bluuebunny/crossref_metadata_2025 huggingface dataset:
Deep Sedation for Patients with Single Ventricle Physiology
Authors: Abdel-Mageed Sarah , Friedman Matthew
Published: December 2020

Background: 
Advancements in the palliative surgery of patients with single ventricle physiology have led to an increase in lifespan, necessitating the study of safe deep sedation protocols for painful procedures. This study aims to describe the practice of deep sedation by intensivists outside the operating from for children with single ventricle physiology. 
  
Methods: 
A retrospective chart review was conducted on consecutive patients with single ventricle physiology who received procedural deep sedation performed by intensivists between January 2013 and July 2020.  Sedative and analgesic medications used were not protocolized and were up to the discretion of the physician performing the sedation. 
  
Results: 
Thirty-three sedations were performed on 27 unique patients.  The median age was 3.7 years (25th%, 75th%: 2.1, 15.6).  The majority of procedures, 88% (29/33), were done on children with Fontan physiology.  The remaining 12% (4/33) were status-post Glenn or hemi-Fontan procedure. The underlying primary cardiac defect was hypoplastic left heart in 52% (17/33) of procedures. 
  
There were 24 chest tube placements and 9 cardioversion procedures; there were no procedural complications. 
  
Ketamine alone [median dose 1.52 mg/kg (range 0.79-3.70)], ketamine [median dose 0.98 mg/kg (range 0.13-2.12)] with propofol [median dose 2.27 mg/kg (range 0.66-3.77)], and ketamine [median dose 1.50 mg/kg (range 0.42-3.02)] with morphine [median dose 0.06 mg/kg (range 0.03-0.20)] were the most common sedation protocols used. 
  
There were minor complications during four procedures.  One patient with transient hypotension, two had desaturation, and the fourth had desaturation and apnea. The patients with desaturation received nasal cannula oxygen delivery.  The patient with apnea had bag mask valve ventilation. No intervention was reported for hypotension. 
  
Conclusions: 
Procedural deep sedation can be safely and effectively administered to single ventricle patients by intensivist led sedation teams.
Incidence of Cerebral Palsy, Seizure Disorder and Developmental Delay in Newborns with Hypoxic Ischemic Encephalopathy Following Treatment with Hypothermia
Authors: Adedokun Kazeerat , Wolfe Heather
Published: December 2020

Neonatal Hypoxic ischemic encephalopathy (HIE) is a serious condition that can lead to significant neurological problems, developmental delay, and mortality. Fetal oxygen deficiency decreases cardiac output, leading to reduced cerebral blood flow and brain injury. In 2006 the United States spent over 300 billion dollars in disability related health care expenditure. HIE if left untreated leads to poor quality of life, and survivors end up with lifelong disabilities. Therapeutic hypothermia became standard of care in 2002, and evidence has shown it has neuroprotective benefit. We hypothesize that neonates treated with hypothermia will have lower incidence of cerebral palsy (CP), seizure disorder (SD) and developmental delay (DD), compared to neonates diagnosed with HIE prior to the current standard of care. Compared to healthy neonates, neonates treated with hypothermia will have higher incidence of CP, SD, and DD 
 
Project Methods: A retrospective chart review will be performed using 200 participants with medical records from Lutheran health network neonate intensive care unit. Historical data from prior to the current standard of care (January 2007 to 2011) will be used for newborns with HIE. Another data set from January 2015 to December 2019 will be used for newborns treated with hypothermia and healthy patients as well. The TIMP test will be used to assess motor performance in early infancy. The Bayley Scales of Infant and Toddler Development third edition will be used to measure cognitive, language and motor development. Cerebral palsy will be assessed using the Gross Motor Function Classification System. 
 
Results: We expect that the results of this study will match previous research, which found that neonates treated with hypothermia had better outcomes compared to neonates not treated with hypothermia. 
 
