bluuebunny/crossref_metadata_2025 huggingface dataset:
A Systematic Review of the Incidence and Outcomes of In-Hospital Cardiac Arrests in Patients With Coronavirus Disease 2019*
Authors: Lim Zheng Jie , Ponnapa Reddy Mallikarjuna , Curtis J. Randall , Afroz Afsana , Billah Baki , Sheth Vishad , Hayek Salim S. , Leaf David E. , Miles Jeremy A. , Shah Priyank , Yuriditsky Eugene , Jones Daryl , Shekar Kiran , Subramaniam Ashwin
Published: March 2021

OBJECTIVES:

To investigate the incidence, characteristics, and outcomes of in-hospital cardiac arrest in patients with coronavirus disease 2019 and to describe the characteristics and outcomes for patients with in-hospital cardiac arrest within the ICU, compared with non-ICU patients with in-hospital cardiac arrest. Finally, we evaluated outcomes stratified by age.

DATA SOURCES:

A systematic review of PubMed, EMBASE, and preprint websites was conducted between January 1, 2020, and December 10, 2020. Prospective Register of Systematic Reviews identification: CRD42020203369.

STUDY SELECTION:

Studies reporting on consecutive in-hospital cardiac arrest with a resuscitation attempt among patients with coronavirus disease 2019.

DATA EXTRACTION:

Two authors independently performed study selection and data extraction. Study quality was assessed with the Newcastle-Ottawa Scale. Data were synthesized according to the Preferred Reporting Items for Systematic Reviews guidelines. Discrepancies were resolved by consensus or through an independent third reviewer.

DATA SYNTHESIS:

Eight studies reporting on 847 in-hospital cardiac arrest were included. In-hospital cardiac arrest incidence varied between 1.5% and 5.8% among hospitalized patients and 8.0–11.4% among patients in ICU. In-hospital cardiac arrest occurred more commonly in older male patients. Most initial rhythms were nonshockable (83.9%, [asystole = 36.4% and pulseless electrical activity = 47.6%]). Return of spontaneous circulation occurred in 33.3%, with a 91.7% in-hospital mortality. In-hospital cardiac arrest events in ICU had higher incidence of return of spontaneous circulation (36.6% vs 18.7%; p < 0.001) and relatively lower mortality (88.7% vs 98.1%; p < 0.001) compared with in-hospital cardiac arrest in non-ICU locations. Patients greater than or equal to 60 years old had significantly higher in-hospital mortality than those less than 60 years (93.1% vs 87.9%; p = 0.019).

CONCLUSIONS:

Approximately, one in 20 patients hospitalized with coronavirus disease 2019 received resuscitation for an in-hospital cardiac arrest. Hospital survival after in-hospital cardiac arrest within the ICU was higher than non-ICU locations and seems comparable with prepandemic survival for nonshockable rhythms. Although the data provide guidance surrounding prognosis after in-hospital cardiac arrest, it should be interpreted cautiously given the paucity of information surrounding treatment limitations and resource constraints during the pandemic. Further research is into actual causative mechanisms is needed.
Optimal Sedation in Patients Who Receive Neuromuscular Blocking Agent Infusions for Treatment of Acute Respiratory Distress Syndrome—A Retrospective Cohort Study From a New England Health Care Network*
Authors: Wongtangman Karuna , Grabitz Stephanie D. , Hammer Maximilian , Wachtendorf Luca J. , Xu Xinling , Schaefer Maximilian S. , Fassbender Philipp , Santer Peter , Kassis Elias Baedorf , Talmor Daniel , Eikermann Matthias ,   for the SICU Optimal Mobilization Team (SOMT) Group
Published: March 2021

OBJECTIVES:

Two previously published trials (ARDS et Curarisation Systematique [ACURASYS] and Reevaluation of Systemic Early Neuromuscular Blockade [ROSE]) presented equivocal evidence on the effect of neuromuscular blocking agent infusions in patients with acute respiratory distress syndrome (acute respiratory distress syndrome). The sedation regimen differed between these trials and also within the ROSE trial between treatment and control groups. We hypothesized that the proportion of deeper sedation is a mediator of the effect of neuromuscular blocking agent infusions on mortality.

DESIGN:

Retrospective cohort study.

SETTING:

Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA).

PATIENTS:

Intubated and mechanically ventilated ICU patients with acute respiratory distress syndrome (Berlin definition) admitted between January 2008 until June 2019.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

The proportion of deeper sedation was defined as days with nonlight sedation as a fraction of mechanical ventilation days in the ICU after acute respiratory distress syndrome diagnosis. Using clinical data obtained from a hospital network registry, 3,419 patients with acute respiratory distress syndrome were included, of whom 577 (16.9%) were treated with neuromuscular blocking agent infusions, for a mean (sd) duration of 1.8 (±1.9) days. The duration of deeper sedation was prolonged in patients receiving neuromuscular blocking agent infusions (4.6 ± 2.2 d) compared with patients without neuromuscular blocking agent infusions (2.4 ± 2.2 d; p < 0.001). The proportion of deeper sedation completely mediated the negative effect of neuromuscular blocking agent infusions on in-hospital mortality (p < 0.001). Exploratory analysis in patients who received deeper sedation revealed a beneficial effect of neuromuscular blocking agent infusions on mortality (49% vs 51%; adjusted odds ratio, 0.80; 95% CI, 0.63–0.99, adjusted absolute risk difference, –0.05; p = 0.048).

