bluuebunny/crossref_metadata_2025 huggingface dataset:
A Quality Improvement Project to Reduce Postcesarean Opioid Consumption
Authors: Kahn Kristien Marie , Demarco Kathleen , Pavsic Joy , Sangillo Julie
Published: May 2021

Background:

The opioid epidemic is a public health emergency in the United States, stemming in part from widespread misuse and overprescribing of opioids following surgery. Approximately 1 in 300 women with no prior exposure to opioids develops an opioid use disorder following cesarean birth. Effective management of postcesarean pain requires individualized treatment and a balance of the woman's goals for optimal recovery and ability to safely care for her newborn. The American College of Obstetricians and Gynecologists recommends a multimodal approach to pain management after cesarean birth.

Methods:

In April 2019, a multidisciplinary team was formed at New York University Langone Health to study opioid use postcesarean. The team used the Plan, Do, Study, Act process model for continuous quality improvement to launch a postcesarean pathway called “Your Plan After Cesarean,” a standardized visual tool with quantifiable milestones. It facilitates integration of women's preferences in their postcesarean care, and emphasizes providers' routine use of nonpharmacological interventions to manage pain.

Results:

During the pilot period of the project, postcesarean high consumption of 55 to 120 mg of opioids was reduced from 25% to 8%. By January 2020, 75% of women postoperative cesarean took little-to-no opioids during their hospital stay. By February 2021, the total number of opioids consumed by women after cesarean birth in-hospital was reduced by 79%. Satisfaction among women with pain management after cesarean continued to be high.

Clinical Implications:

Reduction in postcesarean opioid administration and the number of opioids prescribed at hospital discharge can be accomplished without having a negative effect on women's perceptions of post-op pain relief. These changes can potentially be a factor in helping to avoid an opioid-naive woman who has a cesarean birth from developing an opioid use disorder.
The Navajo Nation Healthy Diné Nation Act: A Description of Community Wellness Projects Funded by a 2% Tax on Minimal-to-No-Nutritious-Value Foods
Authors: Yazzie Del , Tallis Kristen , Curley Caleigh , Sanderson Priscilla R. , Eddie Regina , Shin Sonya , Behrens Timothy K. , George Carmen , Antone-Nez Ramona , Jumbo-Rintila Shirleen , Begay Gloria Ann , de Heer Hendrik “Dirk”
Published: May 2021

Context:

To promote the health of the Navajo people, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014. The HDNA included a 2% tax on “minimal-to-no-nutritional-value” foods and waived 5% sales tax on healthy foods, the first such policy in the United States and any sovereign Tribal nation. Uniquely aligned with Tribal government structures, revenue was directly allocated to 110 small local government entities (Chapters) for self-determined wellness projects.

Objective:

To characterize HDNA-funded wellness projects, test for variation in project type, and funding amount over time by region and community size.

Design:

Longitudinal study assessing funded wellness projects from tax inception through 2019.

Setting:

The Navajo Nation.

Participants:

One hundred ten Navajo Nation Chapters receiving funding for self-determined wellness projects.

Outcome Measures:

The categories and specific types of wellness projects and funding over 4 years by region and community size.

Results:

Of revenue collected in 2015-2018, more than 99.1% was disbursed through 2019 ($4.6 million, $13 385 annually per community) across 1315 wellness projects (12 per community). The built recreational environment category received 38.6% of funds, equipment/supplies 16.5%, instruction 15.7%, food and water initiatives 14.0%, and social events 10.2%. Most common specific projects were walking trails ($648 470), exercise equipment ($585 675), food for events ($288 879), playgrounds ($287 471), and greenhouses ($275 554). Only the proportion allocated to instruction changed significantly over time (increased 2% annually, P = .02). Smaller communities (population <1000) allocated significantly higher proportions to traditional, agricultural, and intergenerational projects and less to the built environment.

Conclusions:

Through 2019, more than 99% of HDNA revenue was successfully disbursed to 110 rural, Tribal communities. Communities chose projects related to promoting the built recreational environment, agriculture, and fitness/nutrition education, with smaller communities emphasizing cultural and intergenerational projects. These findings can inform other indigenous nations considering similar policies and funding distributions.
Gender Inequity in the Public Health Workforce
Authors: Yassine Brianne Bostian , Rojewski Jay W. , Ransom Montrece McNeill
Published: May 2021

Context:

Public health is a gendered field. Although a majority of the public health workforce, women encounter an imbalance of power and experience disparate opportunities within the profession.

Analysis:

This article offers a multidimensional critique of gender inequity within the public health workforce through an examination of the literature.

Results:

There are three existing disparities between men and women in public health: unequal representation in leadership positions; persistence of wage discrimination; and disparities in scholarly publication and citations. Disparities are often more pronounced among women with intersectional identities (eg, race/ethnicity or other identities).

Discussion:

Gender inequity is structural, and solutions must address micro-, interactional, and macro-levels. The changing workforce and practitioners' skills in addressing upstream issues provide the opportunity to address this issue.
The Impact of Covid-19 State Closure Orders on Consumer Spending, Employment, and Business Revenue
Authors: Dunphy Christopher , Miller Gabrielle F. , Rice Ketra , Vo Linda , Sunshine Gregory , McCord Russell , Howard-Williams Mara , Coronado Fátima
Published: May 2021

Context:

In response to the COVID-19 pandemic, states across the United States implemented various strategies to mitigate transmission of SARS-CoV-2 (the virus that causes COVID-19).

