah M. , Huebschmann Nathan A. , Silverberg Noah D. , Maxwell Bruce A. , Zafonte Ross , Berkner Paul D. , Iverson Grant L.
Published: April 2021

Objective:

To examine the association between insufficient sleep and baseline symptom reporting in healthy student athletes.

Design:

Cross-sectional cohort study.

Setting:

Preseason testing for student athletes.

Participants:

Student athletes (n = 19 529) aged 13 to 19 years who completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), including the number of hours slept the night before, and denied having developmental/health conditions, a concussion in the past 6 months, and a previous history of 2 or more concussions.

Independent Variables:

Total hours of sleep the night before testing (grouped by ≤5, 5.5-6.5, 7-8.5, and ≥9 hours), gender, and concussion history.

Main Outcome Measures:

Symptom burden on the Post-Concussion Symptom Scale (modified to exclude sleep-related items), cognitive composite scores, and prevalence of athletes who reported a symptom burden resembling the International Classification of Diseases, 10th Revision (ICD-10) diagnosis of postconcussional syndrome (PCS).

Results:

Fewer hours of sleep, gender (ie, girls), and 1 previous concussion (vs 0) were each significantly associated with higher total symptom scores in a multivariable model (F = 142.01, P < 0.001, R2 = 0.04). When a gender-by-sleep interaction term was included, the relationship between sleep and symptoms was stronger for girls compared with boys. In healthy athletes who slept ≤5 hours, 46% of girls and 31% of boys met the criteria for ICD-10 PCS compared with 16% of girls and 11% of boys who slept ≥9 hours. Sleep duration was not meaningfully associated with neurocognitive performance.

Conclusions:

Insufficient sleep the night before testing is an important factor to consider when interpreting symptom reporting, especially for girls. It will be helpful for clinicians to take this into account when interpreting both baseline and postinjury symptom reporting.
Multi-institutional Analysis of 100 Consecutive Patients with COVID-19 and Severe Pulmonary Compromise Treated with Extracorporeal Membrane Oxygenation: Outcomes and Trends Over Time
Authors: Jacobs Jeffrey p. , Stammers Alfred H. , Louis James St. , Hayanga J.W. Awori , Firstenberg Michael S. , Mongero Linda B. , Tesdahl Eric A. , Rajagopal Keshava , Cheema Faisal H. , Patel Kirti , Esseghir Feriel , Coley Tom , Sestokas Anthony K. , Slepian Marvin J. , Badhwar Vinay
Published: April 2021

The role of extracorporeal membrane oxygenation (ECMO) in the management of severely ill patients with coronavirus disease 2019 (COVID-19) continues to evolve. The purpose of this study is to review a multi-institutional clinical experience in 100 consecutive patients, at 20 hospitals, with confirmed COVID-19 supported with ECMO. This analysis includes our first 100 patients with complete data who had confirmed COVID-19 and were supported with ECMO. The first patient in the cohort was placed on ECMO on March 17, 2020. Differences by the mortality group were assessed using χ2 tests for categorical variables and Kruskal–Wallis rank-sum tests and Welch’s analysis of variance for continuous variables. The median time on ECMO was 12.0 days (IQR = 8–22 days). All 100 patients have since been separated from ECMO: 50 patients survived and 50 patients died. The rate of survival with veno-venous ECMO was 49 of 96 patients (51%), whereas that with veno-arterial ECMO was 1 of 4 patients (25%). Of 50 survivors, 49 have been discharged from the hospital and 1 remains hospitalized at the ECMO-providing hospital. Survivors were generally younger, with a lower median age (47 versus 56.5 years, p = 0.014). In the 50 surviving patients, adjunctive therapies while on ECMO included intravenous steroids (26), anti-interleukin-6 receptor blockers (26), convalescent plasma (22), remdesivir (21), hydroxychloroquine (20), and prostaglandin (15). Extracorporeal membrane oxygenation may facilitate salvage and survival of selected critically ill patients with COVID-19. Survivors tend to be younger. Substantial variation exists in the drug treatment of COVID-19, but ECMO offers a reasonable rescue strategy.
Application of CAD and 3D printing in the treatment of pediatric multiple mandible fractures
Authors: Du Yue , Yang Dongkun , Pang Yaqian , Liu Chang , Zhang Kai
Published: April 2021