CONCLUSIONS:

In acute respiratory distress syndrome patients who receive neuromuscular blocking agent infusions, a prolonged, high proportion of deeper sedation is associated with increased mortality. Our data support the view that clinicians should minimize the duration of deeper sedation after recovery from neuromuscular blocking agent infusion.
Predictive Roles of HER2 Gene Amplification and Neutrophil-to-Lymphocyte Ratio on Survival in HER2-Positive Advanced Gastric Cancer Treated With Trastuzumab-Based Chemotherapy
Authors: Park Joo-Hwan , Yeo Ja Hyun , Kim Young Saing , Park Inkeun , Ahn Hee Kyung , Shin Dong Bok , Lee Woon-Ki , Yang Jun-Young , Kim Hyung-Sik , Sym Sun Jin
Published: March 2021

Objectives:

Trastuzumab is used as an agent against human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer (AGC). The aim of this study was to determine how HER2 gene amplification and neutrophil-to-lymphocyte ratio (NLR) could predict long-term survival in AGC patients that underwent trastuzumab-based chemotherapy.

Methods:

We retrospectively reviewed medical records of 112 patients between 28 and 91 years old (median of 66 y) with AGC treated with first-line trastuzumab-based chemotherapy. The level of HER2 gene amplification was determined by the HER2/centromere enumerator probe 17 (CEP17) ratio and HER2 gene copy number (GCN). NLR was calculated as the neutrophil count divided by the lymphocyte counts.

Results:

Median HER2/CEP17 ratio, HER2 GCN, and NLR values were 2.85, 7.1, and 2.81, respectively. Objective response rate in both high HER2/CEP17 ratio (59.4% vs. 28.1%, P=0.012) and HER2 GCN groups (62.1% vs. 33.3%, P=0.032) was higher than that of each group. High NLR correlated with significantly worse median overall survival (OS) (median OS, 8.2 vs. 18.9 mo, P=0.002) and progression free survival (PFS) (median PFS: 5.1 vs. 8.0 mo, P=0.005). However, median OS and PFS were not significantly different according to HER2/CEP17 ratio or HER2 GCN. In the multivariate analysis, high NLR, Eastern Cooperative Group performance status, and poorly differentiated/signet ring cell type were independent factors for OS.

Conclusions:

NLR was a significant predictor of long-term survival in AGC patients treated with first-line trastuzumab-based chemotherapy. Future validation of prospective trials with larger patient populations will be needed.
Low admission blood pressure as a marker of poor 1-year survival in patients with revascularized critical limb ischemia
Authors: Yannoutsos Alexandra , Lin Franck , Billuart Olivier , Buronfosse Anne , Sacco Emmanuelle , Beaussier Hélène , Mourad Jean-Jacques , Emmerich Joseph , Lazareth Isabelle , Priollet Pascal
Published: March 2021

Objective:

To contrast the association between blood pressure (BP) level and antihypertensive medications at hospital admission with 1-year mortality in patients undergoing revascularization for critical limb ischemia (CLI).

Methods:

From November 2013 to May 2019, 315 consecutive patients were retrospectively included. A median of seven (IQR 3–13) separate readings were recorded for each patient before revascularization procedure and the average represented patient's mean BP. BP-lowering medications, clinical and biological parameters were recorded at baseline. The main outcome was total 1-year mortality.

Results:

The cohort included 172 men (55%) and 143 women (45%), with a mean age of 77.9 ± 11.9 years. Treated hypertension was present in 245 (78%) patients; 288 (91%) patients had BP-lowering drug prescriptions (2.1 ± 1.3 medications at baseline). Mean SBP, DBP, mean BP (MBP) and pulse pressure (PP) were 132 ± 18, 70 ± 8, 90 ± 10 and 62 ± 16mmHg. During 1-year follow-up, 80 (25.4%) patients died. In single-pressure multivariate analysis, SBP (hazard ratio 0.97; 95% CI 0.96–0.99; P = 0.005), MBP (hazard ratio 0.96; 95% CI 0.92–0.99; P = 0.01), PP (hazard ratio 0.97; 95% CI 0.95–0.99; P = 0.009), but not DBP, were inversely correlated with 1-year mortality, independently of age, coronary heart disease, left ventricular ejection fraction, brain natriuretic peptide, serum albumin, institutionalized status and antihypertensive drugs. Association between SBP, MBP and PP with 1-year mortality had a quite linear reverse pattern.

Conclusion:

Among patients undergoing revascularization for CLI, there is an inverse correlation between admission SBP, MBP and PP with 1-year mortality. BP may represent a modifiable therapeutic target to prevent poor outcome in CLI patients.
Antihypertensive treatment decrease stroke occurrence: a prospective cohort study
Authors: Zuo Yingting , Wang Anxin , Wu Shouling , Chen Shuohua , Tian Xue , Li Haibin , He Yan
Published: March 2021

Objective:

Among the risk factors of stroke, hypertension was one of the most important and modifiable factors. The current study aimed to assess whether antihypertensive treatment to ideal levels of blood pressure can eliminate stroke risk in a prospective cohort study.

Methods:

The Kailuan study was a prospective longitudinal cohort study on stroke risk factors and events. We analyzed association of baseline antihypertensive treatment efficacy with the risk of stroke during 11.0-year follow-up, and further evaluated association of newly antihypertensive treatment efficacy at 4-year follow-up with subsequent stroke. Multivariate Cox proportion models were used to calculated hazard ratios and their 95% confidence intervals (CIs) for stroke.

