bluuebunny/crossref_metadata_2025 huggingface dataset:
Nonopioid Versus Opioid Analgesia After Hospital Discharge Following Cesarean Delivery: A Randomized Equivalence Trial
Authors: Dinis J. , Soto E. , Pedroza C. , Chauhan S.P. , Blackwell S. , Sibai B.
Published: February 2021

(Am J Obstet Gynecol. 2020;222:488.e1–488.e8)

Opioid misuse has risen in the United States in recent years. Women may be overprescribed opioids following cesarean delivery, which may lead to opioid misuse by patients. There is no clear recommendation from the American College of Obstetricians and Gynecologists for opioids prescribed upon discharge after cesarean delivery. This study compared analgesia following cesarean delivery with opioids, ibuprofen and acetaminophen with treatment with only ibuprofen and acetaminophen.
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Vertical Transmission in Neonates Born to Mothers With Coronavirus Disease 2019 (COVID-19) Pneumonia
Authors: Hu X. , Gao J. , Luo X. , Feng L. , Liu W. , Chen J. , Benachi A. , Luca D. , Chen L.
Published: February 2021

(Obstet Gynecol. 2020;136:1–3)

Studies on the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have mainly focused on nonpregnant patients. There is a need for studies examining vertical transmission and perinatal infection of SARS-CoV-2. This report focuses on neonatal outcomes from 7 pregnant patients with coronavirus disease 2019 (COVID-19), between the dates of January 20, 2020, and February 20, 2020.
Deciphering Liver Imaging After Interventional Oncology Treatments for Hepatocellular Carcinoma
Authors: Amin Parag , Ness Joseph , Brown McKenzie , Sullivan Ian
Published: February 2021

Cirrhotic patients undergo frequent imaging surveillance for hepatocellular carcinoma (HCC) due to the known oncogenic potential of the chronically injured liver, and patients who undergo treatment for HCC are followed up closely with imaging to evaluate for tumor response, treatment complications, and potential recurrence/residual tumor that may indicate further therapy. As such, radiologists play a key role in ensuring the timely and appropriate treatment of patients with HCC. However, the underlying heterogeneity of the cirrhotic liver on imaging, along with the spectrum of findings that can occur after various locoregional therapies (LRTs), can complicate posttreatment image interpretation. This article reviews expected MRI and CT findings after LRT in this patient population.
The Use of Vitamins and Supplements for Lung Cancer Prevention
Authors: Wissen Kim van , Blanchard Denise
Published: February 2021

Editor's note: The mission of Cochrane Nursing is to provide an international evidence base for nurses involved in delivering, leading, or researching nursing care. Cochrane Corner provides summaries of recent systematic reviews from the Cochrane Library. For more information, see https://nursing.cochrane.org.
Polypharmacy Negatively Affects Oral Health in Older Adults
Authors: Rosenberg Karen
Published: February 2021

According to this study:

Polypharmacy is independently associated with poor oral health in older adults.
Right Under Our Noses: Nursing Homes and COVID-19
Authors: Daunt Debbie J.
Published: February 2021

A medical mission volunteer bears witness to nightmarish inequalities.
Hemodynamic monitoring with the CardioMEMS HF System
Authors: Falls Candice
Published: February 2021

Heart failure readmission rates continue to rise and cause economic burden in the US. Advancements in hemodynamic monitoring offer the ability to monitor intracardiac pressures at home and provide data that are used to optimize outpatient management of heart failure, resulting in reduced hospitalization and mortality associated with heart failure.
Diversifying the Research Workforce as a Programmatic Priority for a Career Development Award Program at Duke University
Authors: Johnson Kimberly S. , Gbadegesin Rasheed , McMillan Amanda E. , Molner Stephanie , Boulware L. Ebony , Svetkey Laura P.
Published: February 2021

The National Institutes of Health (NIH) has prioritized efforts to increase diversity in the biomedical research workforce. NIH-funded institutional career development awards may serve as one mechanism to facilitate these efforts. In 2013, the Duke University KL2 program, an internal career development program funded by the National Center for Advancing Translational Sciences, set a goal to increase the number of investigators from underrepresented racial and ethnic groups (UREGs) to ≥ 50% of KL2 awardees. From 2013 to 2019, 133 KL2 applications were received, 38% from UREG investigators. Of the 21 scholars selected, 10 (47.6%) were UREG investigators; all were Black/African American. This represents a threefold increase in the proportion of UREG applications and a sixfold increase in the proportion of UREG KL2 scholars compared with Duke’s previous KL2 cycles (2003–2012), during which only 13% of applicants and 8.3% of funded scholars were UREGs. Of the 12 KL2 scholars (7 UREG) who completed the program, 5 have received NIH funding as principal investigators of an external K award or R01, and 4 of them are UREG investigators; this constitutes a post-KL2 NIH funding success rate of 57% (4/7) for UREG scholars. Achieving this programmatic priority was facilitated by institutional support, clear communication of goals to increase the proportion of UREG KL2 awardees, and intentional strategies to identify and support applicants. Strategies included targeted outreach to UREG investigators, partnerships with other institutional entities, structured assistance for investigators with preparing their applications, and a KL2 program structure addressing common barriers to success for UREG investigators, such as lack of consistent mentorship, protected research time, and peer support. The authors’ experience suggests that KL2 and other internal career development programs may represent a scalable, national strategy to increase diversity in the biomedical research workforce.
Impact of the COVID-19 Pandemic on the Clinical Learning Environment: Addressing Identified Gaps and Seizing Opportunities
Authors: Triemstra Justin D. , Haas Mary R.C. , Bhavsar-Burke Indira , Gottlieb-Smith Rachel , Wolff Margaret , Shelgikar Anita V. , Samala Renato V. , Ruff Allison L. , Kuo Kevin , Tam Marty , Gupta Amit , Stojan Jennifer , Gruppen Larry , Ellinas Herodotos
Published: February 2021