Introduction:

Mandible fracture is the second most common facial bone fractures in pediatric patients. The goal of treatment is to restore the displaced bones to their pre-injury position by a stable method, and ensure normal facial development. This case report demonstrates the effective use of Computer-aided design (CAD), three-dimensional printing (3D printing) and rigid internal fixation in the treatment of multiple mandibular fractures in a child.

Patient concerns:

The patient was a 5-year-old female child with mandible fractures, teeth trauma, and facial lacerated wounds.

Diagnosis:

Pediatric multiple mandible fracture with abnormal occlusion.

Interventions:

Based on the CAD and 3D printing technology, we designed the shape and position of titanium plate to accurately protect the tooth germs. Articulator, mandible and maxillary model were utilized to construct the positioning biteplate for the purpose of fracture reduction and fixation.

Outcome:

A 3-year follow-up showed the effectiveness of this treatment. The permanent teeth and facial bones were observed developing normally. Normal occlusion and facial shape was achieved.

Conclusion:

This case report demonstrates the effective use of CAD, 3D printing and rigid internal fixation in the treatment of multiple mandibular fractures in a child. It also provides a reference for the treatment of jaw fractures in a single site. In our patient, this method was highly effective with less surgical trauma. There is not much research on the treatment of pediatric mandible fractures, and we believe the treatment method described in this case report will help avoid damage to the tooth germs and allow normal bone development in pediatric mandible fractures.
Abdominal A-lines as an ultrasonic sign for the evaluation of gastrointestinal flatulence
Authors: Li Ruiting , Shang You
Published: April 2021

Introduction:

A lot of critical illness can cause flatulence, which can give rise to gastrointestinal peristalsis disorder, gut barrier function damage, intestinal mucosal ischemia, and other conditions. Currently, in clinical practice, the suitable detection methods for gastrointestinal flatulence are lacking. The A-lines are the key characteristic defining the normal lung tissue ultrasound. The gastrointestinal tract is also the gas-bearing organ under certain conditions. When the patient has flatulence, will there be abdominal A-lines similar to lung ultrasound? In addition, whether the abdominal A-lines can be used to assess the severity of flatulence also needs proper investigation.

Patient concerns:

Two male patients with digestive tract tumors were transferred to department of Critical Care Medicine due to acute respiratory failure and hyperkalemia.

Diagnosis:

Gastrointestinal paralysis and flatulence after cavity viscera perforation.

Interventions:

The 2 patients with severe flatulence presented with abdominal A-lines during the ultrasound examination.

Outcomes:

Both the patients died when their families gave up further treatment.

Conclusion:

The abdominal A-lines reflect the ultrasound sign related to flatulence. Their range and location has been found to be consistent with the degree and position of gastrointestinal flatulence. In addition, in the future, it can be expected to be used to semi-quantitatively evaluate the degree and etiology of flatulence in combination with the other abdominal ultrasonographic signs.
Can Collaboration Between Nonprofit Hospitals and Local Health Departments Influence Population Health Investments by Nonprofit Hospitals?
Authors: Santos Tatiane , Lee Shoou-Yih D. , East Chloe , Lindrooth Richard C.
Published: April 2021

Background:

The patient protection and Affordable Care Act (ACA) sought to improve population health by requiring nonprofit hospitals (NFPs) to conduct triennial community health needs assessments and address the identified needs. In this context, some states have encouraged collaboration between hospitals and local health department (LHD) to increase the focus of community benefit spending onto population health.

Objectives:

The aim was to examine whether a 2012 state law that required NFPs to collaborate with LHDs in local health planning influenced hospital population health improvement spending.