Results:

A total of 97 772 participants (median age: 51.65 years) without previous stroke were included. At baseline, 55 518 participants had normotension, 2339 treated and controlled, 32 331 untreated hypertension and 7584 treated but uncontrolled. Compared with normotension, individuals with treated and controlled, untreated hypertension and treated but uncontrolled, had 83, 97 and 162% higher risk of developing total stroke after adjusting for potential stroke risk factors, respectively (hazard ratio 1.83 [95% CI 1.56–2.15], 1.97 [95% CI 1.85–2.11] and 2.62 [95% CI 2.40–2.86]; all P < 0.05). Whereas, normotension at baseline, who were newly normotension with antihypertensives at 4-year follow-up, exhibited no elevated total stroke risk (hazard ratio, 1.41 [95% CI 0.87–2.30]). Similar results existed for stroke subtypes (ischemic stroke and hemorrhagic stroke).

Conclusion:

The data suggest that, antihypertensive treatment to normotensive individuals can reduce stroke risk in a short time.
Blood pressure, blood pressure variability and the risk of poststroke dementia
Authors: Hilkens Nina A. , Klijn Catharina J.M. , Richard Edo
Published: March 2021

Objective:

High blood pressure and blood pressure variability are potential, modifiable risk factors of poststroke dementia. We aimed to investigate the association between achieved blood pressure, blood pressure variability and poststroke dementia.

Methods:

We studied 17 064 patients with noncardioembolic ischemic stroke included in the Prevention Regimen for Effectively avoiding Second Strokes (PRoFESS) trial. We analysed the data as a single observational cohort. We studied mean achieved SBP and DBP and blood pressure variability defined as coefficient of variation (SD/mean∗100). The association between blood pressure and dementia was investigated with logistic regression analysis, correcting for sociodemographic factors and cardiovascular risk factors.

Results:

During 39 818 person-years of follow-up, 817 patients were diagnosed with dementia (2.1 per 100 person-years). We found a significant nonlinear association between mean SBP and the risk of dementia, implying a U-shaped association between mean SBP and dementia. Mean SBP of 120–129 mmHg was associated with a significantly higher risk of dementia than 130–139 mmHg [odds ratio (OR) 1.28; 95% confidence interval (95% CI) 1.03–1.58]. There was no indication of a U-shaped association between mean DBP and dementia, and no significant association between mean DBP categories and dementia. Higher blood pressure variability was associated with an increased risk of dementia (OR 1.06 per point increase, 95% CI 1.02–1.04), independent of mean SBP.

Conclusion:

Among patients with a recent noncardioembolic ischemic stroke, there appears to be a U-shaped association between achieved SBP and dementia. High blood pressure variability is associated with an increased risk of poststroke dementia.
Opioids and ophthalmology: review of the current literature
Authors: Starr Matthew R. , Patel Luv G. , Ammar Michael , Yonekawa Yoshihiro
Published: March 2021

Purpose of review

The number of opioid-related overdose deaths has rapidly increased since 2000, increasing more than five-fold from 1999 to 2016. Although surgeons only write 10% of opioid prescriptions annually, with ophthalmologists writing only a fraction of this amount, all physicians need to be cognizant of the current opioid epidemic and ways to decrease unnecessary opioid prescriptions.

Recent findings

Previous work within ophthalmology has shown that retrobulbar anesthesia along with peri-operative intravenous or oral nonopioid analgesics can lead to decreased postoperative opioid use following ophthalmic surgery. Recent literature has shifted focus towards the use of opioid prescription guidelines in managing postoperative pain and decreasing the number of unnecessary opioids being prescribed by ophthalmologists. Overall, the frequency of opioid prescriptions may have gradually declined the past few years with such efforts, increased awareness, and new healthcare policies to monitor opioid prescriptions. However, ophthalmologists still continue to prescribe a substantial number of opioid medications, much of which may not be necessary.

This review serves as a tool to aid all ophthalmologists in managing postoperative pain. There is a recent trend in addressing the opioid epidemic and efforts are being made to limit the overprescribing of opioids. Continued efforts are still required by all ophthalmologists to address the current opioid epidemic.
Depression and Severity of Glaucoma Among Older Adults in Urban and Suburban Areas
Authors: Tharmathurai Sangeetha , Muhammad-Ikmal Mohamad K. , Razak Asrenee A. , Che-Hamzah Jemaima , Azhany Yaakub , Fazilawati Qamaruddin , Liza-Sharmini Ahmad T.
Published: March 2021

Précis:

Depression increases with severity of visual field defect in older adults with primary open-angle glaucoma (POAG).

Purpose:

This study aimed to determine the prevalence of depression among patients with POAG and examine the relationship between depression and the severity of POAG in older adults.

Materials and Methods:

Three hundred and sixty patients with POAG aged 60 years or above were recruited from 2 tertiary centers located in an urban and suburban area. The participants were stratified according to the severity of their glaucoma based on the scores from the modified Advanced Glaucoma Intervention Study (AGIS) to mild, moderate, severe, and end stage. Face-to-face interviews were performed using the Malay Version Geriatric Depression Scale 14 (mGDS-14) questionnaire. Depression is diagnosed when the score is ≥8. One-way analysis of variance was used to compare the subscores between the groups. Multifactorial analysis of variance was also applied with relevant confounding factors.