Potential Impact: If found to be effective, this intervention may improve the quality and quantity of a patient’s life and reduce the cost of healthcare spending on disability.
Clinical Courses and Characteristics of Residents During a SARS-CoV-2 Outbreak at a Central Indiana Skilled Nursing Facility
Authors: Albert Lauren , Lieb Kristi , Mack Laramie , Unroe Kathleen
Published: December 2020

Background/Objective: Older adults such as skilled nursing facility residents have increased risk of serious SARS-CoV-2 infection and comprise a large proportion of the COVID-19 pandemic’s deceased—the US Centers for Medicare & Medicaid Services report 232,831 cases and 38,518 resident deaths to date. Recent case reports reveal, as in other diseases, older adults may experience atypical symptomology, complicating identification of ill residents and efforts to slow transmission. While a few facility outbreaks have been characterized epidemiologically, little research exists regarding clinical timelines and trajectories which residents experience during COVID-19 illness.  
Methods: From May 9, 2020-June 1, 2020, daily notes on each COVID-19 positive resident’s status (n = 69) were taken by the medical director of a central Indiana nursing facility. Combined with a retrospective resident chart review of this same period, these notes were examined for COVID-19 infection symptoms and illness timelines to descriptively categorize a number of common illness trajectories and symptoms seen in residents with SARS-CoV-2 infection. 
Results: Residents fit four descriptive clinical timelines: concurrent symptom load with quick death (Avg 5.6 days) (n = 5), accumulating symptom load with gradual decline (Avg. 13.9 days) (n = 9), prolonged active symptom load with periods of stabilization and symptom reoccurrence (n = 42), and asymptomatic or atypical symptom load (n = 12). Most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. Of the 14 residents who died (20.3% of infected), 8 died in the facility and 6 died in the hospital. 
Conclusion and Implications: This retrospective case study adds to literature describing the presentation and symptomology of SARS-CoV-2 infection in residents of skilled nursing facilities and aids efforts to evaluate resident presentation, prognosis, and disease course. Robust descriptions of expected clinical courses may support realistic expectations of disease progression for residents and their family members experiencing future outbreaks.
Targeting of Non-Structural Protein 9 as a Novel Therapeutic Target for the Treatment of SARS-CoV-2
Authors: Anderson Matthew , Turchi John
Published: December 2020

Background/Hypothesis: 
The 2019 novel coronavirus (SARS-CoV-2) is a human coronavirus responsible for a global pandemic with over 13 million confirmed cases. Currently, there are no treatments to block viral infection or replication. Exploring novel therapeutic targets for SARS-CoV-2 and future coronaviruses holds great promise for treating the current and future outbreaks. One such target is the non-structural protein 9 (nsp9), which has been shown to be highly conserved and unique to the coronavirus family as well as playing a role in viral replication. We hypothesize nsp9 is a viable target for therapeutic development.  
 
Methods: 
Towards determining the utility of targeting nsp9, a series of databases were queried for articles pertaining to nsp9 in SARS-CoV-2 and other coronaviruses and coronaviruses in general. We assessed structural, biochemical and cellular features of nsp9.   
 
Results: 
Nsp9 forms a homodimer via a conserved a-helix containing a glycine-rich interaction motif (GxxxG). Dimerization at the GxxxG interface is required for efficient viral replication. Nsp9’s core is an open, six-stranded b-barrel whose fold gives it a structure similar to nucleic acid binding OB-fold proteins. This OB-like fold has not been detected in replicative complexes of other RNA viruses and may reflect the unique and complex CoV replication machinery. Nsp9 is an indispensable component of the replication complex that binds single-stranded RNA in a concentration-dependent manner. A recent bioinformatic approach also found that nsp9 interacts with NF-kappa-B-repressing factor and may play a role in the IL-8/IL-6 mediated chemotaxis of neutrophils and inflammatory response observed in Covid-19 patients.  
 
Conclusion/Potential Impact:  
Based on this research, we conclude nsp9 represents a novel therapeutic target whose OB-like-fold may provide a targetable structure for interrupting RNA binding and impairing viral replication. This study will help inform current and future research that seeks to target nsp9’s structure and biochemical interactions as treatment for coronavirus infection.
Postoperative Pancreatic Fistula Following Traumatic Splenectomy: What Techniques Affect Incidence?
Authors: Arnold Peter , Meagher Ashley , Hartwell Jennifer
Published: December 2020

Background and Hypothesis: 
Development of postoperative pancreatic fistula (POPF) in cases of adult splenectomy following trauma occur in 1-3% of cases. Incidence of this complication leads to increased mortality rates, length-of-stays (LOS), and costs for patients. In cases where no previous pancreatic injury was noted, we hypothesized that the use of sutures in splenic hilum ligation instead of staples reduced the rate of incidence. 
 