Research Design:

We merged Internal Revenue Service data on NFP community benefit spending with data on hospital, county and state-level characteristics and estimated a difference-in-differences specification of hospital population health spending in 2009–2016 that compared the difference between hospitals that were required to collaborate with LHDs to those that were not, before and after the requirement.

Measures:

The primary outcome was population health spending divided by operating expenses.

Results:

We found that the requirement for hospital-LHD collaboration was associated with increased mean population health spending of ∼$393,000–$786,000 (P=0.03). This association was significant in 2015–2016, perhaps reflecting the lag between assessments and implementation. Urban hospitals were responsible for most of the increased spending.

Conclusions:

Policymakers have sought to encourage hospitals to increase their investment in population health; however, overall community benefit spending on population health has remained flat. We found that requiring hospital-LHD collaboration was associated with increased hospital investment in population health. It may be that hospitals increase population health spending because collaboration improves expected effectiveness or increases hospital accountability.
Mechanical circulatory support in pre and postheart transplant period
Authors: Kolodziej Andrew R. , Vaidya Gaurang N. , Reddy Neeti , Birks Emma J.
Published: April 2021

Purpose of review

Progression of heart failure (HF) and its unpredictable and volatile nature, often requires advanced therapies including heart transplant. Mechanical circulatory support plays an integral part in the advanced treatment options. This technology can be deployed in several ways, particularly in the preparation and patient optimization for heart transplants. This article discusses the use of temporary and durable devices and their deployment strategies in the pre and posttransplant period.

Recent findings

Recently temporary mechanical support devices have allowed us to improve survival to transplant as well as posttransplant. Early implementation of temporary devices both for stabilization of advanced HF patients being considered for transplant as well as those with posttransplant primary graft dysfunction (although utilization of extracorporeal membrane oxygenation has repeatedly shown to be associated with worse outcomes compared to the other devices discussed), is reflective of the degree of disease progression in these patients. The outcomes of patients supported with durable devices have significantly improved with advancing technology. HeartMate 3 device has not only been shown to improve survival as well as the quality of life but in comparison to its predecessor, has been shown to decrease the morbidity associated with this technology.

Both temporary and durable devices are now associated with improved survival and allow us to transplant patients in a more stable and safer manner with fewer adverse events. Based on the new United Network of Organ Sharing allocation system, it allows us to upgrade those who do not have the luxury of time to wait for a transplant. Primary graft dysfunction now also can be assisted with those devices, which is reflected in improved survival of posttransplant patients.
Expression of Nectin-4 in Bladder Urothelial Carcinoma, in Morphologic Variants, and Nonurothelial Histotypes
Authors: Hoffman-Censits Jean H. , Lombardo Kara A. , Parimi Vamsi , Kamanda Sonia , Choi Woonyoung , Hahn Noah M. , McConkey David J. , McGuire Bridget M. , Bivalacqua Trinity J. , Kates Max , Matoso Andres
Published: April 2021

The antibody-drug conjugate enfortumab-vedotin acts by targeting nectin-4, a protein that is nearly ubiquitously expressed in conventional urothelial cancer. However, expression of nectin-4 in morphologic variants of urothelial carcinoma and nonurothelial histotypes was unknown. Immunohistochemistry for nectin-4 using was performed on 169 patients including 83 with nonmuscle invasive bladder cancer and 86 patients with muscle invasive bladder cancer. Staining was scored for intensity (0 to 3) and extent (% positive cells) using the histological score system, where >15 was considered positive. Overall, 72/83 (87%) samples of nonmuscle invasive urothelial carcinoma were positive, including 29/30 (97%) noninvasive papillary urothelial carcinomas, 7/8 (87.5%) carcinomas in situ, 36/45 (80%) papillary urothelial carcinomas invading the lamina propria. Overall, 50/86 muscle invasive tumors were positive, including 15/22 (68.2%) urothelial carcinomas, 7/10 (70%) squamous cell carcinomas, 3/11 (28%) micropapillary tumors, 4/6 (66%) adenocarcinomas, 2/4 (50%) nested carcinomas, 5/8 (63%) plasmacytoid, 1/10 (10%) sarcomatoid carcinomas, and 0/15 (0%) small cell carcinomas. Whole transcriptome RNA sequencing revealed that compared with conventional urothelial carcinomas, most sarcomatoid carcinomas and all but 2 small cell carcinomas expressed very low levels of nectin-4 mRNA but expressed significant levels of either trop2 or ERBB2, which are the molecular targets of 2 other antibody-drug conjugates—sacituzumab gavitecan (trop2) or trastuzumab deruxtecan (ERBB2/HER2). In summary, our study demonstrates that there is heterogeneity of expression of nectin-4 in morphologic variants of urothelial cancer and nonurothelial histotypes, and suggests that testing expression of nectin-4 should be considered in morphologic variants or nonurothelial histotypes found to have lower expression.
Evaluation of Pediatric Maxillofacial Injury
Authors: Ulusoy Emel , Armağan Coşkun , Çağlar Aykut , Er Anil , Akgül Fatma , Çitlenbik Hale , Yilmaz Durgül , Duman Murat
Published: April 2021