The clinical learning environment (CLE) encompasses the learner’s personal characteristics and experiences, social relationships, organizational culture, and the institution’s physical and virtual infrastructure. During the COVID-19 pandemic, all 4 of these parts of the CLE have undergone a massive and rapid disruption. Personal and social communications have been limited to virtual interactions or shifted to unfamiliar clinical spaces because of redeployment. Rapid changes to the organizational culture required prompt adaptations from learners and educators in their complex organizational systems yet caused increased confusion and anxiety among them. A traditional reliance on a physical infrastructure for classical educational practices in the CLE was challenged when all institutions had to undergo a major transition to a virtual learning environment.

However, disruptions spurred exciting innovations in the CLE. An entire cohort of physicians and learners underwent swift adjustments in their personal and professional development and identity as they rose to meet the clinical and educational challenges they faced due to COVID-19. Social networks and collaborations were expanded beyond traditional institutional walls and previously held international boundaries within multiple specialties. Specific aspects of the organizational and educational culture, including epidemiology, public health, and medical ethics, were brought to the forefront in health professions education, while the physical learning environment underwent a rapid transition to a virtual learning space. As health professions education continues in the era of COVID-19 and into a new era, educators must take advantage of these dynamic systems to identify additional gaps and implement meaningful change. In this article, health professions educators and learners from multiple institutions and specialties discuss the gaps and weaknesses exposed, opportunities revealed, and strategies developed for optimizing the CLE in the post–COVID-19 world.
Association of Pregnancy Intentions With Substance Use During Early Pregnancy
Authors: Young-Wolff Kelly C. , Slama Natalie , Sarovar Varada , Conway Amy , Tucker Lue-Yen , Goler Nancy , Terplan Mishka , Ansley Deborah , Adams Sara R. , Armstrong Mary Anne
Published: February 2021

Objectives:

The goal of this study was to evaluate the association between pregnancy intentions and substance use in early pregnancy among pregnant women receiving prenatal care in a large, integrated healthcare system.

Methods:

The sample comprised 29,787 Kaiser Permanente Northern California pregnant women (12.1% aged <25, 36.4% non-Hispanic White) screened for prenatal substance use in 2018 via a self-reported questionnaire and urine toxicology test given as part of standard prenatal care (at ∼8 weeks gestation). Multivariable logistic regression models tested for associations of pregnancy intentions with prenatal substance use (any use and specific substances) by self-report and/or a positive urine toxicology test.

Results:

Adjusting for covariates, women with an unintended pregnancy (23.9% of the sample) had higher odds of any prenatal substance use than women with an intended pregnancy (28.8% vs 16.1%; adjusted odds ratio [aOR] = 1.80, 95% confidence interval [CI]:1.67–1.93). Having an unintended pregnancy was also associated with higher odds of using alcohol (14.4% vs 10.4%; aOR = 1.73, 95%CI:1.59–1.89), cannabis (15.6% vs 5.6%; aOR = 1.91, 95%CI:1.73–2.11), nicotine (3.8% vs 1.3%; aOR = 2.33, 95%CI:1.92–2.82), pain medication (2.3% vs 1.2%; aOR = 1.64, 95%CI:1.32–2.03), and stimulants (0.8% vs 0.3%; aOR = 1.85, 95%CI:1.23–2.79) early in pregnancy.

Discussion:

Having an unintended pregnancy was associated with higher odds of substance use during early pregnancy. Connecting women of reproductive age with health education about pregnancy prevention and recognition of early signs of pregnancy, effective contraception, and early screening and interventions for prenatal substance use may help to reduce prenatal substance use and its associated consequences.
Normalization of Deviance
Authors: Wright M. Imelda , Polivka Barbara , Odom-Forren Jan , Christian Becky J.
Published: February 2021

Normalization of deviance is a phenomenon demonstrated by the gradual reduction of safety standards to a new normal after a period of absence from negative outcomes, which suggests that the absence of negative outcomes tends to reinforce the behaviors associated with cutting corners, bypassing safety checklists, and ignoring alarms. While the concept was first identified within the National Aeronautics and Space Administration, it has a strong, dangerous presence within health care, holding specific peril within high-risk environments such as the operating room. The aims of this article are to (1) analyze the concept of normalization of deviance and (2) identify the role of normalization of deviance with respect to the behavior of nurses in high-risk health care environments to prevent adverse patient outcomes. The steps outlined by Walker and Avant are applied to guide the concept analysis.
Symptom Monitoring in Children With Life-Threatening Illness
Authors: Vaughn Jacqueline , Shah Nirmish , Docherty Sharron L. , Yang Qing , Shaw Ryan J.
Published: February 2021