Methods: 
Adult trauma patients (age ≥17 years) that underwent non-elective splenectomy from 2010-2020 at Indiana University Methodist Hospital were retrospectively evaluated from the hospital’s trauma registry. Due to the low incidence of POPF, our review was not adequately powered to perform statistical analysis with integrity; thus, we report our findings as a case series. 
 
Results: 
262 adult splenectomies following trauma occurred between 2010 and 2020; 160 passed exclusion criteria and were included in our analysis. Sutures alone across hilar structures were used in 135 cases, 6 of which developed POPF (4.4%). Staples alone across hilar structures were used in 13 cases, 3 of which developed POPF (23%). A combination of staples and sutures was used in 10 cases, none of which developed POPF. In cases of POPF, individuals averaged hospital LOS of 31.6 days, ICU LOS of 15.8 days, and 47.3 days with an abdominal drain in place. These patients averaged 4.78 abdominal CT scans, 1.11 endoscopic retrograde cholangio-pancreatography (ERCP), and 0.78 drain exchanges performed. 
 
Conclusion: 
Though not statistically significant, we noted that POPF are more likely to develop when staples alone are used across hilar structures. In our 10-year retrospective review of POPF, we found the complication to be rare but morbid, with associated prolonged length of hospital and ICU stays and requiring multiple imaging studies and interventions, leading to increased costs. We conclude that further study of optimal technique for emergent splenectomy is warranted.
Reducing Length of Stay is not Associated with Increased Readmission Rates Following Lower Extremity Arterial Bypass
Authors: Arungwa Dirichi , Gonzalez Andrew
Published: December 2020

Objective: 
Traditional fee-for-service reimbursement models for medical services have been increasingly replaced with the merit-based and efficiency-driven pay-for-performance initiatives. Financial incentives to decrease expenditures have added pressure on hospitals and providers to reduce length of stay (LOS). Concern has been raised that this strategy may unwittingly increase readmission rates. We sought to better understand potential trade-offs between these two outcome measures for hospitals performing lower extremity arterial bypass (LEAB). 
Methods: 
We performed a retrospective observational cohort study of 479,366 Medicare beneficiaries undergoing LEAB in 1,708 hospitals from 2005-2009. Using LOS quintiles and a multiple logistic regression model, we generated risk-adjusted readmission rates (RARR) accounting for age, gender, pre-existing comorbidities, non-elective admission status, post-operative complications, and discharge destination. We then compared RARRs across LOS quintiles. Finally, we evaluated the association between hospital LOS on readmissions performance after adjusting for hospital volume, location, teaching status, bed size, and non-home discharges. 
Results: 
The mean hospital 30-day RARR was 14.5% (SD 3.5%) and the median LOS 4 days (range 3-6 days). Hospitals with the shortest median LOS (2.3 days) had slightly lower readmission rates compared to those with the highest median LOS (9.2 days) (13.3% vs 15.8%, p <0.001). The Spearman correlation coefficient was 0.15 (p < 0.001), indicating a very weak correlation between LOS and RARR. 
Conclusion and Potential Implications: 
At the hospital-level, there appears to be little tradeoff between LOS and RARR, implying these outcomes measure different domains of hospital quality and can be used as indicators of care quality and the likelihood for post-discharge adverse events. As it is possible for hospitals to perform well on both measures, pay-for-performance initiatives may consider incentivizing reducing LOS and readmissions.
Incidence of Femoral Stem Subsidence Following Aseptic Hip Revision Using Tapered, Fluted Titanium Stems
Authors: Baldwin Thomas , Deckard Evan , Ziemba-Davis Mary , Buller Leornard , Meneghini R. Michael
Published: December 2020

Background and Hypothesis:  Implant design in revision total hip arthroplasty (rTHA) has evolved such that tapered, fluted titanium (TFT) femoral stems have become the gold standard. However, there is a paucity of data on TFT stem subsidence rates following aseptic rTHA. Subsidence can lead to stem loosening, hip instability, leg length discrepancy, and gait impairment in which patients experience great physical challenges requiring undesirable repeat revision surgery. This study assessed the incidence of subsidence in aseptic rTHA performed with TFT stems. 
 