Objective:

To examine the effect of COVID-19–related state closures on consumer spending, business revenue, and employment, while controlling for changes in COVID-19 incidence and death.

Design:

The analysis estimated a difference-in-difference model, utilizing temporal and geographic variation in state closure orders to analyze their impact on the economy, while controlling for COVID-19 incidence and death.

Participants:

State-level data on economic outcomes from the Opportunity Insights data tracker and COVID-19 cases and death data from usafacts.org.

Interventions:

The mitigation strategy analyzed within this study was COVID-19–related state closure orders. Data on these orders were obtained from state government Web sites containing executive or administrative orders.

Main Outcome Measures:

Outcomes include state-level estimates of consumer spending, business revenue, and employment levels.

Results:

Analyses showed that although state closures led to a decrease in consumer spending, business revenue, and employment, they accounted for only a small portion of the observed decreases in these outcomes over the first wave of COVID-19.

Conclusions:

The impact of COVID-19 on economic activity likely reflects a combination of factors, in addition to state closures, such as individuals' perceptions of risk related to COVID-19 incidence, which may play significant roles in impacting economic activity.
The Evolution of the Healthy People Initiative: A Look Through the Decades
Authors: Ochiai Emmeline , Blakey Carter , McGowan Angela , Lin Yen
Published: May 2021

Each decade, the US Department of Health and Human Services launches a new iteration of the Healthy People initiative. Healthy People strives to create a healthier nation and tracks data-driven outcomes to monitor progress toward achieving the initiative's goals throughout the decade. Although the initiative's mission, vision, and goals have evolved over time, since the initiative's inception in 1979, Healthy People remains dedicated to addressing the social determinants of health and improving the nation's health and well-being. In 2020, the US Department of Health and Human Services released the fifth iteration of the initiative, Healthy People 2030. This decade-long initiative provides a focused set of science-based, national objectives with targets to achieve by the year 2030. Healthy People 2030 is available online and offers users access to updated information and tools and resources for implementation. This article discusses the evolution of Healthy People across the decades, highlights Healthy People 2030 and its tools, and illustrates how stakeholders can use Healthy People to achieve their missions and improve the health and well-being of the nation.
Improving Care for Childhood Obesity: A Quality Improvement Initiative
Authors: Satti Komal F. , Tanski Susanne E. , Jiang Yike , McClure Auden
Published: May 2021

Introduction:

Obesity affected 13.7 million children in the United States in 2015. The American Academy of Pediatrics (AAP) offers an evidence-based approach to obesity management, but adherence to recommendations is suboptimal. Our objective was to improve provider adherence to the AAP recommendations for care of patients with obesity by making systematic changes in our practice for patients of ages > 2 and younger than 19 years with a BMI > 95th percentile.

Methods:

We performed a retrospective chart review of 417 qualifying encounters to assess adherence in the six months preceding the initiative. We measured adherence as a proportion of eligible patients who had (1) obesity on the problem list; (2) laboratory work offered; (3) counseling provided; (4) early follow-up recommended; (5) referral to a weight management program. In 2018, a multidisciplinary QI team conducted plan-do-study-act cycles to educate providers on the AAP recommendations and improve obesity-related care systems. The initiative lasted 18 months.

Results:

During the initiative, we tracked 885 patient encounters via chart review. We witnessed continued improvement in 4 out of 5 measures. For early follow-up offered, we saw improvement after PDSA 1, followed by a decline after PDSA 3. Providers ordered laboratory tests in only 13% of encounters for eligible children ages younger than 6 years versus 45% for ages older than 6 years, an age-dependent disparity that persisted despite the QI initiative.

Conclusion:

Our pediatric practice sustained improvement in adherence to AAP recommendations. There is a need to assess the reasons behind the care disparity based on patient ages.
A Quality Improvement Initiative to Reduce Blood Culture Contamination in the Neonatal Unit
Authors: Allen Elizabeth , Cavallaro Angela , Keir Amy K.
Published: May 2021

Introduction:

Peripheral blood culture contamination (BCC) can lead to an initiation of unnecessary antimicrobial treatment, further laboratory tests, increased length of stay, and increased costs. This study describes a 12-month quality improvement (QI) program to reduce the BCC rate in a neonatal unit by 50%.

Methods:

The QI team focused on standardizing processes to align with best practices using process mapping and cause and effect diagrams. Plan-Do-Study-Act (PDSA) 1: inoculation of blood culture bottles with the introduction of transfer device; PDSA 2: preparation of the skin for peripheral intravenous cannula insertion; PDSA 3: aseptic technique education package; and PDSA 4: optimizing blood volume of blood collected for culture. The team used statistical process control methodology to detect special cause variation.

Results:

Compliance with the standard processes as part of PSDA 1 improved from a mean level of 50% to 100% and for PDSA 2 improved from a mean level of 50% to 95%. After implementation of PDSA 3, scores on a relevant knowledge test increased from a mean of 39% (pretraining test; n = 10) to 92% (posttraining test; n = 10) (P < 0.001). Postimplementation of the processes for PDSA 4, a minimum of 1 mL was collected in 94% of blood culture collection events (n = 450) (mean 1.1 mL; range 0.5–3.5 mL). Special cause variation occurred after the implementation of the PDSA cycles. During the baseline period, the BCC rate was 2.0% and decreased to 1.0% postinterventions implementation.