Objective

Isolated facial injuries are less common among pediatric trauma patients. The literature has focused on, especially, fractures in facial injuries. There is a limited number of studies evaluating all facial injuries in childhood. The study aims to evaluate the clinical characteristics of maxillofacial injuries and to identify patients who require further intervention.

Methods

The data from pediatric patients with maxillofacial injury (<18 years) between January 2011 and December 2015 were collected. Demographic characteristics, trauma mechanisms, concomitant injuries, treatments, hospitalization, and follow-up results were recorded.

Results

The median age of the patients (N = 2926) was 5.0 years (2.0–10.0 years), and 63.1% were boys. Falls and motor vehicle accidents were the leading mechanism of injury. The most common injury types were lacerations (49.3%) and fractures (15.5%). One hundred thirty (0.4%) patients had concomitant injuries. Surgical treatment was performed in only 3.4% of the patients, and the mortality rate was 0.6%. Patients with concomitant injuries had more hospitalization rates, surgical treatment, and organ dysfunction. All patients who underwent cardiopulmonary resuscitation and resulted in mortality were in the concomitant injury group.

Conclusions

Isolated facial injuries are unlikely to be life-threatening, and basic interventions are sufficient in most of the maxillofacial injuries. The primary issue in maxillofacial injuries is to recognize and manage concomitant injuries that can lead to organ dysfunction and mortality.
Injuries Suggestive of Physical Abuse in Young Children With Subconjunctival Hemorrhages
Authors: Wolford Jennifer E. , Berger Rachel P. , Eichman Adelaide L. , Lindberg Daniel M.
Published: April 2021

Objective

The aim of this study was to compare the demographic characteristics, clinical presentations, medical evaluation, and injuries identified in a cohort of children with and without subconjunctival hemorrhage who were evaluated by a child abuse specialist.

Methods

This was a case-control study that used data from the ExSTRA (Examining Siblings to Recognize Abuse) research network. Subjects with a subconjunctival hemorrhage(s) were designated as cases. Four controls matched for age and participating center were included for each case. Descriptive statistics were used to compare cases and controls.

Results

Fifty of the 2890 subjects in the parent study had a subconjunctival hemorrhage(s) and were designated as cases. The cases had a median (interquartile range) age of 5.0 months (2.0–23.6 months). Two hundred controls were matched to the cases. There was no difference in the demographics, clinical characteristics, medical evaluation, or rate of occult injuries identified in cases and controls. Almost one-quarter of children with subconjunctival hemorrhages had no other external sign of trauma but had the same rate of occult injuries as children with bruises.