Design/Methods:  102 TFT femoral stems implanted between 2011 and 2020 at a single center were retrospectively reviewed. Stem subsidence was measured on digital radiographic images taken immediately after surgery, at 4-weeks and 1-year postoperatively, and at subsequent follow-up clinic visits. Patient characteristics and risk factors for subsidence, revision etiology, and surgical details (stem type, size, etc.) also were extracted from the electronic medical record. 
 
Results:  102 aseptic rTHAs were analyzed. 21.8% (22/101) of stems subsided between the immediate postoperative and 4 week follow-up period. 43.1% (22/51) of stems subsided between 4 weeks and 1 year postoperatively, and 39.3% (11/28) of stems subsided between 1 year and latest follow-up (>12 months post-op).  At all three time periods, the amount of subsidence was <3 mm in a majority of cases (77% to 96%) which is considered to be an acceptable amount of stem subsidence or “settling.” Only seven TFT stems had subsided more than 3 mm. Two of these stems subsided 10 or more mm but had not required revision at latest follow-up of 4 and 8 years.  
 
Conclusion and Potential Impact:  The incidence of significant TFT stem subsidence requiring repeat revision surgery was relatively low in this cohort. Further research is warranted to identify specific risk factors for subsidence of TFT femoral stems.
Analysis of Incident DKA in the Indiana New Onset T1D Patient Population
Authors: Beer Brianna , Moors Kelly , Evans-Molina Carmella , Sims Emily
Published: December 2020

Background/Objective: Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes (T1D) resulting from ketone body production and metabolic acidosis occurring due to insulin deficiency. We sought to define the occurrence of DKA amongst pediatric patients presenting with new-onset T1D in Indiana and to determine whether patterns of DKA were affected by the COVID-19 pandemic.  
 
Methods: This was a retrospective chart review for patients <18 years admitted to Riley Children’s Hospital with a clinical diagnosis of new onset T1D who had available chemistry values. Patients diagnosed from March 23- June 30, 2020 and over the same period in 2019 were included. DKA was classified as mild (bicarbonate 10-15 mmol/L) or severe (bicarbonate <10 mmol/L). 
 
Results: Ninety-four patients met inclusion criteria. The total number of incident T1D cases in 2019 and 2020 were similar (48 vs. 46, respectively). Similarly, there was no significant difference in rates of DKA (21 in 2019 vs. 25 in 2020; p>0.05). Of the 94 patients, 49% met criteria for DKA; 79% of cases were classified as severe and 21% as mild. More males were diagnosed with DKA in both 2019 and 2020 (61% of DKA cases). Non-Hispanic whites comprised 75% of all new onset T1D patients and no differences in race or ethnicity were present amongst those presenting in DKA.  
 
Conclusion: DKA was present in nearly half of all new onset pediatric T1D cases in Indiana in 2019 and 2020. There was no observed impact of the COVID-19 pandemic on T1D or DKA.   
 
Impact and Implications: DKA is common amongst pediatric patients with new onset T1D in Indiana. Prompt recognition of symptoms is needed to prevent this life-threatening complication of T1D.
Patient Reported Outcomes after Local Flap Coverage for Lower Extremity Trauma
Authors: Bhagat Neel , Loewenstein Scott , Knox Kevin , Adkinson Joshua , Hassanein Aladdin , Bamba Ravinder
Published: December 2020

Background: 
Complex lower extremity trauma can result in devastating outcomes including amputation and poor quality of life. Limb salvage can be achieved with the use of local flaps like muscle flaps such as the gastrocnemius or soleus flaps, which detach muscles in order to use them for local coverage.  Fasciocutaneous flaps such as reverse sural and propeller flaps are other examples of local flaps which utilize overlying soft tissue for local rearrangement.  Patient-reported outcome (PRO) studies have not been reported for local flaps. Additionally, the potential for functional deficits as a result of muscle flaps in comparison to fasciocutaneous flaps has not been investigated. 
 
Methods: 
Local flap coverage for lower extremity traumas between 2014-2019 were reviewed. 248 local flaps were performed for lower extremity salvage following trauma. PROs were recorded utilizing both the Lower Extremity Functional scale (LEFS) and the 36-Item Short-Form Health Survey (SF-36).  
 