Results:

Depression was detected in 16% of older adults with POAG; a higher percentage of depression was seen in those with end stage disease. There was a significant increase in the mean score of mGDS-14 according to the severity of POAG. There was evidence of an association between depression and severity of visual field defect (P<0.001). There was a significant difference in mGDS-14 score between the pairing of severity of POAG [mild-severe (P=0.003), mild-end stage (P<0.001), moderate-severe (P<0.001), and moderate-end stage (P<0.001)] after adjustment to living conditions, systemic disease, and visual acuity.

Conclusion:

Ophthalmologists should be aware that older adults with advanced visual field defects in POAG may have depression. The detection of depression is important to ensure adherence and persistence to the treatment of glaucoma.
COVID-19–related Ocular Hypertension Secondary to Anterior Uveitis as Part of a Multisystemic Inflammatory Syndrome
Authors: Alonso Ruiz S. , Alonso Fabio O.M. , Fernandes Bruno F. , Ecard Virginia O. , Ventura Marcelo P.
Published: March 2021

It is the consensus of the medical community that ocular complications associated with Coronavirus Disease 2019 (COVID-19) are mild, self-limiting, and there are no reports to date of a sight-threatening event. We report a patient with a systemic inflammatory syndrome in the context of COVID-19, with ophthalmological (uveitis), dermatological (erythema and skin nodules), and cardiovascular (edema) manifestations. The anterior uveitis led to an increase in the intraocular pressure that failed to respond to clinical treatment and prompted a surgical intervention to save the vision. To the best of our knowledge, this is the first report of a COVID-19–related ocular hypertension. Timely surgical intervention was key to save the vision in the patient’s only eye.
Pharmacokinetics and Safety of Single-dose Tedizolid Phosphate in Children 2 to <12 Years of Age
Authors: Arrieta Antonio C. , Ang Jocelyn Y. , Espinosa Claudia , Fofanov Oleksandr , Tøndel Camilla , Chou Margaret Z. , De Anda Carisa S. , Kim Jason Y. , Li Dan , Sabato Philip , Sears Pamela S. , Bradley John S.
Published: March 2021

Background:

Infections with Gram-positive bacteria, including acute bacterial skin and skin structure infections (ABSSSIs), are common in children. We describe a single-dose pharmacokinetics and safety study of tedizolid phosphate, a new oxazolidinone under investigation for the treatment of ABSSSIs in children, in hospitalized participants 2 to <12 years of age.

Methods:

This open-label, multicenter, phase 1 trial (NCT02750761) enrolled hospitalized children 2 to <12 years of age receiving treatment for a confirmed/suspected Gram-positive bacterial infection. Participants were stratified by age (2 to <6 years and 6 to <12 years) to receive a single oral or intravenous dose of tedizolid phosphate. Evaluations included safety and pharmacokinetics of tedizolid phosphate and its active metabolite, tedizolid. Palatability of the oral suspension was also evaluated.

Results:

Thirty-two participants were enrolled and received 3–6 mg/kg of study medication. For both routes of administration, tedizolid phosphate was rapidly converted to tedizolid; median time to maximum tedizolid plasma concentration was 1–2 hours after initiation of the 1-hour intravenous infusion and 2–3 hours after oral dosing. The tedizolid mean terminal half-life was 5–6 hours and 6–7 hours for the intravenous and oral administration groups, respectively. The oral tedizolid phosphate suspension demonstrated high bioavailability comparable to that of the parenteral administration. A single dose of intravenous or oral tedizolid phosphate was well tolerated; no unexpected safety findings were observed.

Conclusions:

Pharmacokinetic and safety observations provide the information necessary for the continued development of tedizolid phosphate for the treatment of Gram-positive infections in children, particularly ABSSSIs.
Atypical, Extremely Rapid Growth of Pediatric Orbital Neurilemmoma
Authors: Vahdani Kaveh , Luthert Philip J. , Rose Geoffrey E.
Published: March 2021

Solitary orbital neurilemmoma—a benign tumor of Schwann cells in a peripheral nerve-sheath—are typically very slow growing and present in middle age; in the absence of neurofibromatosis, they are almost never seen in childhood. We describe the clinical presentation, imaging, pathology, and management of this tumor in a 12 years old—the tumor growing extremely rapidly over 5 months and without any evidence of cystic degeneration, hemorrhage, or sarcomatous features. The possibility of tumor growth having been accelerated by prior biopsy is discussed.
The Effect of Zero Gravity on Eyelid and Brow Position
Authors: Karlin Justin N. , Farajzadeh Justin , Stacy Stephanie , Esfandiari Mahtash , Rootman Daniel B.
Published: March 2021

Purpose:

To describe the effect of spaceflight on upper eyelid and brow position.

Materials and Methods:

Images of astronauts on earth and in space were collected from a National Aeronautics and Space Administration image library. For each astronaut, front facing portraits captured within a 5-year period were obtained. At least 6 photos were collected per astronaut, 3 taken on earth, and 3 in zero gravity. Measurements from the center of the pupil to the upper eyelid margin (MRD1) and center of the pupil to the inferior eyebrow margin [pupil-to-brow (PTB)] were performed digitally for each image and averaged for each condition and each individual. Differences in mean MRD1 and PTB were assessed to illustrate the effects of zero gravity on eyelid and eyebrow position respectively. Linear-mixed effects modeling, analysis of variance and post hoc power analysis were performed.