Children with life-threatening illness (C-LTI) experience considerable symptom distress. Mobile technology may offer opportunities to better obtain symptom data that will lead to better symptom management. A mixed-methods study was conducted to explore the feasibility of monitoring and visualizing symptoms using 2 mobile health devices in C-LTI. Participants engaged with the Apple Watch 56% and recorded in the study app 63% of their study days. Our findings showed feasibility of using mobile technology for monitoring symptoms and further explored opportunities to visualize these data showing symptom occurrences, patterns, and trajectories in C-LTI.
Nursing With the People
Authors: Dillard-Wright Jessica , Shields-Haas Vanessa
Published: February 2021

We wish to advance a theory of nursing that intentionally engages in questions of politics and economics, centering equity and justice as a foundation for the provision of nursing care. As health care costs rise and health disparities widen, nurses have a clear imperative to develop alternative health care delivery models unmoored from the conventional employment and profit-driven structures that now disappoint us. This mandate arises from our disciplinary focus that emphasizes social justice as a social and moral good linked to the human services nurses provide. This kind of sociopolitical engagement is not auxiliary to nursing but rather central to our ethos. A health care environment that prioritizes profit over the well-being of people is an anathema to our disciplinary focus which, we believe, should center communities and people. The health care system that has forged nursing in the United States, transforms nursing into a commodity. This reinscribes inequality for those who are unable to access care, contributes to environmental harm through profligate hospital pollution and waste, and exploits nursing staff as workers. Nurses have a history of both upholding oppressive systems that disenfranchise segments of the public, usually poor, often People of Color, and engaging in innovative alternatives to the status quo. We wish to foster revolutionary alternative care delivery models that free us from the neoliberal confines of for-profit health care. Ultimately, we argue, nursing as a discipline and a science cannot neglect our role as whistleblowers and change agents. Nor can we presuppose that our dysfunctional and harmful health care structure in the United States is a foregone conclusion. Health care is constructed, which means it can be reconstructed. If we wish to realize our emancipatory potential as nurses, critically examining our role in upholding oppressive structures is a critical step toward a more robust future of nursing.
COVID-19 and rheumatoid arthritis
Authors: D'Silva Kristin M. , Wallace Zachary S.
Published: February 2021

Purpose of review

The coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality worldwide. Patients with rheumatoid arthritis (RA) face unique challenges during the pandemic, including concerns regarding infection risk, drug shortages, limited access to care, social isolation, and mental health. This review will examine the multifaceted impacts of the COVID-19 pandemic on patients living with RA.

Recent findings

In patients with RA, risk factors for severe COVID-19 outcomes include older age and comorbidities, similar to those in the general population. Glucocorticoids, but not other classes of disease-modifying antirheumatic drugs (DMARDs), appear to be associated with a higher risk of severe COVID-19 outcomes. RA patients have been affected by changes in access to care, telemedicine, drug shortages, anxiety, and social isolation, which may contribute to disease flares.

Glucocorticoids, but not other DMARDs, are associated with a higher risk of severe COVID-19 outcomes in RA patients. Further studies are needed to explore the impact of specific DMARDs on COVID-19 outcomes, understand the broader implications of the COVID-19 pandemic on RA disease activity, and optimize the use of telemedicine in RA management.
Preliminary evaluation of sagittal and transverse plane cross-sectional variations of the trunk during quiet and deep breathing by optical reflective motion analysis in patients with scoliosis
Authors: Xun FuXing , Canavese Federico , Xu HongWen , Xu FuLong , Li YiQiang , Liu YanHan , Kaelin André , Dimeglio Alain
Published: February 2021

Trunk movements during quiet and deep breathing in untreated and in operated patients with scoliosis are not well defined. To evaluate sagittal and transverse plane cross-sectional variations of the trunk during quiet and deep breathing by optical reflective motion analysis (ORMA) in children with scoliosis. Twenty-one patients were divided into three groups: normal subjects (A; n = 6), subjects with untreated scoliosis >50° (B; n = 7) and operated patients (C; n = 8). Standing and sitting height, T1–T12 and L1–L5 length, arm span, chest perimeter, weight and BMI were recorded. Trunk movements of all patients, during quiet and deep breathing, were measured with a 10-camera 3D ORMA system (82 markers) with the subjects in a standard standing position. Groups were comparable with respect to age, sex, height, arm span and weight (P > 0.05). Significant differences were found in Cobb angle, chest perimeter and BMI (P < 0.05). Trunk sagittal and transverse plane movements during quiet and deep breathing decreased significantly in group B and group C when compared to group A (P < 0.05). Surgery does not completely eliminate sagittal and transverse plane kinematics, although the spine is rendered more rigid. This preliminary study involving a relatively limited number of patients outlines ORMA is a useful tool for analyzing sagittal and transverse plane motion abnormalities of the trunk. Trunk kinematics was altered during breathing in unoperated patients with scoliosis >50°. Operated subjects had sagittal plane trunk kinematics closer to normal subjects, although changes were less pronounced at the level of the convex side.
Technique, Time Demand, Radiation Exposure, and Outcomes of Skin-anchored Intraoperative 3D Navigation in Minimally Invasive Posterior Cervical Laminoforaminotomy
Authors: Vaishnav Avani S. , Louie Philip , Gang Catherine H. , Iyer Sravisht , McAnany Steven , Albert Todd , Qureshi Sheeraz A.
Published: February 2021

Study Design:

This was a retrospective review.