Conclusions

These data suggest that subconjunctival hemorrhages are relatively rare among children undergoing evaluation by a child abuse specialist, but that they are often an indicator of occult injury. Even in the absence of other external signs of trauma, the presence of subconjunctival hemorrhages should prompt an age-appropriate evaluation for physical abuse.
Optimizing Critical Care Documentation in a Pediatric Emergency Department
Authors: Jain Shobhit , Shastri Nirav J. , Sharma Nikita , Conners Gregory P.
Published: April 2021

Objective

Emergency department (ED) physicians frequently provide critical care (CC) but document inconsistently. Variability in documentation can result in underbilling and is inconsistent with financial stewardship. We used admissions to the intensive care unit (ICU) as a proxy for CC provision. At baseline, CC notes were correctly documented for 20% of eligible visits, with potential missed charges of $1.8 million per year.

Our objective was to increase CC note placement for eligible patients from 20% to 60% over 2 years. Additionally, we measured CC notes and the number of ICU admissions per 1000 ED visits, and change in facility fees.

Methods

We performed this project at a midwestern quaternary children's hospital with 2 EDs (combined volume 120,000 visits/year). We surveyed the ED physicians to inform our interventions. We used maintenance of certification points and financial incentives for quality improvement work to obtain buy-in. We used serial interventions with plan-do-study-act cycles: (1) CC note simplification, (2) education, (3) follow-up surveys, (4) additional location for CC note, and (5) timely reminders. We reviewed sample charts and used χ2 test and control charts for analysis.

Results

Critical care note placement for ICU admissions increased from 20% to 60% in 8 months, and further to greater than 75%. The CC notes increased from 4 to 16 per 1000 ED visits. Intensive care unit admissions increased but remained appropriate. The billed facility fee for CC increased by 263%.

Conclusions

This project resulted in significant and sustained improvements in CC note completion. We believe providing education, simplifying the documentation process, automating reminders, and incentivizing optimal documentation were vital to success.
Living Alone and Clinical Outcomes in Patients With Heart Failure With Preserved Ejection Fraction
Authors: Zhu Wengen , Wu Yuzhong , Zhou Yuanyuan , Liang Weihao , Xue Ruicong , Wu Zexuan , Wu Dexi , He Jiangui , Dong Yugang , Liu Chen
Published: April 2021

Objective

In patients with heart failure with preserved ejection fraction (HFpEF), whether living alone could contribute to a poor prognosis remains unknown. We sought to investigate the association of living alone with clinical outcomes in patients with HFpEF.

Methods

Symptomatic patients with HFpEF with a follow-up of 3.3 years (data collected from August 2006 to June 2013) in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial were classified as patients living alone and those living with others. The primary outcome was defined as a composite of cardiovascular death, aborted cardiac arrest, or HF hospitalization.

Results

A total of 3103 patients with HFpEF were included; 25.2% of them were living alone and were older, predominantly female, and less likely to be White and have more comorbidities compared with the other patients. After multivariate adjustment for confounders, living alone was associated with increased risks of HF hospitalization (hazard ratio [HR] = 1.29, 95% confidence interval [CI] = 1.03–1.61) and any hospitalization (HR = 1.26, 95% CI = 1.12–1.42). A significantly increased risk of any hospitalization (HR = 1.16, 95% CI = 1.01–1.34) was also observed in the Americas-based sample. In addition, each year increase in age, female sex, non-White race, New York Heart Association functional classes III and IV, dyslipidemia, and chronic obstructive pulmonary disease were independently associated with living alone.

Conclusions

We assessed the effect of living arrangement status on clinical outcomes in patients with HFpEF and suggested that living alone was associated with an independent increase in any hospitalization.

Clinical Trial Registration: ClinicalTrials.gov identifier: NCT00094302.
Using Novel Approaches to Evaluate Behavioral Interventions: Overlooked Significant HIV Prevention Effects in the HPTN 015 Project EXPLORE
Authors: Pitpitan Eileen V. , MacKinnon David P. , Eaton Lisa A. , Smith Laramie R. , Wagman Jennifer , Patterson Thomas L.
Published: April 2021

Background:

Mediated and moderated processes that lead to intervention efficacy may underlie results of trials ruled as nonefficacious. The overall purpose of this study was to examine such processes to explain the findings of one of the largest, rigorously conducted behavioral intervention randomized controlled trials, EXPLORE.