Conclusions:

Interventions focused on standardizing practices around collection of blood cultures in neonates were associated with fewer contaminants.

This study is reported according to the SQUIRE 2.0 guidelines.
Definition of a Risk Zone for the Axillary Nerve Based on Superficial Landmarks
Authors: Schwarz Angelika M. , Weiglein Andreas H. , Schwarz Ulrike M. , Gänsslen Axel , Krassnig Renate , Grechenig Peter , Maier Marco J. , Hohenberger Gloria M.
Published: May 2021

Background:

The aim of this study was to investigate the axillary nerve’s location along superficial anatomical landmarks, and to define a convenient risk zone.

Methods:

A total of 123 upper extremities were evaluated. After dissection of the axillary nerve, the vertical distance between the upper border of the anterolateral edge of the acromion and the proximal border of the nerve was measured. Furthermore, the interval between the proximal border and the distal border of the axillary nerve’s branches was evaluated. The interval between the distal border of the branches and the most distal part of the lateral humeral epicondyle was measured. The distance between the anterolateral edge of the acromion and the lateral humeral epicondyle was evaluated. Measurements were expressed as proportions with respect to the distance between the acromion and the lateral humeral epicondyle.

Results:

The distance between the acromion and the proximal border of the axillary nerve’s branches was at a height of 10 percent of the distance between the acromion and the lateral humeral epicondyle, starting from the acromion (90 percent when starting from the lateral humeral epicondyle). The interval between the proximal and distal margins of the axillary nerve’s branches was between 10 percent and 30 to 35 percent of this interval, starting from the acromion (65 to 70 percent when starting from the lateral humeral epicondyle).

Conclusions:

The authors were able to locate the branches of the axillary nerve at an interval between 10 and 35 percent of the distance between the acromion and the lateral humeral epicondyle, starting from the acromion. This makes the proximal third of this distance an easily applicable risk zone during shoulder surgery.
Fifteen-Year Review of the American Board of Plastic Surgery Maintenance of Certification Tracer Data: Clinical Practice Patterns and Evidence-Based Medicine in Zygomatico-Orbital Fractures
Authors: Kearney Aaron M. , Shah Nikhil , Zins James , Gosain Arun K.
Published: May 2021

Background:

From 2005 to 2020, the American Board of Plastic Surgery collected data on 20 common plastic surgery operations as part of the Maintenance of Certification process. These data allow the authors to examine national trends in zygomatico-orbital fracture repair over a 15-year period.

Methods:

Tracer data for zygomatico-orbital fracture repair were reviewed in cohorts from 2005 to 2013 and 2014 to 2020. Results were categorized based on their presence in evidence-based medicine articles published during this period. Differences between years were assessed using the t test or chi-square test as appropriate.

Results:

Four hundred thirty patients were included as of March of 2020. Average age was 37 years (range, 6 to 85 years), and 76 percent were male. Operations took place on average 10 days from injury. There were significant decreases in the use of subciliary (31.9 percent versus 10.0 percent; p < 0.001), gingival buccal (84.3 percent versus 56.4 percent; p < 0.001), and lateral brow (45.2 percent versus 22.3 percent; p < 0.001) incisions, with an increase in lower lid external incisions (15.2 percent versus 30.9 percent; p < 0.001); 2.7 percent of patients had a complication requiring readmission and 4.5 percent required reoperation. The incidence of postoperative diplopia was 7.7 percent, and the infection rate was 1.7 percent.

Conclusions:

This article reviews the American Board of Plastic Surgery tracer data for zygomatico-orbital fracture repair. The Maintenance of Certification tracer data provide a national database with longer follow-up and more specific information than comparable databases. Analysis of these data over time enables the authors to describe practice trends and gives surgeons the opportunity to compare their outcomes to national norms.
Distal Arterialized Venous Supercharging Improves Perfusion and Survival in an Extended Dorsal Three-Perforasome Perforator Flap Rat Model
Authors: Wu Hongqiang , Zhang Chenxi , Chen Zhengtai , Lou Junsheng , Ding Jian , Wang Long , Xie Chenglong , Gao Weiyang , Lin Damu
Published: May 2021

Background:

Perforator flaps are commonly applied for a variety of skin defects. Many strategies (e.g., hyperbaric oxygen and preconditioning) have been investigated to improve flap survival, but a postoperative 2.03 to 18.2 percent flap necrosis frequency remains a major complication. The authors hypothesized that a distal arterialized venous supercharged (DAVS) flap procedure might improve perfusion and survival in an extended three-perforasome perforator flap rat model and rescue flap ischemia intraoperatively.

Methods:

One hundred twenty male Sprague-Dawley rats (200 to 300 g) were divided into the thoracodorsal artery (TDA) flap group and the DAVS flap group (n = 60 per group). An approximately 11 × 2.5-cm2 flap based on the TDA perforasome was designed in the TDA flap. A DAVS flap was designed based on the TDA flap and supercharged by anastomosing the rat caudal artery with the deep circumflex iliac vein. At postoperative times 1, 3, 6, and 12 hours and 1, 3, 5, and 7 days, perfusion and angiography were compared. On day 7, flap viability and angiogenesis were assessed using histology and Western blotting.