Results:

One hundred and twelve photographs (55 earth, 57 space) from 18 astronauts (4 women, 14 men; mean age 45.9 years) were retrieved. Zero gravity resulted in a mean PTB increase of 3.7 mm (p < 0.01) but did not result in significant change in MRD1 (p = 0.21). Post hoc power analysis of the measured MRD1 difference was performed by simulation. At an MRD1 difference of 0.5 mm, the probability of a type II error is 2.6%, equivalent to a beta power of 97.4%. Thus, we can be 97.4% confident that a difference in MRD of 0.5 mm or greater would be detected.

Conclusions:

While spaceflight led to significant elevation of PTB, it did not consistently alter MRD1. As such, the brow and eyelid appear to be independently regulated with respect to gravitational changes.
Preliminary Development of Value Scorecards as ICU Telemedicine Evaluation Tools
Authors: Nadig Nandita , Hynden Liz , Sterba Katherine , McElligott James , Valenta Shawn , Warr Emily , Beeks Rebecca , Ford Dee
Published: March 2021

EXECUTIVE SUMMARY

Intensive care unit (ICU) telemedicine has grown exponentially to the point that approximately 10% of U.S. hospitals use such programs. However, no studies have focused on strategic decision tools in the context of rural hospitals. We applied the pervasive balanced scorecard framework and used a sequential, mixed methods design with qualitative and quantitative data sources. We then triangulated them to generate value scorecards for four rural South Carolina hospitals. Four domains, each with numerous components, were identified and compiled to create a composite value scorecard. Domains and numbers of components included organizational (n = 10), clinical (n = 5), financial (n = 8), and strategic (n = 3) effects of ICU telemedicine. When weighting each component within domains and then comparing across hospitals, we identified substantial variation in the relative value derived from ICU telemedicine. Our novel, multidimensional value scorecard could be prospectively applied by hospitals seeking a structured approach to decision-making for ICU telemedicine investments.
Factors Affecting Burnout Among Medical Assistants
Authors: Seay-Morrison Timothy P. , Hirabayshi Kimberly , Malloy Courtney L. , Brown-Johnson Catherine
Published: March 2021

EXECUTIVE SUMMARY

Medical assistants—key professionals supporting physician practices—have not been studied with regard to burnout and professional fulfillment, which may affect other healthcare professionals. This study examined the factors associated with burnout among medical assistants in an academic healthcare organization while validating the use of a tool previously used to assess burnout in physicians. Using portions of the Professional Fulfillment Index (PFI) and questions designed for this mixed methods study, medical assistants employed across Stanford Health Care were surveyed. The authors assessed demographic characteristics and the impact of control, organizational culture, team knowledge, self-efficacy, and professional fulfillment/meaningfulness on burnout. Of the 505 eligible participants, 261 (52%) completed the survey; 76% were women. The study validated the PFI for use with this population and validated three additional scales. Burnout was found to be low among medical assistants (M = 2.32); professional fulfillment/meaningfulness of work was found to be high (M = 4.08). Organizational culture, professional fulfillment, and self-efficacy were found to be predictors of burnout (R

2
= 0.438), with negative perceptions of organizational culture as the strongest predictor of burnout among medical assistants (β = –0.34). These results indicate that a survey tool is useful in understanding components of burnout and professional fulfillment in this population. Although limited to one site, this study could be replicated in other organizations.
Use of a Reperfusion Cannula for Acute Limb Ischemia in a Patient with Carotid Artery Extracorporeal Membrane Oxygenation Cannulation
Authors: Parrado Raphael H. , Cardona Monika , Garred Charles , Tecklenburg Frederick W. , Veeraswamy Ravi K. , Lesher Aaron P. , Walz Alice A.
Published: March 2021

Acute limb ischemia is a rare but potentially devastating event in a critically ill patient. In the pediatric population, limb ischemia is usually related to iatrogenic vascular damage and arterial thrombus formation secondary to arterial catheter placement. Children who have undergone femoral artery cannulation for venoarterial extracorporeal membrane oxygenation (VA-ECMO) are particularly at risk for this complication. In these cases, there have been reports of the successful use of a percutaneous limb reperfusion cannula to prevent or treat limb ischemia. We present a case of an 18 month old female who required VA-ECMO via carotid artery cannulation for viral myocarditis and subsequently developed acute lower limb ischemia related to a thrombus from an indwelling femoral arterial catheter in place for hemodynamic monitoring. This case highlights the usage of a distal reperfusion cannula and extracorporeal membrane oxygenation (ECMO) circuit for a novel purpose, which coupled with near infrared spectroscopy (NIRS) monitoring successfully re-established blood flow to the ischemic limb.
Prognostic role of albumin level in heart failure
Authors: El Iskandarani Mahmoud , El Kurdi Bara , Murtaza Ghulam , Paul Timir K. , Refaat Marwan M.
Published: March 2021

Background:

Hypoalbuminemia (HA) is common in HF, however, its pathophysiology and clinical implications are poorly understood. While multiple studies have been published in the past decade investigating the role of serum albumin in HF, there is still no consensus on the prognostic value of this widely available measure. The objective of this study is to assess the prognostic role of albumin in heart failure (HF) patient

Methods:

Unrestricted searches of MEDLINE, EMBASE, Cochrane databases were performed. The results were screened for relevance and eligibility criteria. Relevant data were extracted and analyzed using Comprehensive Meta-Analysis software. The Begg and Mazumdar rank correlation test was utilized to evaluate for publication bias.