Results: 
Surveys were completed by 37 patients (response rate 18.3%, mean follow-up time 3.16 years, average age 49.72 years old). The average LEFS score was 42.09 ± 14.18, and the average physical functioning score was 43.03 ± 21.54. LEFS score and SF-36 physical functioning scores were significantly lower in patients who underwent muscle flaps compared to fasciocutaneous flaps (p=0.021 and p=0.022 respectively). 
 
Conclusions and Impact: 
Patients undergoing local flaps for lower extremity reconstruction have low quality of life scores. Patients who underwent fasciocutaneous flaps had significantly higher quality of life scores compared to muscle flap patients suggesting that fasciocutaneous flaps may cause less functional deficit in salvage operations.
Connecting Faith and Health: Improving Health Outcomes Through Congregant Networks
Authors: Campbell Meredith , Christenson Jacob , Craig David
Published: December 2020

Background and Hypothesis: People living in areas of high social vulnerability face health disparities in part due to disconnection. Health institutions recognize the importance of treating whole persons but are disconnected from local knowledge of community health assets and social and cultural barriers. People in health-challenged neighborhoods may experience disconnection and distrust in seeking the many resources and services needed for good health. Congregations are longstanding anchor institutions in marginalized communities. They build trusted relationships among members through shared values and care for wellness. Sometimes they extend these connections through on-the-ground service to neighboring communities. We hypothesize that a network of congregations can build trusted connections and share local knowledge and cultural competence to improve health outcomes and holistic wellness in vulnerable neighborhoods. 
 
Methods: Community-engaged participatory research requires reciprocity in mapping assets, identifying priorities, narrating shared values, designing projects and messaging results. We developed mixed-methods tools to ensure community expertise drives an iterative research process. Methods include: an initial health and wellness survey, follow-up wellness interviews to collect stories and assets, an online learning community for 14 congregations with monthly focus groups, and visual maps of health data and wellness assets. 
 
Results: While the study is ongoing, preliminary survey data demonstrates that congregations have local knowledge of issues affecting health and wellness among their congregants and the surrounding neighborhood. Their preexisting support for health and wellness through community outreach programs indicates building on their current network could expand their reach and improve health and wellness in vulnerable neighborhoods. 
 
Conclusion and Potential Impact: Successful community engaged research prioritizes iterative methods that allow community participants to use their voice and tell their stories.  
Congregations' practice of shared values and knowledge of lived experience can forge connections for greater resilience and health supports in socially vulnerable communities.
Characterization of the Tumor Microenvironment of Neurofibromatosis Type I Plexiform Neurofibromas
Authors: Chmiel Abigail , Rhodes Steven , Angus Steve , He Yongzheng , Lu Quingbo , Sciaky Noah , Johnson Gary , Clapp Wade
Published: December 2020

Background/Objective: 
Neurofibromatosis type 1 (NF1) is a cancer predisposition syndrome caused by mutations in the NF1 tumor suppressor gene. Patients with NF1 develop tumors of the peripheral nervous system called plexiform neurofibromas (PNs). These histopathologically complex tumors are composed of various immune and inflammatory cells. Mast cells have previously been identified as one key immune cell lineage underpinning PN initiation and progression, however new technologies leveraging RNA-sequencing (RNAseq) allow for the broad and systematic characterization of the PN tumor microenvironment. Here we utilized these tools to delineate PN cellular composition. 
Methods: 
RNA seq was performed on murine wild type (n=6) and PN (n=6) tissues. We utilized CIBERSORT to profile the cellular constituents of the PN microenvironment. CIBERSORT is a deconvolution method that uses a reference matrix to estimate the relative proportions of various cell types. Statistical analyses were performed on cell lineage subtypes delineated by CIBERSORT. We further performed a Gene Set Enrichment Analysis (GSEA) to identify which pathways and cytokines might be upregulated in PNs.  
Results: 
Using a murine reference matrix, the macrophage lineage, M0 (p = 0.072), M1 (p = 0.1), were upregulated in PNs (n=6) compared to WT (n=6). A human reference matrix showed M2 (p=0.025) to be upregulated in PNs. GSEA showed IL-1, IL-6, IL-8, TNF and Type I IFN and cytokine secretion to be upregulated in PNs compared to WT.  
Conclusion: 
Macrophages were among the most upregulated components of the NF1 tumor microenvironment and upregulation of IL-1, IL-6, IL-8, TNF and Type I IFN production may be contributing to inflammation that is critical in the initiation and progression of PNs.   
Scientific/Clinical/Policy Impact and Implications: 
Pharmacotherapies that can target the macrophage lineage and/or aforementioned cytokines may have utility in the treatment of PNs. Further studies are necessary to evaluate this hypothesis.
Serum Biomarkers in Postoperative Delirium after Esophagectomy
Authors: Dalal Azhar , Khan Sikandar , Lindroth Heidi , Khan Babar
Published: December 2020