Objective:

The objective of this study was to describe our technique and evaluate the time demand, radiation exposure, and outcomes of minimally invasive posterior cervical laminoforaminotomy (MI-PCLF) using skin-anchored intraoperative navigation (ION).

Background:

Although bone-anchored trackers are most commonly used for ION, a novel technique utilizing noninvasive skin-anchored trackers has recently been described for lumbar surgery and has shown favorable results. There are currently no reports on the use of this technology for cervical surgery.

Methods:

Time demand, radiation exposure, and perioperative outcomes of MI-PCLF using skin-anchored ION were evaluated.

Results:

Twenty-one patients with 36 operative levels were included. Time for ION setup and operative time were a median of 34 and 62 minutes, respectively. Median radiation to the patient was 2.5 mGy from 10 seconds of fluoroscopy time. Radiation exposure to operating room personnel was negligible because they are behind a protective lead shield during ION image acquisition. There were no intraoperative complications or wrong-level surgeries. One patient required a repeat ION spin, and in 2 patients, ION was abandoned and standard fluoroscopy was used.

Conclusions:

Skin-anchored ION for MI-PCLF is feasible, safe, and accurate. It results in short operative times, minimal complications, low radiation to the patient, and negligible radiation to operating room personnel.
Osteotomy Guides Created Through 3D Tomographic Model for Talus Osteotomies in Massive Allograft Technology Presentation for Massive Fresh Talus Allograft Transplant
Authors: Yañez Arauz Juan M. , Raimondi Nicolas , Lauritto Diego , Terrarossa Bruno , Pedemonte Facundo A.
Published: February 2021

The use of 3-dimensional (D) printing in the medical segment has been increasing. In cases in which osteotomies are necessary, the use of tomographic reconstruction is useful for their planning. And if we were to add the design of osteotomy guides and 3D printing, we can ensure more precise cuts. This study aims to present 3D printing for the creation of more precise osteotomy guides, in the treatment of massive talus osteochondral lesions; and proving its use in the transplant of fresh osteochondral allografts. We present the planning and the surgery performed on a patient, using this 3D printing method with specific osteotomy guides designed for the massive osteochondral defect in zones 1, 4, and 5 (Raikin) with 2570 mm3 volume and symptomatic. At 3 months and 1 year postoperation it was evaluated with a computerized axial tomography scan, objectifying a good articular reduction and congruence of the allograft without its collapse. Planning with 3D digital design, as it is the design and production of specific surgical tools for this surgery, improved surgical time, achieving the correct fit of the allograft, and allowed for a full coverage of the osteochondral defect.

Level of Evidence: Diagnostic Level V according to the criteria of the Oxford Centre for Evidence-Based Medicine (CEBM). See Instructions for Authors for a complete description of levels of evidence.
Functional and Cosmetic Reconstruction of Floating Thumb: A Thumb-preserving Technique
Authors: Takagi Takehiko , Seki Atsuhito , Takayama Shinichiro
Published: February 2021

For the severely hypoplastic thumb, including floating thumb, it is difficult to acquire function while preserving the thumb. Pollicization using the index finger after removing the hypoplastic thumb is usually indicated for such cases. However, most parents of children undergoing surgery for deformed hands desire retaining the digit number, 1 thumb and 4 fingers. A floating thumb has a neurovascular band in its pedicle, and we can identify and divide the band with precision for preservation, although it seems impossible to retain it. For acquiring function while retaining the thumb, we developed carpometacarpal arthroplasty of the floating thumb. For the first stage, the fourth metatarsal head was transferred to the first metacarpal base, followed by third metatarsal half-slip transfer to the space of the excised fourth metatarsal head with the first web plasty using a dorsal sliding flap. Second stage surgery was performed ∼6 months after the first stage. For creating stable opponensplasty, the abductor digiti minimi tendon was anchored to the ulnar side of the metacarpophalangeal joint; for extension, extensor indicis proprius transfer to the hypoplastic extensor pollicis longus tendon was performed; for flexion, ring finger flexor digitorum superficialis transfer to the hypoplastic flexor pollicis longus tendon was performed. In general, the functional results were acceptable with a high degree of family satisfaction, although in some cases function was limited to simple object holding. We explain the surgical procedures to preserve the thumb while gaining function as well as appearance using high-quality illustrations, figures, and videos. This should be helpful for surgeons who want children with hypoplastic thumbs to have both 5 digits and reasonable functional ability.
Combination of Procalcitonin Value on Hospital Admission and Its Subsequent Change in Value Is Associated With the Prognosis of Sepsis
Authors: Muratsu Arisa , Muroya Takashi , Katayama Yusuke , Shimizu Kentaro , Ogura Hiroshi , Kuwagata Yasuyuki , Shimazu Takeshi
Published: February 2021

Objectives:

To evaluate the relationship between the procalcitonin value in blood on hospital admission and its subsequent change and prognosis among sepsis patients.

Design:

A single-center, retrospective, observational study.

Setting:

Critical care center in Japan.

Patients:

Sepsis patients 18 years old or older admitted from January 1, 2015, to March 31, 2018.

Interventions:

None.