Results:

A total of 48 studies examining 44,048 patients with HF were analyzed. HA was found in 32% (95% confidence interval [CI] 28.4%–37.4%) HF patients with marked heterogeneity (I
2 = 98%). In 10 studies evaluating acute HF, in-hospital mortality was almost 4 times more likely in HA with an odds ratios (OR) of 3.77 (95% CI 1.96–7.23). HA was also associated with a significant increase in long-term mortality (OR: 1.5; 95% CI: 1.36–1.64) especially at 1-year post-discharge (OR: 2.44; 95% CI: 2.05–2.91; I
2 = 11%). Pooled area under the curve (AUC 0.73; 95% CI 0.67–0.78) was comparable to serum brain natriuretic peptide (BNP) in predicting mortality in HF patients.

Conclusion:

Our results suggest that HA is associated with significantly higher in-hospital mortality as well as long-term mortality with a predictive accuracy comparable to that reported for serum BNP. These findings suggest that serum albumin may be useful in determining high-risk patients.
Clinical study on cystogastrostomy and Roux-en-Y-type cystojejunostomy in the treatment of pancreatic pseudocyst
Authors: Ye Jun , Wang Lan , Lu Shan , Yang Dujiang , Hu Weiming , Lu Huimin , Zhang Yi
Published: March 2021

The main purpose is to compare the efficacy of cystogastrostomy (CG) and Roux-en-Y-type cystojejunostomy (RCJ) in the treatment of pancreatic pseudocyst (PPC), and to explore the risk factors of recurrence and complications after internal drainage.

Two hundred eight patients undergoing either CG or RCJ for PPC Between January 1, 2013and February 1, 2019, at West China Hospital of Sichuan University were retrospectively analyzed. The cure rate, complication rate and related factors were compared between the 2 groups.

Two hundred eight patients with PPC underwent either a CG (n = 119) or RCJ (n = 89). The median follow-up time was 42.7 months. Between the 2 cohorts, there were no significant differences in cure rate, reoperation rate, and mortality (all P > .05). The operative time, estimated intraoperative blood loss, install the number of drainage tubes and total expenses in CG group were lower than those in RCJ group (all P < .05). The Logistic regression analysis showed that over twice of pancreatitis’ occurrence was were independent risk factor for recurrence after internal drainage of PPC (OR 2.760, 95% CI 1.006∼7.571, P = .049). Short course of pancreatitis (OR 0.922, 95% CI 0.855∼0.994, P = .035), and RCJ (OR 2.319, 95% CI 1.033∼5.204, P = .041) were independent risk factors for complications after internal drainage of PPC.

Both CG and RCJ are safe and effective surgical methods for treating PPC. There were no significant differences in cure rate, reoperation rate, and mortality between the 2 groups, while the CG group had a short operation time, less intraoperative bleeding and less cost.
Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness
Authors: DeLia Derek , Nova Jose , Chakravarty Sujoy , Tiderington Emmy , Kelly Taiisa , Cantor Joel C.
Published: March 2021

Background:

Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations.

Objective:

To evaluate the effects of PSH on Medicaid enrollees across New Jersey.

Research Design:

Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement.

Subjects:

A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013–2014.

Results:

PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC).

Conclusions:

Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.
Explaining Service Use and Residential Stability in Supported Housing
Authors: Schutt Russell K. , Schultz Mark , Mitchell-Miland Chantele , McCarthy Sharon , Chinman Matthew , Ellison Marsha
Published: March 2021

Background:

The behavioral model of health service use identified health needs, service preferences (predispositions), and service availability (enabling factors) as important predictors, but research has not conceptualized consistently each type of influence nor identified their separate effects on use of substance abuse and mental health services or their value in predicting service outcomes.

Objectives:

To test hypotheses predicting use of substance abuse and mental health services and residential stability and evaluate peer specialists’ impact.

Research Design:

Randomized trial of peer support added to standard case management in VA-supported housing program (Housing and Urban Development-VA Supportive Housing program).

Subjects:

One hundred sixty-six dually diagnosed Veterans in Housing and Urban Development-VA Supportive Housing program in 2 cities.

Measures:

Average VA service episodes for substance abuse and mental illness; residential instability; preferences for alcohol, drug, and psychological services; extent of alcohol, drug, and psychological problems; availability of a peer specialist.

Results:

Self-assessed health needs, mediated by service preferences, and assignment to a peer specialist predicted use of VA behavioral health services and residential stability, as did chronic medical problems, sex, and race.

Conclusions:

The behavioral model identifies major predictors of health service use and residential stability, but must recognize the mediating role of service preferences, the differing effects of alcohol and drug use, the unique influences of social background, and the importance of clinical judgment in needs assessment. Service availability and residential stability can be increased by proactive efforts involving peer specialists even in a health care system that provides services without a financial barrier.
A Pragmatic Scoring Tool to Predict Hydroxyurea Response Among β-Thalassemia Major Patients in Pakistan
Authors: Ansari Saqib H. , Hussain Zeeshan , Zohaib Muhammad , Parveen Sadia , Kaleem Bushra , Qamar Hina , Adil Omair , Khan Muhammad T. , Shamsi Tahir S.
Published: March 2021