Results:

The DAVS flap showed a higher survival rate compared with the TDA flap (100 percent versus 81.93 ± 5.38 percent; p < 0.001). All blood flow ratios of deep circumflex iliac artery to TDA perforasome and of choke zone II to choke zone I were higher in the DAVS flap (all p < 0.05). Angiography qualitatively revealed that choke vessels in choke zone II dilated earlier and extensively in the DAVS flap group. CD34+ vessels (68.66 ± 12.53/mm2 versus 36.82 ± 8.99/mm2; p < 0.001) and vascular endothelial growth factor protein level (0.22 ± 0.03 versus 0.11 ± 0.03; p < 0.001) were significantly increased in the DAVS flap group.

Conclusions:

The DAVS procedure improves three-perforasome perforator flap survival and can be used for rescuing flap ischemia intraoperatively. Further study is needed before possible clinical adoption for reconstructive operations.
Adjunctive Procedures and Informed Consent with Breast Implant Explantation
Authors: Manahan Michele A.
Published: May 2021

Background:

The use of injectable or implantable materials or devices in the breast for augmentation or reconstruction has a history of innovation and controversy. Staying current in the field of breast implant management today means understanding not just the published literature but also its absence. Cutting edge breast implant treatment also means awareness of patient and media-driven interests and requests.

Methods:

Adjuvant treatments to optimize physical and psychological well-being with breast implant explantation, without replacement, will be addressed through literature review and analysis.

Results:

The body of literature demonstrates evidence of variable, and sometimes contradictory, methods to address adjunctive management of systemic concerns, the capsule, soft tissue of the native breast/chest, and treatment timing related to explantation. Few approaches are supported by very strong evidence. Many treatment methodologies are defensible. Any current attempts at optimizing management in patients undergoing explantation will be somewhat impaired by the ongoing nebulousness of related issues, such as breast implant illness. It seems clear, therefore, that plastic surgeons must fulfill their duty as caregivers to provide explantation surgery, either to attempt to improve physical health, mental well-being, or simply to respect patients’ wishes. A well-informed surgeon will likely employ a variety of approaches, adapted to the unique patient presentations at hand.

Conclusion:

It is expected that consultations, incisions, tissue rearrangements, surgical timing, and treatment indications will continue to vary as scientific investigation strives to understand and to optimize treatment of patients experiencing difficulty with breast implants.
Management of Symptomatic Patients with Textured Implants
Authors: Asaad Malke , Offodile Anaeze C. , Santanelli Di Pompeo Fabio , Bevers Therese B. , Stelly Sharon , Carew Lori A. , Barnea Yoav , Miranda Roberto N. , Butler Charles E. , Clemens Mark W.
Published: May 2021

Proper management of symptomatic textured implant patients is critical to identify and treat associated oncologic disease. Textured surface breast implants were first introduced more than 50 years ago in an effort to decrease high rates of capsular contracture and implant malposition observed with first-generation smooth surface breast implants. Textured implants were dominant over smooth devices in the United States in the late 1990s, but they fell out of favor for newer-generation smooth implants, while texture remained the dominant selling implants worldwide until recently. A class I device recall by the US Food and Drug Administration in 2019 precipitated a removal of the highest selling implant worldwide, Allergan Biocell, due to a disproportionately increased risk of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL). Operative strategies, such as bacterial control at the time of textured implant insertion, have not been credibly shown to affect or prevent the future development of BIA-ALCL. BIA-ALCL patients require complete surgical excision of their disease, whereas textured implant patients who are otherwise asymptomatic do not require surgical removal. For suspicious cases, diagnostic testing with CD30 immunohistochemistry should be performed before any surgical intervention. Capsules are evaluated with 12 strategic regional biopsies in a standardized approach. If surgeons are revising or exchanging textured implants, they may reasonably consider a total capsulectomy, though this is not advocated by the Food and Drug Administration or national societies, and has not been shown to mitigate future risk of BIA-ALCL. The purpose of this article is to review data on and outcomes for textured surface implants, disease-associated risk, and the management strategy for revisionary surgery and device surveillance.
What’s in a Name? Implicit Bias Affects Patient Perception of Surgeon Skill
Authors: Bhat Deepa , Kollu Tejas , Ricci Joseph A. , Patel Ashit
Published: May 2021

Background:

Implicit bias is the unconscious associations and beliefs held toward specific demographic groups. Instagram is commonly used by plastic surgeons to market their practice. This study investigates whether a surgeon’s name on a social media platform influences perception of their competence and their likelihood of gaining a new patient.

Methods:

A mock Instagram post was created using before-and-after photographs of a breast augmentation patient. Eight different ethnicities were selected, and common female and male names were selected based on U.S. Census data for each ethnicity. Surveys using the Instagram post were distributed asking responders to evaluate the competency of the surgeon and how likely they are to become a patient of that plastic surgeon. The surgeon’s name was the only variable in the survey.

Results:

A total of 2965 survey responses were analyzed. The majority of responders were Caucasian (57 percent); 55 percent were men and 45 percent were women. Overall, competence and recruitment likelihood scores between surgeons of different ethnicities were not significantly different. Caucasian and Latinx responders both assigned higher competence and recruitment likelihood scores to their own respective ethnicities.