Measurement and Main Results:

Among 173 sepsis patients enrolled, the median age was 74 years old (interquartile range, 64–79 yr old), and there were 102 men. The median value of procalcitonin in blood on hospital admission was 14.8 ng/mL (interquartile range, 3.5–78.4 ng/mL), and the median change in serum procalcitonin value between hospital admission and the next day was 0 ng/mL (interquartile range, –4.5 to 5.2 ng/mL). Mortality at 28 days after hospital admission was 5.8% (10/173). In univariate logistic regression analysis, elderly (crude odds ratio, 5.314; 95% CI, 1.094–25.806; p = 0.044), procalcitonin value of less than 33.2 ng/mL on hospital admission (p = 0.007), and change in serum procalcitonin of less than 0.0 ng/mL (crude odds ratio, 5.056; 95% CI, 1.041–24.545; p = 0.046) were associated with mortality at 28 days after hospital admission. The mortality of patients with a procalcitonin value of less than 33.2 ng/mL on hospital admission and change in serum procalcitonin of less than 0.0 ng/mL was 18.6% (8/43) and was significantly higher than that of other patients (p < 0.001).

Conclusions:

Our study showed the sepsis patients with a procalcitonin value in blood of less than 33.2 ng/mL on hospital admission and change in serum procalcitonin of less than 0.0 ng/mL had high mortality at 28 days after hospital admission.
SURvival PRediction In SEverely Ill Patients Study—The Prediction of Survival in Critically Ill Patients by ICU Physicians
Authors: Ros Marijke M. , van der Zaag-Loonen Hester J. , Hofhuis José G.M. , Spronk Peter E.
Published: February 2021

Objectives:

The surprise question, “Would I be surprised if this patient died in the next 12 months?” is a tool to identify patients at high risk of death in the next year. Especially in the situation of an ICU admission, it is important to recognize patients who could and could not have the benefits of an intensive treatment in the ICU department.

Design and Setting:

A single-center, prospective, observational cohort study was conducted between April 2013 and April 2018, in ICU Gelre hospitals, location Apeldoorn.

Patients:

A total of 3,140 patients were included (57% male) with a mean age of 63.5 years. Seven-hundred thirteen patients (23%) died within 1 year.

Interventions:

The physician answered three different surprise question’s with either “yes” or “no”: “I expect that the patient is going to survive the ICU admission” (surprise question 1), “I expect that the patient is going to survive the hospital stay” (surprise question 2), and “I expect that the patient is going to survive one year after ICU admission” (surprise question 3). We tested positive and negative predicted values of the surprise questions, the mean accuracy of the surprise questions, and kappa statistics.

Measurements and Main Results:

The positive and negative predictive values of the surprise questions for ICU admission, hospital admission, and 1-year survival were, respectively, 64%/94%, 59%/92%, and 60%/86%. Accordingly, the mean accuracy and kappa statistics were 93% (95% CI, 92–94%), κ equals to 0.43, 89% (95% CI, 88–90%), κ equals to 0.40, and 81% (95% CI, 80–82%), κ equals to 0.43.

Conclusions:

The frequently overlooked simple and cheap surprise question is probably an useful tool to evaluate the prognosis of acutely admitted critically ill patients.
Presence of Spontaneous Echo Contrast on Point-of-Care Vascular Ultrasound and the Development of Major Clotting Events in Coronavirus Disease 2019 Patients
Authors: Connor-Schuler Randi , Daniels Lisa , Coleman Caroline , Harris Danny , Herbst Nicole , Fiza Babar
Published: February 2021

Objectives:

The presence of spontaneous echo contrast on ultrasonography is a predisposition to increased thromboembolic risk. The purpose of this study was to assess for the prevalence and consequences of spontaneous echo contrast on point-of-care vascular ultrasound in coronavirus disease 2019.

Design, Setting and Patients:

This was a retrospective cohort study of 39 adult patients admitted to the ICU with a confirmed coronavirus disease 2019 diagnosis at a large tertiary-care academic medical center. Patients were included if they had undergone a vascular ultrasound examination during their ICU admission. Overall, 48 venous ultrasound studies among the 39 patients were reviewed in blinded fashion by two reviewers for the presence of venous spontaneous echo contrast, and charts were analyzed for laboratory data and outcomes.

Measurements and Main Results: S

pontaneous echo contrast correlated with serum viscosity (mean values of 2.64, 2.54, and 2.04 cP for dense spontaneous echo contrast, spontaneous echo contrast , and no spontaneous echo contrast, respectively, with a p value of 0.0056 for spontaneous echo contrast compared with negative spontaneous echo contrast) and hyperfibrinogenemia (mean values of 726.6, 668.5, and 566.6 mg/dL for dense spontaneous echo contrast, positive spontaneous echo contrast, and negative spontaneous echo contrast, respectively, with a p value of 0.0045 for dense spontaneous echo contrast compared with negative spontaneous echo contrast). About 36% of patients with dense spontaneous echo contrast and 33% of individuals with positive spontaneous echo contrast experienced significant clotting events compared with 17% of those with negative spontaneous echo contrast. A total of 19% of patients with spontaneous echo contrast suffered a cardiac arrest following a major clotting event, and there were no cardiac arrests from clotting events in the negative spontaneous echo contrast group. There was no association with the presence of spontaneous echo contrast and right or left cardiac function or other laboratory values such as d-dimer, external thromboelastometry - maximum lysis, platelet counts, C-reactive protein, or interleukin-6.