Methods:

Four thousand two hundred ninety-five HIV-negative men who have sex with men (MSM) in the United States were randomized in a 2-armed trial. Participants completed follow-up and an HIV test every 6 months up to 48 months. We used multiple and causal mediation analyses to test 5 mediators, including safer sex self-efficacy and condomless receptive anal sex with HIV-positive or status-unknown partners on our primary outcome (HIV seroconversion). We also examined whether intervention effects on the mediators would be moderated by robust correlates of HIV among MSM, including stimulant use.

Results:

There were significant effects of the intervention on all hypothesized mediators. Stimulant use moderated the effect on condomless receptive anal sex In stratified multiple mediation models, we found that among MSM with low stimulant use, the intervention significantly prevented HIV by reducing condomless receptive anal sex with HIV-positive or status-unknown partners. Among MSM with higher stimulant use, there were no indirect effects of the intervention on HIV through any of the hypothesized mediators.

Conclusion:

The results suggest that the null effect found in the original EXPLORE trial might have occurred as a function of previously unexplored mediated and moderated processes. This study illustrates the value of testing mediated and moderated pathways in randomized trials, even in trials ruled out as nonefficacious.
Accelerometer-Based Physical Activity Patterns and Associations With Outcomes Among Individuals With Osteoarthritis
Authors: Beauchamp Tyler , Arbeeva Liubov , Cleveland Rebecca J. , Golightly Yvonne M. , Hales Derek P. , Hu David G. , Allen Kelli D.
Published: April 2021

Background

This study examined patterns of physical activity and associations with pain, function, fatigue, and sleep disturbance among individuals with knee or hip osteoarthritis.

Methods

Participants (n = 54) were enrolled in a telephone-based physical activity coaching intervention trial; all data were collected at baseline. Self-reported measures of pain and function (WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index] subscales), fatigue (10-point numeric rating scale), and PROMIS (Patient-Reported Outcomes Information System) Sleep Disturbance were collected via telephone. Accelerometers were mailed to participants and were worn for at least 3 days. Proportion of time participants spent in sedentary behavior during the morning (from wake until 12:00 pm), afternoon (12:00 pm until 5:59 pm) and evening (6:00 pm until sleep) each day was averaged across all days of wear. Pearson correlations assessed associations between activity and self-reported measures.

Results

Participants spent a large proportion of time in sedentary behavior: 65.6% of mornings, 70.0% of afternoons, and 76.6% of evenings. Associations between proportion of time spent in sedentary behavior and reported outcomes were generally strongest in the afternoon, strongest for WOMAC function, and lowest for PROMIS Sleep Disturbance. In the evening hours, sedentary time was most strongly associated with fatigue.

Conclusions

Overall, findings stress the importance of reducing sedentary behavior among adults with osteoarthritis and suggest behavioral interventions may be strengthened by considering patients’ within-day variation in symptoms and activity.
COVID-19 and Inpatient Rehabilitation Nursing Care: Lessons Learned and Implications for the Future
Authors: Camicia Michelle E. , Cournan Michele C. , Rye Jill
Published: April 2021

The SARS-CoV-2 coronavirus (COVID-19) pandemic is impacting post-acute inpatient rehabilitation nursing practice from preadmission assessment to inpatient care delivery and transition planning. Patients with disability following COVID-19 require interventions to address respiratory, cardiovascular, neurological, musculoskeletal, and psychosocial issues. The pandemic has resulted in changes to program structures and how inpatient rehabilitation facilities approach family caregiver engagement amidst visitation restrictions. Technology solutions can be utilized to reduce the patient and their family's feelings of isolation and support caregiver preparation for discharge. Nurse leaders are essential in supporting staff during this crisis through authentic presence and providing resources and training. Rehabilitation nurses are key in helping patients and families manage rehabilitation and the aftermath of COVID-19 to restore optimal functioning. In this clinical consultation, we synthesize insights learned from the COVID-19 responses at three inpatient rehabilitation facilities. We describe the impact of rehabilitation nursing interventions to improve outcomes for patients with COVID-19 and their caregivers.