Conclusions:

Implicit bias plays a role in whether or not a patient is likely to seek care from a surgeon with an ethnically identifiable name. The two most common cosmetic surgery demographic groups, Caucasians and Latinxs, were also the only two ethnic groups to display in-group favoritism. Public education should be directed toward surgeon qualifications and experience in an effort to reduce implicit bias on patient decision-making.
Development and validation of a sensitive MEDLINE search strategy to identify literature relevant to limb prostheses
Authors: Nylander Elisabeth , Ramstrand Nerrolyn , Hjort Margareta , Rusaw David F.
Published: May 2021

Background:

Researchers and clinicians may find it challenging to identify relevant articles about limb prostheses in online databases. Searches may be improved by using standardized strategies, also known as filters or hedges.

Objectives:

To develop and validate a highly sensitive MEDLINE (EBSCOHost) search strategy for limb prostheses.

Study Design:

Search strategy development/validation.

Methods:

A gold standard (GS) list of peer-reviewed articles on the topic of limb prostheses was created using a relative recall method. This involved identifying and including relevant systematic reviews/meta-analyses and then adding articles that were included in the analysis section of these reviews. Possible terms for the search strategy were identified through brainstorming and exploration of medical subject headings in MEDLINE (MeSH) and standards from the International Organization for Standardization (ISO). Concepts were grouped using relevant Boolean operators (e.g. AND and OR) and database record search fields (i.e. MeSH terms, title, and abstract). Part of the GS was used to refine the search strategy and reduce the number of records retrieved in total. The remaining GS set was used to validate and calculate sensitivity of the search strategy. Performance of the search strategy was compared against searches using only relevant MeSH terms.

Results:

After screening, the final GS totaled 853 records. The developed search strategy was highly sensitive (99.80%) and performed with higher relative recall than searches with relevant MeSH terms.

Conclusions:

This study provides a highly sensitive search strategy that can be used by clinicians and researchers when searching for relevant literature on limb prostheses in MEDLINE (EBSCOHost).
Prehospital tourniquet use: An evaluation of community application and outcome
Authors: Barnard Leslie M. , Guan Sally , Zarmer Lori , Mills Brianna , Blackwood Jennifer , Bulger Eileen , Yang Betty Y. , Johnston Peter , Vavilala Monica S. , Sayre Michael R. , Rea Thomas D. , Murphy David L.
Published: May 2021

BACKGROUND

There is substantial investment in layperson and first responder training involving tourniquet use for hemorrhage control. Little is known however about prehospital tourniquet application, field conversion, or outcomes in the civilian setting. We describe the experience of a metropolitan region with prehospital tourniquet application.

METHODS

We conducted a retrospective cohort study characterizing prehospital tourniquet use treated by emergency medical services (EMS) in King County, Washington, from January 2018 to June 2019. Emergency medical services and hospital records were abstracted for demographics, injury mechanism, tourniquet details, clinical care, and outcomes. We evaluated the incidence of tourniquet application, who applied the device (EMS, law enforcement, or layperson), and subsequent course.

RESULTS

A total of 168 patients received tourniquet application, an incidence of 5.1 per 100,000 person-years and 3.48 per 1,000 EMS responses for trauma. Tourniquets were applied for penetrating trauma (64%), blunt trauma (30%), and bleeding ateriovenous fistulas (7%). A subset was critically ill: 13% had systolic blood pressures of <90 mm Hg, 8% had Glasgow Coma Scale score of <13, and 3% had cardiac arrest. Among initial applications, 48% were placed by law enforcement, 33% by laypersons, and 18% by EMS. Among tourniquets applied by layperson or law enforcement (n = 137), EMS relied solely on the original tourniquet in 45% (n = 61), placed a second tourniquet in 20% (n = 28), and removed the tourniquet without replacement in 35% (n = 48). Overall, 24% required massive transfusion, 59% underwent urgent surgery, and 21% required vascular surgery. Mortality was 3% (n = 4). At hospital discharge, the tourniquet limb was fully functional in 81%, partially functional in 10%, and nonfunctional in 9%; decreased function was not attributed to tourniquet application.

CONCLUSION

The high rate of application, need for urgent hospital intervention in a subset, and low incidence of apparent complication suggest that efforts to increase access and early tourniquet use can provide public health benefit.

LEVEL OF EVIDENCE

Therapeutic, level IV.
Extrathoracic multiple trauma dysregulates neutrophil function and exacerbates pneumonia-induced lung injury
Authors: Leonard Jennifer M. , Zhang Christina X. , Lu Liang , Hoofnagle Mark H. , Fuchs Anja , Clemens Regina A. , Ghosh Sarbani , Hughes Shin-Wen , Bochicchio Grant V. , Hotchkiss Richard , Turnbull Isaiah R.
Published: May 2021

BACKGROUND

Forty percent of critically ill trauma patients will develop an infectious complication. Pneumonia is the most common cause of death of trauma patients surviving their initial insult. We previously demonstrated that polytrauma (PT), defined as two or more severe injuries in at least two areas of the body, induces emergency hematopoiesis characterized by accelerated myelopoiesis in the bone marrow and increased myeloid cell frequency in the peripheral tissues. We hypothesized that PT alone induces priming of neutrophils, resulting in hyperactivation upon secondary exposure to bacteria and causing acute lung injury and increased susceptibility to secondary exposure to Pseudomonas aeruginosa pneumonia.