Background: The pathophysiology of postoperative delirium in patients undergoing esophagectomy is not well understood but has been hypothesized to involve neuroinflammation. Inflammatory biomarkers may therefore be associated with delirium incidence and severity. We conducted this study to measure the association between serum inflammatory biomarkers and postoperative delirium and delirium severity.  
 
Methods: Blood samples were obtained from patients enrolled in a randomized double-blind placebo-controlled trial undergoing elective esophagectomy at Indiana University Health University Hospital. S100 calcium-binding protein B, C-Reactive Protein (CRP), interleukins 8, 10, tumor necrosis factor-alpha, and insulin like growth factor 1 (IGF1) were analyzed at preoperative, and postoperative days 1 and 3 timepoints. Delirium status and severity were assessed using the Confusion Assessment Method for Intensive Care Unit and Delirium Rating Scale (DRS-R-98), respectively.  
 
Results: Samples from 71 patients were included. Higher median CRP values were associated with delirium incidence at post-operative day 1 (no delirium: 22.7 IQR:2.2, 42.7; delirium: 35.4 IQR:25.0, 50.0, p=0.031) but not at post-operative day 3. Median CRP S100B serum values were correlated with mean delirium severity (-0.289, p=0.020). IGF-1 serum values were associated with delirium severity on post-operative day 1 (0.270, p=0.040).  
 
Conclusion: Postoperative delirium incidence was associated with higher median CRP values at POD1. The findings of this study provide evidence for the early measurement of post-operative serum biomarkers to ascertain likely incidence and severity of delirium.
Decreased brain volumes in infants with prenatal opioid exposure
Authors: Dietrich Jonathan , Guckien Zoe , Picklesimer MaKayla , Sparks Christina , Haas David , Sadhasivam Senthilkumar , Radhakrishnan Rupa
Published: December 2020

Background/Objective: Previous small studies have shown that prenatal opioid-exposed (POE) infants and older children display decreased cerebral, cerebellar, or subcortical brain volumes. However, these studies are plagued by suboptimal reference standards or were unable to correct for the influence of other environmental factors in older children. Therefore, our goal was to study differences in brain volume of POE infants when compared to a geographically matched population. We hypothesized that there will be a significant decrease in total brain volume of the POE infants in comparison to the non-opioid exposed control infants, including a reduction in the cerebellar volume. 
 
Methods: This was an IRB approved prospective study of mothers and infants with POE and controls without POE. All recruited infants underwent MRI scans of the brain before they reached a corrected age of 2 months. The T1-weighted MRI images were analyzed by Infant FreeSurfer and segmented into ROIs. The segmentations were manually checked and edited. An ANOVA analysis was performed to compare the cerebellar and total brain volume datasets. We corrected for gender, corrected gestational age at MRI scan, and total brain volume where necessary.  
 
Results: 42 infants were included in the study, 21 with POE and 21 control infants. There was a significant difference in the mean gestational age of POE infants (38.28±2.13) compared to control infants (39.42±0.72). On quantitative analysis, the POE group had a significantly reduced total brain and supratentorial volume in comparison to the controls. The cerebellar volume was also significantly smaller in POE, but this significance did not persist when the total brain volume was included in the model.  
 
Conclusion: The supratentorial region is affected disproportionately more than the cerebellum in POE. Specific reductions in cortical, subcortical, and white matter volume need to be further investigated and their influence on developmental outcomes need to be studied.
An Implementation Evaluation of A Comprehensive Sex Education Program in a Rural Indiana County
Authors: Estes Lauren , Meagher Carolyn , Hensley Monique , Hunt Abby , Wuerch Cory , Ott Mary
Published: December 2020