Conclusions:

Point-of-care venous ultrasonography is easily performed and reliably interpreted for visualization of spontaneous echo contrast. The presence of spontaneous echo contrast in patients with coronavirus disease 2019 is associated with hyperviscosity and increased rates of thrombotic events and complications.
Motoric Subtypes of Delirium and Long-Term Functional and Mental Health Outcomes in Adults After Critical Illness
Authors: Rengel Kimberly F. , Hayhurst Christina J. , Jackson James C. , Boncyk Christina S. , Patel Mayur B. , Brummel Nathan E. , Shi Yaping , Shotwell Matthew S. , Ely E. Wesley , Pandharipande Pratik P. , Hughes Christopher G.
Published: February 2021

OBJECTIVES:

Adult ICU survivors that experience delirium are at high risk for developing new functional disabilities and mental health disorders. We sought to determine if individual motoric subtypes of delirium are associated with worse disability, depression, and/or post-traumatic stress disorder in ICU survivors.

DESIGN:

Secondary analysis of a prospective multicenter cohort study.

SETTING:

Academic, community, and Veteran Affairs hospitals.

PATIENTS:

Adult ICU survivors of respiratory failure and/or shock.

INTERVENTIONS:

We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation and Sedation Scale daily during hospitalization. We classified delirium as hypoactive (Richmond Agitation and Sedation Scale ≤ 0) or hyperactive (Richmond Agitation and Sedation Scale > 0). At 3- and 12-month postdischarge, we assessed for dependence in activities of daily living and instrumental activities of daily living, symptoms of depression, and symptoms of post-traumatic stress disorder. Adjusting for baseline and inhospital covariates, multivariable regression examined the association of exposure to delirium motoric subtype and long-term outcomes.

MEASUREMENTS AND MAIN RESULTS:

In our cohort of 556 adults with a median age of 62 years, hypoactive delirium was more common than hyperactive (68.9% vs 16.8%). Dependence on the activities of daily living was present in 37% at 3 months and 31% at 12 months, whereas dependence on instrumental activities of daily living was present in 63% at 3 months and 56% at 12 months. At both time points, depression and post-traumatic stress disorder rates were constant at 36% and 5%, respectively. Each additional day of hypoactive delirium was associated with higher instrumental activities of daily living dependence at 3 months only (0.24 points [95% CI, 0.07–0.41; p = 0.006]). There were no associations between the motoric delirium subtype and activities of daily living dependence, depression, or post-traumatic stress disorder.

CONCLUSIONS:

Longer duration of hypoactive delirium, but not hyperactive, was associated with a minimal increase in early instrumental activities of daily living dependence scores in adult survivors of critical illness. Motoric delirium subtype was neither associated with early or late activities of daily living functional dependence or mental health outcomes, nor late instrumental activities of daily living functional dependence.
Evolution Over Time of Ventilatory Management and Outcome of Patients With Neurologic Disease*
Authors: Tejerina Eva E. , Pelosi Paolo , Robba Chiara , Peñuelas Oscar , Muriel Alfonso , Barrios Deisy , Frutos-Vivar Fernando , Raymondos Konstantinos , Du Bin , Thille Arnaud W. , Ríos Fernando , González Marco , del-Sorbo Lorenzo , Marín Maria del Carmen , Valle Pinheiro Bruno , Soares Marco Antonio , Nin Nicolas , Maggiore Salvatore M. , Bersten Andrew , Amin Pravin , Cakar Nahit , Young Suh Gee , Abroug Fekri , Jibaja Manuel , Matamis Dimitros , Ali Zeggwagh Amine , Sutherasan Yuda , Anzueto Antonio , Esteban Andrés
Published: February 2021

OBJECTIVES:

To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality.

DESIGN:

Secondary analysis of three prospective, observational, multicenter studies.

SETTING:

Cohort studies conducted in 2004, 2010, and 2016.

PATIENTS:

Adult patients who received mechanical ventilation for more than 12 hours.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma.

CONCLUSIONS:

More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.
Plasma Nucleosomes Are Associated With Mortality in Pediatric Acute Respiratory Distress Syndrome
Authors: Yehya Nadir , Fazelinia Hossein , Lawrence Gladys G. , Spruce Lynn A. , Mai Mark V. , Worthen G. Scott , Christie Jason D.
Published: February 2021

OBJECTIVES:

Circulating nucleosomes and their component histones have been implicated as pathogenic in sepsis and acute respiratory distress syndrome in adults. However, their role in pediatric acute respiratory distress syndrome is unknown.

DESIGN:

We performed a prospective cohort study in children with acute respiratory distress syndrome, with plasma collection within 24 hours of acute respiratory distress syndrome onset. We associated nucleosome levels with severity of acute respiratory distress syndrome and with nonpulmonary organ failures and tested for association of nucleosomes with PICU mortality and ventilator-free days at 28 days in univariate and multivariable analyses. We also performed proteomics of DNA-bound plasma proteins in a matched case-control study of septic children with and without acute respiratory distress syndrome in order to identify specific histone proteins elevated in acute respiratory distress syndrome.

SETTING:

Large academic tertiary-care PICU.