METHODS

C57BL/6 mice were subjected to PT consisting of a lower extremity pseudofracture, liver crush injury, and 15% blood-volume hemorrhage. Pneumonia was induced by intratracheal injection of 5 × 106 CFU live P. aeruginosa or 1 × 107 of heat-killed P. aeruginosa (HKPA). For reactive oxygen species (ROS), studies polymorphonuclear neutrophils (PMNs) were isolated by immunomagnetic bead negative selection and stimulated ex-vivo with HKPA. Reactive oxygen species production was measured by immunofluorescence. For histology, lung sections were stained by hematoxylin-eosin and analyzed by a blinded grader.

RESULTS

Polytrauma induced persistent changes in immune function at baseline and to secondary infection. Pneumonia after injury resulted in increased mortality (60% vs. 5% p < 0.01). Blood neutrophils from PT mice had higher resting (unstimulated) ROS production than in naive animals (p < 0.02) demonstrating priming of the neutrophils following PT. After intratracheal HKPA injection, bronchoalveolar lavage PMNs from injured mice had higher ROS production compared with naive mice (p < 0.01), demonstrating an overexuberant immunopathologic response of neutrophils following PT.

CONCLUSION

Polytrauma primes neutrophils and causes immunopathologic PMN ROS production, increased lung injury and susceptibility to secondary bacterial pneumonia. These results suggest that trauma-induced immune dysfunction can cause immunopathologic response to secondary infection and suggests neutrophil-mediated pulmonary damage as a therapeutic target for posttrauma pneumonia.
The impact of delayed management of fall-related hip fracture management on health outcomes for African American older adults
Authors: Jarman Molly P. , Sokas Claire , Dalton Michael K. , Castillo-Angeles Manuel , Uribe-Leitz Tarsicio , Heng Marilyn , von Keudell Arvind , Cooper Zara , Salim Ali
Published: May 2021

BACKGROUND

Black hip fracture patients experience worse health outcomes than otherwise similar White patients, but causes of these disparities are not known. We sought to determine if delays in hip fracture surgery and/or hospital structures contribute to racial disparities in hip fracture outcomes.

METHODS

Using 2006 to 2016 Trauma Quality Program Public Use Files, we identified hip fracture patients with primary mechanisms of fall from standing and determined surgical treatment category (no surgery, surgery within 24 hours after arrival, surgery 24–48 hours after arrival, surgery more than 48 hours after arrival) as well as hospital structure characteristics (trauma center designation, teaching status, profit status, bed size). We used generalized structural equation models to conduct path analyses and determine if hip fracture treatment and hospital characteristics mediated the relationship between race (non-Hispanic Black/non-Hispanic White) and outcomes (complications, length of stay, disposition).

RESULTS

Non-Hispanic Black patients were more likely than non-Hispanic White patients to receive treatment at an academic medical center (49.1% vs. 28.0%), at a hospital with >600 inpatient beds (39.5% vs. 25.3%), and at a level I or II trauma center (86.8% vs. 77.7%); were more likely to go without hip fracture repair surgery (22.8% vs. 21.4%); and were more likely to have delayed surgery >48 hours after hospital arrival (15.5% vs. 10.6%). Path analysis suggests hip fracture treatment group and hospital characteristics mediate the relationship with complications, length of stay, and disposition.

CONCLUSION

Non-Hispanic Black patients with fall-related hip fracture are more likely to experience delays in care, complications, and longer inpatient stays. Hospital characteristics contribute to increased risk of complications and longer length of stay, both as independent determinants of outcomes and as determinants of delays in hip fracture surgery.

LEVEL OF EVIDENCE

Prognostic and epidemiologic, level III.
A systematic review of neuropsychological and psychiatric sequalae of COVID-19: implications for treatment
Authors: Vanderlind William Michael , Rabinovitz Beth B. , Miao Iris Yi , Oberlin Lauren E. , Bueno-Castellano Christina , Fridman Chaya , Jaywant Abhishek , Kanellopoulos Dora
Published: May 2021

Purpose of review

COVID-19 impacts multiple organ systems and is associated with high rates of morbidity and mortality. Pathogenesis of viral infection, co-morbidities, medical treatments, and psychosocial factors may contribute to COVID-19 related neuropsychological and psychiatric sequelae. This systematic review aims to synthesize available literature on psychiatric and cognitive characteristics of community-dwelling survivors of COVID-19 infection.

Recent findings

Thirty-three studies met inclusion/exclusion criteria for review. Emerging findings link COVID-19 to cognitive deficits, particularly attention, executive function, and memory. Psychiatric symptoms occur at high rates in COVID-19 survivors, including anxiety, depression, fatigue, sleep disruption, and to a lesser extent posttraumatic stress. Symptoms appear to endure, and severity of acute illness is not directly predictive of severity of cognitive or mental health issues. The course of cognitive and psychiatric sequelae is limited by lack of longitudinal data at this time. Although heterogeneity of study design and sociocultural differences limit definitive conclusions, emerging risk factors for psychiatric symptoms include female sex, perceived stigma related to COVID-19, infection of a family member, social isolation, and prior psychiatry history.