Despite high prevalence and incidence of β-thalassemia in Pakistan, there is very limited work on the use of hydroxyurea (HU) in thalassemia patients in the country. This is the first insight regarding genetic profiling of BCL11A and HU responses in Pakistani β-thalassemia. It correlates single-nucleotide polymorphisms on BCL11A (rs4671393, rs766432) and HBG2 (XmnI), age at first transfusion, and β-globin mutations with HU response in β-thalassemia major (BTM). Of 272 patients treated with HU, 98 were complete responders, 55 partial responders, and 119 nonresponders. Our analysis shows that HU response was significantly associated with patients having IVSI-1 or CD 30 mutation (P<0.001), age at first transfusion >1 year (P<0.001), and with the presence of XmnI polymorphism (P<0.001). The single-nucleotide polymorphisms of BCL11A were more prevalent among responders, but could not show significant association with HU response (P>0.05). Cumulative effect of all 5 predicting factors through simple binary scoring indicates that the likelihood of HU response increases with the number of primary and secondary genetic modifiers (P<0.001). Predictors scoring is a pragmatic tool to foresee HU response in patients with BTM. The authors recommend a score of ≥2 for starting HU therapy in Pakistani patients with BTM.
Desmoplastic Small Round Cell Tumor With Ascending Intraspinal Metastasis at Recurrence: Case Report and Review of the Literature
Authors: Cacciotti Chantel , Samji Nasrin , Cox Stephanie , Yikilmaz Ali , Hann Crystal , Marin Jorge A. , Fowler JoAnn , VanHouwelingen Lisa , Athale Uma
Published: March 2021

Background:

Desmoplastic small round cell tumor (DSRCT) is a rare and aggressive malignancy commonly involving the abdomen and/or pelvic peritoneum. Despite aggressive therapy, the prognosis remains poor. Central nervous system relapse is rare in abdominal/pelvic primary DSRCT.

Observation:

We report a case of a 10-year-old female with a large pelvic DSRCT and involvement of the rectosigmoid colon and liver. Following treatment with chemotherapy, and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy an initial response was noted. With progressive lower limb weakness, recurrence with perineural invasion in the lumbosacral nerve root involving the conus was noted 2.5 years from diagnosis. Cerebrospinal fluid showed tumor cells with a molecular confirmation.

Conclusions:

Perineural invasion and ascending paralysis secondary to primary abdominal DSRCT has not been previously reported to our knowledge. We recommend a high index of suspicion for early and accurate diagnosis of this rare presentation.
Immunostaining for NeuN Does Not Show all Mature and Healthy Neurons in the Human and Pig Brain: Focus on the Hippocampus
Authors: Luijerink Lauren , Waters Karen A. , Machaalani Rita
Published: March 2021

Neuronal nuclei (NeuN) is a neuron-specific nuclear protein, reported to be stably expressed in most postmitotic neurons of the vertebrate nervous system. Reduced staining has been interpreted by some to indicate loss of cell viability in human studies, while others suggest this may be because of changes in the antigenicity of the target epitope. Preliminary studies in our laboratory found low immunostaining for the NeuN antibody on formalin fixed and paraffin embedded (FFPE) human brain tissue. We report on the techniques and results used to enhance the staining for NeuN in that tissue. In parallel, we stained NeuN in piglet brain tissue, sourced from an experimental model where methodological parameters, including those for tissue fixation and storage, were tightly controlled. In human FFPE brain tissue, we were unable to enhance NeuN immunostaining to a degree sufficient for cell counting. In contrast, we found consistently high levels of staining in the piglet brain tissue. We conclude that processes used for fixation and storage of human FFPE brain tissue are responsible for the reduced staining. These results emphasize that a cautionary approach should be taken when interpreting NeuN staining outcomes in human FFPE brain tissue.
Digital Pathology Slides-based Measurement of Tumor Cells and Lymphocytes Within Cytology Samples Supports the Relevance of the Separation by Size of Nonhematological Tumor and Hematological Nontumor Cells in Liquid Biopsies
Authors: Uguen Arnaud
Published: March 2021

Filtration by size is one method used to study circulating tumor cells in blood samples. Filtration-migration ability is highly dependent of the size of cell nucleus. This implies to search for the appropriate nucleus size able to separate between hematological nucleated and nonhematological nucleated blood cells to maximize circulating tumor cell isolation. Digitalized cytology slides [May-Grünwald Giemsa (MGG) stained and immunocytochemistry (ICC) slides] from various cancer metastases served for manual measurements of nuclei about tumor cells and adjacent lymphocytes to determine the diameters the more able to separate between tumor cells and lymphocytes. Among 2022 cells analyzed (1067 tumor cells and 955 lymphocytes) on MGG stained slides, the mean diameter of tumor cells nuclei was 14.77 µm whereas the mean diameter of lymphocytic nuclei was 6.47 µm (P<0.001). In ICC slides, about 6583 cells (4753 tumor cells and 1830 lymphocytes), the mean diameter of tumor cells nuclei was 9.28 µm whereas the mean diameter of lymphocytic nuclei was 4.95 µm (P<0.001). Areas under the receiver operating characteristic curves analyses concluded that diameters of 9.37 µm and 6 µm separated the best between tumor cells and lymphocytes in MGG and ICC slides, respectively. Measuring manually the diameters of the smallest tumor cells in ICC slides, we established more than 99% of tumor cells had diameters superior to 8 µm. The sizes differences between tumor cells and lymphocytes support the relevance of the filtration by size to isolate blood circulating nonhematological tumor cells. The existence of small tumor cells with sizes overlapping with those of lymphocytes is worth to optimize the threshold to separate between tumor cells and hematological cells.
Pediatric Index of Mortality 3—An Evaluation of Function Among ICUs In South Africa*
Authors: Solomon Lincoln J. , Naidoo Kuban D. , Appel Ilse , Doedens Linda G. , Green Robin J. , Long Michael A. , Morrow Brenda , Parker Noor M. , Parris Denise , Robroch Afke H. , Salie Shamiel , Singh Shivani A. , Argent Andrew C.
Published: March 2021

Objectives:

To evaluate the performance of the Pediatric Index of Mortality 3 as mortality risk assessment model.