PATIENTS:

Intubated children meeting Berlin criteria for acute respiratory distress syndrome.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

We enrolled 333 children with acute respiratory distress syndrome, with 69 nonsurvivors (21%). Plasma nucleosomes were correlated with acute respiratory distress syndrome severity and with the number of nonpulmonary organ failures at acute respiratory distress syndrome onset. Nucleosomes were higher (p < 0.001) in nonsurvivors (0.40 [interquartile range, 0.20–0.71] arbitrary units) relative to survivors (0.10 [interquartile range, 0.04–0.25] arbitrary units). Nucleosomes were associated with PICU mortality in multivariable analysis (adjusted odds ratio 1.84 per 1 sd increase; 95% CI, 1.38–2.45; p < 0.001). Nucleosomes were also associated with a lower probability of being extubated alive by day 28 after multivariable adjustment (adjusted subdistribution hazard ratio, 0.74; 95% CI, 0.63–0.88; p = 0.001). Proteomic analysis demonstrated higher levels of the core nucleosome histones H2A, H2B, H3, and H4 in septic children with acute respiratory distress syndrome, relative to septic children without acute respiratory distress syndrome.

CONCLUSIONS:

Plasma nucleosomes are associated with acute respiratory distress syndrome severity, nonpulmonary organ failures, and worse outcomes in pediatric acute respiratory distress syndrome.
The Effect of Early Sedation With Dexmedetomidine on Body Temperature in Critically Ill Patients*
Authors: Grayson Kim E. , Bailey Michael , Balachandran Mayurathan , Banneheke Piyusha P. , Belletti Alessandro , Bellomo Rinaldo , Naorungroj Thummaporn , Serpa-Neto Ary , Wright Jason D. , Yanase Fumitaka , Young Paul J. , Shehabi Yahya
Published: February 2021

OBJECTIVES:

Previous case series reported an association between dexmedetomidine use and hyperthermia. Temperature data have not been systematically reported in previous randomized controlled trials evaluating dexmedetomidine. A causal link between dexmedetomidine administration and elevated temperature has not been demonstrated.

DESIGN:

Post hoc analysis.

SETTING:

Four ICUs in Australia and New Zealand.

PATIENTS:

About 703 mechanically ventilated ICU patients.

INTERVENTIONS:

Early sedation with dexmedetomidine versus usual care.

MEASUREMENTS AND MAIN RESULTS:

The primary outcome was mean daily body temperature. Secondary outcomes included the proportions of patients with body temperatures greater than or equal to 38.3°C and greater than or equal to 39°C, respectively. Outcomes were recorded for 5 days postrandomization in the ICU. The mean daily temperature was not different between the dexmedetomidine (n = 351) and usual care (n = 352) groups (36.84°C ± sd vs 36.78°C ± sd; p = 0.16). Over the first 5 ICU days, more dexmedetomidine group (vs usual care) patients had a temperature greater than or equal to 38.3°C (43.3% vs 32.7%, p = 0.004; absolute difference 10.6 percentage points) and greater than or equal to 39.0°C (19.4% vs 12.5%, p = 0.013; absolute difference 6.9 percentage points). Results were similar after adjusting for diagnosis, admitting temperature, age, weight, study site, sepsis occurrence, and the time from dexmedetomidine initiation to first hyperthermia recorded. There was a significant dose response relationship with temperature increasing by 0.30°C ±0.08 for every additional 1 μg/kg/hr of dexmedetomidine received p < 0.0002.

CONCLUSIONS:

Our study suggests potentially important elevations in body temperature are associated with early dexmedetomidine sedation, in adults who are mechanically ventilated in the ICU.
Early Seizures Are Predictive of Worse Health-Related Quality of Life at Follow-Up After Intracerebral Hemorrhage
Authors: Naidech Andrew M. , Weaver Bradley , Maas Matthew , Bleck Thomas P. , VanHaerents Stephen , Schuele Stephan U.
Published: February 2021

OBJECTIVES:

Early seizures are a common complication of intracerebral hemorrhage, occurring in ~10% of patients. However, the independent effect of early seizures on patient outcomes, particularly health-related quality of life, is unclear. Without a potential benefit to patient outcomes, the widespread use (~40%) of prophylactic seizure medications has no reasonable chance of improving patient outcomes. We tested the hypothesis that health-related quality of life at follow-up is different between patients with and without early seizures (and secondarily, with nonconvulsive status epilepticus) after intracerebral hemorrhage.

DESIGN:

Patients with intracerebral hemorrhage were enrolled in an observational cohort study that prospectively collected clinical data and health-related quality of life at follow-up.

SETTING:

Academic medical center.

PATIENTS:

One-hundred thirty-three patients whose health-related quality of life was assessed 3 months after intracerebral hemorrhage onset.

MEASUREMENTS AND MAIN RESULTS:

Health-related quality of life was obtained at 3 months after intracerebral hemorrhage onset. T Scores of health-related quality of life were modeled with multivariable linear models accounting for severity with the intracerebral hemorrhage Score and hematoma location. Health-related quality of life was measured with National Institutes of Health Patient Reported Outcomes Measurement Information System/Neuroquality of life, expressed in T Scores (U.S. normal 50 ± 10). The modified Rankin Scale (a global measure) was a secondary outcome. There were 12 patients (9%) with early seizures. T Scores of health-related quality of life at follow-up were lower (worse) in patients with early seizure compared with patients without an early seizure (44 [32.75–51.85] vs 30.25 [18.9–39.15]; p = 0.04); results for other domains of health-related quality of life were similar. The association persisted in multivariable models. There was no association between early seizures and prophylactic seizure medications (p = 0.4). Results for patients with nonconvulsive status epilepticus were similar. There was no association between early seizures and the modified Rankin Scale at 3 months.