The extant literature elucidates treatment targets for cognitive and psychosocial interventions. Research using longitudinal, prospective study designs is needed to characterize cognitive and psychiatric functioning of COVID-19 survivors over the course of illness and across illness severity. Emphasis on delineating the unique contributions of premorbid functioning, viral infection, co-morbidities, treatments, and psychosocial factors to cognitive and psychiatric sequelae of COVID-19 is warranted.
Effects of the COVID-19 pandemic and lockdown on alcohol use disorders and complications
Authors: Murthy Pratima , Narasimha Venkata Lakshmi
Published: May 2021

Purpose of review

To understand the effect of COVID-19 pandemic and lockdown on persons with alcohol use disorders.

Recent findings

From a total of 455 titles on COVID-19 and alcohol, 227 abstracts were screened, and 95 articles were reviewed (on November 25th, 2020). The immediate effect was an increase in alcohol related emergencies including alcohol withdrawal, related suicides, and methanol toxicity. Although there are mixed findings with respect to changes in the quantity of drinking, there are reports of binge/heavy drinking during the lockdown as well as relapse postlockdown. Psychological, social, biological, economic and policy-related factors appear to influence the changes in drinking. Although preliminary data suggest no change in alcohol use among persons with comorbid mental illness, findings in this population are presently limited. Among patients with alcohol related liver disease, outcomes appear worse and caution is warranted with the use of medications. Alcohol also appears to increases the risk of COVID-19 infection and complicates its course.

Although some nations banned alcohol sales completely during lockdown, others declared it as an essential commodity, resulting in different problems across countries. Alcohol use has added to the burden of the problem particularly among vulnerable groups like the adolescents, elderly, patients with cancer, as well as health professionals. Services for patients with alcohol use disorders have been affected.

The COVID-19 pandemic has had considerable impact on alcohol use, with an increase in alcohol related emergencies, changes in alcohol use patterns, increased risk of contracting COVID-19, effect on alcohol policies and sales, and an effect on vulnerable groups. It is essential to understand and respond to the current situation, intervene early, and prevent further repercussions of the pandemic.

Video abstract link: https://drive.google.com/file/d/1IJWtIs6e554PryKWhdma4VB--mjSZq1C/view?usp=sharing.
SARS-CoV-2 infection of BNT162b2(mRNA)-vaccinated individuals is not restricted to variants of concern or high-risk exposure environments
Authors: Magalis Brittany Rife , Mavian Carla , Tagliamonte Massimiliano , Rich Shannan N. , Cash Melanie , Riva Alberto , Loeb Julia C. , Norris Michael , Amador David Moraga , Zhang Yanping , Shapiro Jerne , Starostik Petr , Marini Simone , Myers Paul , Ostrov David , Lednicky John A. , Glenn Morris J. John , Lauzardo Michael , Salemi Marco
Published: May 2021

The emergence of SARS-CoV-2 variants of concern (VOC) has raised questions regarding the extent of protection of currently implemented vaccines. Ten “vaccination breakthrough” infections were identified in Alachua County, Florida, among individuals fully vaccinated with the BNT162b2 mRNA vaccine as a result of social or household transmission. Eight individuals presented mild symptoms in the absence of infection with other common respiratory viruses, confirmed using viral genetic sequencing. SARS-CoV-2 genomes were successfully generated for five of the vaccine breakthroughs and 399 individuals in the surrounding area and were included for reference-based phylogenetic investigation. These five individuals were characterized by infection with both VOCs and low-frequency variants present within the surrounding population. Mutations, in the Spike glycoprotein, were consistent with their respective circulating lineages. However, we detected an additional mutation in Spike’s N-terminal domain of a B.1.1.7 strain, present at low-frequency (∼1%) in the unvaccinated population, potentially affecting protein’s stability and functionality. The findings highlight the critical need for continued testing and monitoring of infection among individuals regardless of vaccination status.
Dysbiosis and structural disruption of the respiratory microbiota in COVID-19 patients with severe and fatal outcomes
Authors: Hernández-Terán Alejandra , Mejía-Nepomuceno Fidencio , Herrera María Teresa , Barreto Omar , García Emma , Castillejos Manuel , Boukadida Celia , Matias-Florentino Margarita , Rincón-Rubio Alma , Avila-Rios Santiago , Mújica-Sánchez Mario , Serna-Muñoz Ricardo , Becerril-Vargas Eduardo , Guadarrama-Pérez Cristobal , Ahumada-Topete Víctor Hugo , Rodríguez Sebastián , Martínez-Orozco José Arturo , Salas-Hernández Jorge , Pérez-Padilla Rogelio , Vázquez-Pérez Joel Armando
Published: May 2021