Design:

This prospective study included all admissions 30 days to 18 years old for 12 months during 2016 and 2017. Data gathered included the following: age and gender, diagnosis and reason for PICU admission, data specific for the Pediatric Index of Mortality 3 calculation, PICU outcomes (death or survival), and length of PICU stay.

Setting:

Nine units that care for children within tertiary or quaternary academic hospitals in South Africa.

Patients:

All admissions 30 days to 18 years old, excluding premature infants, children who died within 2 hours of admission, or children transferred to other PICUs, and those older than 18 years old.

Interventions:

None.

Measurements and Main Results:

There were 3,681 admissions of which 2,253 (61.3%) were male. The median age was 18 months (interquartile range, 6–59.5 mo). There were 354 deaths (9.6%). The Pediatric Index of Mortality 3 predicted 277.47 deaths (7.5%). The overall standardized mortality ratio was 1.28. The area under the receiver operating characteristic curve was 0.81 (95% CI 0.79–0.83). The Hosmer-Lemeshow goodness-of-fit test statistic was 174.4 (p < 0.001). Standardized mortality ratio for all age groups was greater than 1. Standardized mortality ratio for diagnostic subgroups was mostly greater than 1 except for those whose reason for PICU admission was classified as accident, toxin and envenomation, and metabolic which had an standardized mortality ratio less than 1. There were similar proportions of respiratory patients, but significantly greater proportions of neurologic and cardiac (including postoperative) patients in the Pediatric Index of Mortality 3 derivation cohort than the South African cohort. In contrast, the South African cohort contained a significantly greater proportion of miscellaneous (including injury/accident victims) and postoperative noncardiac patients.

Conclusions:

The Pediatric Index of Mortality 3 discrimination between death and survival among South African units was good. Case-mix differences between these units and the Pediatric Index of Mortality 3 derivation cohort may partly explain the poor calibration. We need to recalibrate Pediatric Index of Mortality 3 to the local setting.
Ultrasound-Guided Quadratus Lumborum Block for Postoperative Pain in Abdominoplasty: A Randomized Controlled Study
Authors: Meouchy Michelle G. , Awaida Cyril J. , Jabbour Hicham J. , Rayess Youssef A. , Jabbour Samer F. , Nasr Marwan W.
Published: March 2021

Background:

Postoperative pain after abdominoplasty can delay postoperative ambulation, leading to life-threatening complications. Previous reports have shown the utility of quadratus lumborum block in providing adequate pain relief and avoiding side effects after numerous abdominal operations. The purpose of this randomized controlled trial was to demonstrate the efficacy of the quadratus lumborum block in abdominoplasty.

Methods:

Patients were randomly allocated to receive a bilateral quadratus lumborum block with either ropivacaine or normal saline. Postoperative cumulative analgesic medication consumption, pain severity at rest and on movement, and quality of recovery were evaluated and compared in both groups.

Results:

Twenty patients were allocated to each group. Total morphine dose received in the postanesthesia care unit was lower in the ropivacaine group than in the control group, with a mean of 3.4 mg and 6.6 mg, respectively. Cumulative tramadol consumption per patient in the first 48 hours postoperatively was significantly lower in the ropivacaine group compared with the control group (42.5 mg versus 190 mg;p= 0.0031). The Numeric Rating Scale both at rest and with effort was significantly lower in the ropivacaine group compared with the control group. The median quality of recovery for the ropivacaine group was 133 compared with 112 for the control group (p< 0.0001).

Conclusions:

Quadratus lumborum block in abdominoplasty reduces postoperative pain and opioid consumption and improves the quality of recovery. Further studies are needed to compare the quadratus lumborum block to more traditional blocks.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
Corset Autodermis External Obliqueplasty Reinforcement of Rectus Diastasis and Umbilical Hernia Repairs during Abdominoplasty
Authors: Perry Dylan J. , Driscoll Daniel N.
Published: March 2021

Abdominoplasty is among the most commonly performed aesthetic operations and is frequently combined with rectus abdominis musculoaponeurotic plication of rectus diastasis and repair of umbilical and ventral hernias. The authors present a spare parts technique to assist in reinforcement of both rectus diastasis plication and hernia repair during abdominoplasty operations using an autodermis onlay reinforcement graft. The graft is harvested from the excess abdominal pannus normally discarded during abdominoplasty and is inset on tension between the bilateral semilunar lines and plicated along a concave “corset” contour. This reduces distracting forces on the hernia and diastasis repairs and further augments abdominal contour. This technique has been performed for 8 years on 82 low-surgical-risk patients, without any noted increase in complications. The corset autodermis external obliqueplasty is a spare parts technique that may reduce recurrence of rectus diastasis and abdominal hernias repaired at the time of abdominoplasty and is an alternative strategy to mesh placement in this risk-averse aesthetic surgery population.