CONCLUSIONS:

Early seizures and nonconvulsive status epilepticus were associated with lower health-related quality of life at follow-up in survivors of intracerebral hemorrhage.
Understanding the tumor-immune microenvironment in prostate cancer
Authors: Dong Liang , Myers Kayla V. , Pienta Kenneth J.
Published: February 2021

Purpose of review

This review aims to highlight recent advances in prostate cancer tumor-immune microenvironment research and summarize the state-of-the-art knowledge of immune checkpoint inhibitors in prostate cancer.

Recent findings

Immune checkpoint inhibitors are the cornerstone of modern immunotherapy which have shown encouraging results across a spectrum of cancers. However, only limited survival benefit has been seen in patients with prostate cancer. Prostate cancer progression and its response to immunotherapies are strongly influenced by the tumor-immune microenvironment, whose feature can be summarized as low amounts of tumor-specific antigens, low frequency of tumor-infiltrating lymphocytes and high frequency of tumor-associated macrophages. To improve the therapeutic effect of immunotherapies, in recent years, many strategies have been applied, of which the most promising ones include the combination of multiple immunotherapeutic agents, the combination of an immunotherapeutic agent with other modalities in parallel or in sequential, and the development of biomarkers to find a subgroup of patients who may benefit the most from immunotherapeutic agents.

The impact of immune content and specific immune cell types on prostate cancer biology is highly complex. Recent clinical trials have shed light on the optimal use of immunotherapies for prostate cancer.
Obesity and incident gastrointestinal cancers: overall body size or central obesity measures, which factor matters?
Authors: Hashemi Madani Nahid , Etemadi Arash , Nalini Mahdi , Poustchi Hossein , Khajavi Alireza , Mirzazade Elahe , Mirfakhraei Hosna , Pourshams Akram , Khoshnia Masoud , Gharavi Abdolsamad , Merat Shahin , Khamseh Moahammad E. , Malekzadeh Reza
Published: February 2021

BMI does not reflect the location or amount of body fat. We aimed to investigate the role of general and central obesity measures in the prediction of incident gastrointestinal cancers. In this analysis of the Golestan Cohort Study, we included 47 586 cancer-free individuals followed for 12.3 years (IQR: 10.5–13.2). We investigated the association of obesity measures including BMI, waist circumference and waist-to-hip ratio (WHR) at enrollment and the incidence of esophageal, gastric, colorectal and pancreatic cancers. Cox proportional hazard models were used to estimate the association between covariates and gastrointestinal cancer risk. We observed no significant associations between obesity measures and incidence of the above-mentioned gastrointestinal cancers in men. In women, BMI, waist circumference and WHR were associated with significant reductions in the risk of esophageal squamous cell carcinoma (ESCC): hazard ratio (HR): 0.67 [95% confidence interval (CI): 0.56–0.81], HR: 0.71 (95% CI: 0.60–0.84) and HR: 0.80 (95% CI: 0.68– 0.94), respectively. In addition, WHR was associated with significantly increased risks for colorectal cancer (HR: 1.39, 95% CI: 1.08–1.78) and gastric cancer (HR: 1.24, 95% CI: 1.01–1.51) in women. In this study, statistically significant associations between obesity measures and incident esophageal, gastric and colorectal cancers were seen in women.
Prolonged recombinant pregnancy hormone use in BRCA1 and BRCA2 mutation carriers
Authors: Depypere Herman , Su Yanrong , Dang Nhi , Poppe Bruce , Stanczyk Frank , Janssens Jaak , Russo Jose
Published: February 2021

Background

An early first full-time pregnancy substantially reduces the risk of developing breast cancer later in life. Extensive studies indicate that this protective effect is mediated by the pregnancy hormone human chorionic gonadotrophin (hCG).

Methods

In this proof-of-concept study 33 women with a BRCA mutation received recombinant-hCG (r-hCG). A 4-mm breast biopsy was obtained before (T1) and after 12 weeks of r-hCG injections (T2), as well as 6 months later (T3). The tissue was examined using RNA-sequencing methodology to determine if the ‘high-risk’ transcriptomic signature was converted to a ‘low-risk’ signature as in an early first full-time pregnancy. A stringent clinical safety monitoring was performed.

Results

The r-hCG administration was well tolerated in all participants. No clinically relevant changes were observed. In 25 women, the RNA quality was good for RNA sequencing in all three breast tissue biopsies. In response to the r-hCG, we observed 1907 differentially expressed genes (DEGs) (1032 up, 875 down) at T2 vs. T1 and 1065 DEGs (897 up, 168 down) at T3 vs. T1 in the group of women (n = 11) not using any hormonal contraceptives during the study. There was no response at T2 vs. T1 and a small number of DEGs, 260 (214 up, 46 down) at T3 vs. T1 in the group of 14 women using contraceptives.

Conclusions

In summary, r-hCG has a remarkable effect on the gene expression profile of breast tissues from BRCA1/2 carriers who did not use any contraception. This opens an opportunity for a novel preventive strategy to reduce the incidence of breast cancer.