COVID-19 outbreak has caused over 3 million deaths worldwide. Understanding disease pathology and the factors that drive severe and fatal clinical outcomes is of special relevance. Studying the role of the respiratory microbiota in COVID-19 is particularly important since it’s known that the respiratory microbiota interacts with the host immune system, contributing to clinical outcomes in chronic and acute respiratory diseases. Here, we characterized the microbiota in the respiratory tract of patients with mild, severe, or fatal COVID-19, and compared with healthy controls and patients with non-COVID-19-pneumonia. We comparatively studied the microbial composition, diversity, and microbiota structure across study groups and correlated the results with clinical data. We found differences in diversity and abundance of bacteria between groups, higher levels of dysbiosis in the respiratory microbiota of COVID-19 patients (regardless of severity level), differences in diversity structure among mild, severe, and fatal COVID-19, and the presence of specific bacteria that correlated with clinical variables associated with increased mortality risk. Our data suggest that host-related and environmental factors could be affecting the respiratory microbiota before SARS-CoV-2 infection, potentially compromising the immunological response of the host against disease and promoting secondary bacterial infections. For instance, the high levels of dysbiosis coupled with low microbial structural complexity in the respiratory microbiota of COVID-19 patients, possibly resulted from antibiotic uptake and comorbidities, could have consequences for the host and microbial community level. Altogether, our findings identify the respiratory microbiota as a potential factor associated with COVID-19 severity.
Modelling the relative benefits of using the measles vaccine outside cold chain for outbreak response
Authors: Azam James M. , Saitta Barbara , Bonner Kimberly , Ferrari Matthew J. , Pulliam Juliet R.C.
Published: May 2021

Introduction

Rapid outbreak response vaccination is a strategy for measles control and elimination. Measles vaccines must be stored and transported within a specified temperature range, but this can present significant challenges when targeting remote populations. Measles vaccine licensure for delivery outside cold chain (OCC) could provide more vaccine transport/storage space without ice packs, and a solution to shorten response times. However, due to vaccine safety and wastage considerations, the OCC strategy will require other operational changes, potentially including the use of 1-dose (monodose) instead of 10-dose vials, requiring larger transport/storage equipment currently achieved with 10-dose vials. These trade-offs require quantitative comparisons of vaccine delivery options to evaluate their relative benefits.

Methods

We developed a modelling framework combining elements of the vaccine supply chain - cold chain, vial, team, and transport equipment types - with a measles transmission dynamics model to compare vaccine delivery options. We compared 10 strategies resulting from combinations of the vaccine supply elements and grouped into three main classes: OCC, partial cold chain (PCC), and full cold chain (FCC). For each strategy, we explored a campaign with 20 teams sequentially targeting 5 locations with 100,000 individuals each. We characterised the time needed to freeze ice packs and complete the campaign (campaign duration), vaccination coverage, and cases averted, assuming a fixed pre-deployment delay before campaign commencement. We performed sensitivity analyses of the pre-deployment delay, population sizes, and two team allocation schemes.

Results

The OCC, PCC, and FCC strategies achieve campaign durations of 50, 51, and 52 days, respectively. Nine of the ten strategies can achieve a vaccination coverage of 80%, and OCC averts the most cases.

Discussion

The OCC strategy, therefore, presents improved operational and epidemiological outcomes relative to current practice and the other options considered.
Implementation of a TMS-fMRI system: A primer
Authors: Alamian Golnoush , Ge Ruiyang , Humaira Afifa , Gregory Elizabeth , MacMillan Erin L. , Barlow Laura , Vila-Rodriguez Fidel
Published: May 2021

Transcranial magnetic stimulation (TMS) is a non-invasive and non-pharmacological intervention, approved for the treatment of individuals diagnosed with treatment-resistant depression. This well-tolerated approach uses magnetic pulses to stimulate specific brain regions and induce changes in brain networks at multiple levels of human functioning. Combining TMS with other neuroimaging techniques, such as functional magnetic resonance imaging (fMRI), offers new insights into brain functioning, and allows to map out the causal alterations brought on by TMS interventions on neural network connectivity and behaviour. However, the implemention of concurrent TMS-fMRI brings on a number of technical challenges that must be overcome to ensure good quality of functional images. The goal of this study was thus to investigate the impact of TMS pulses in an MR-environment on the quality of BRAINO phantom images, in terms of the signal of the images, the temporal fluctuation noise, the spatial noise and the signal to fluctuation noise ratio, at the University of British Columbia (UBC) Neuroimaging facility. The results of our analyses replicated those of previous sites, and showed that the present set-up for concurrent TMS-fMRI ensures minimal noise artefact on functional images obtained through this multimodal approach. This step was a key stepping stone for future clinical trials at UBC.
Mutational signatures are markers of drug sensitivity of cancer cells
Authors: Levatić Jurica , Salvadores Marina , Fuster-Tormo Francisco , Supek Fran
Published: May 2021

Genomic analyses have revealed mutational signatures that are associated with DNA maintenance gone awry, a common occurrence in tumors. Because cancer therapeutics often target synthesis of DNA building blocks, DNA replication or DNA repair, we hypothesized that mutational signatures would make useful markers of drug sensitivity. We rigorously tested this hypothesis by a global analysis of various drug screening and genetic screening data sets, derived from cancer cell line panels. We introduce a novel computational method that detects mutational signatures in cell lines by stringently adjusting for the confounding germline mutational processes, which are difficult to remove when healthy samples from the same individuals are not available. This revealed many associations between diverse mutational signatures and drug activity in cancer cell lines, which are comparably or more numerous than associations with classical genetic features such as cancer driver mutations or copy number alterations. Validation across independent drug screening data and across genetic screens involving drug target genes revealed hundreds of robustly supported associations, which are provided as a resource for drug repurposing guided by mutational signature markers. We suggest that cancer cells bearing genomic signatures of deficiencies in certain DNA repair pathways may be vulnerable to particular types of therapeutics, such as epigenetic drugs.