Background and Objective: Rural teen pregnancy is a significant public health problem, yet there are no evidence-based prevention programs (EBPs) developed for rural communities. Little is known about the process of implementing and adapting EBPs for rural communities. An implementation science framework is a useful way to methodologically examine EBPs replicated in new contexts. Specifically, the Evaluation, Preparation, Implementation, Sustainment (EPIS) framework was utilized for this project. The purpose of this study is to describe the challenges and sucesses in the implementation of EBPs in a rural community. 
Project Methods: Youth RISE! is a federally funded, evidence based, community-wide sex education program implemented in Clinton County, Indiana. Qualitative interviews were conducted with key stakeholders involved in implementing the program (n=22). Participants fulfilled diverse roles such as school administrators, teachers, local program partners, and the grantor. These interviews, conducted in-person or via telephone in 2018 and via Zoom in 2020, were subsequently transcribed, coded and analyzed using thematic analysis.  Codes were developed from the EPIS implementation framework and an initial review of transcripts and field notes. 
Results: Participants described the Youth RISE! Program as overwhelmingly successful. Qualitative analysis revealed three central themes of Community Readiness, Transparency, and Buy-In. Community readiness included timing, involvement of trusted community partners, and framing teen pregnancy as a public health issue rather than a values issue. Transparency included frequent communication between all parties, positive messaging, and a strong presence in the community. Buy-in included parent, teacher, and school administration support as well as maintaining equal partnerships between the community, school, and partner agencies. 
Conclusion and Potential Impact: Contrary to popular beliefs, this rural community was willing to implement comprehensive sex education programs in its schools. This data may be used to inform future implementation of EBPs in rural communities.
Novel Participatory Methodologies for Identifying Motivations of Minority Women to Participate in a Breast Cancer Clinical Trial
Authors: Evans Madeline , Ridley-Merriweather Katherine
Published: December 2020

Background: The Komen Tissue Bank (KTB), a biorepository that stores healthy breast tissue for use as controls in breast cancer (BC) research, has a notable deficiency in tissue donations from racial and ethnic minority women. Though studies have documented similar disparities in many clinical trials, the reasons why minority women agree or decline to participate in clinical trials remain largely unknown. This study used two novel participatory communication methodologies with minimal researcher intervention to explore potential motivations for minority women (Latinas, Asian Americans, and Black women) to donate breast tissue to the KTB. 
Methods: Two novel methodologies rooted in Grounded Practical Theory and Grounded Theory were used to study the attitudes of non-donors toward tissue donation and the reasons donors chose to donate tissue to the KTB, respectively. The non-donors (Latinas, n=14; Asian Americans, n=17) participated in interactive focus groups, and donors (Black, n=20) participated in open-ended interviews, all of which were then transcribed and coded to identify common motivations for donating breast tissue. 
Results: The interactive methodology of both the focus groups and interviews yielded rich data that may not have arisen in a traditional question-driven format. Though the manifestation differed between minority groups, three common factors influencing the decision to donate breast tissue were present in all groups: altruistic tendencies, cultural norms, and personal connection to BC. Non-donors also expressed their need for more information before making the decision to donate. 
Conclusion and Potential Impact: Common factors that influence the decision to donate tissue were identified using these two novel interactive methodologies, though the expression differed between minority groups. The information gleaned from this study will inform future communication efforts by the KTB and other clinical trial researchers, with the ultimate goal of distributing targeted recruitment materials to increase the representation of minority women in clinical trials.
Improving Post-Stroke Outcomes in Ischemic Stroke Animal Models Using C3a Monoclonal Antibody Treatment
Authors: Failinger David , Yen Jui-Hung
Published: December 2020

Background 
Stroke is one of the leading causes of death in the world and a majority of strokes cases are ischemic stroke. Ischemia causes tissue damage by preventing nutrient delivery, but damage is also caused by inflammation after reperfusion. The complement pathway is active during reperfusion. Our study focuses on the effects of C3a component inhibition during post stroke inflammation.  
 
Material and Methods 
A total of 30 C57BL/6 mice will be randomly divided into 3 groups (n=10/group) and subjected to a 40-minute middle cerebral artery occlusion (MCAO). The control group will receive a vehicle (saline, Group 1) and two experiment groups will receive 5 ml/kg IV injections of neutralizing C3a monoclonal antibody. The first experimental group (Group 2) will receive the injection 30 minutes after the start of occlusion and the second experimental group (Group 3) will receive two injections at 30 minutes and 3h after the start of occlusion. All groups will be subject to neurological function tests at 24h and 48h. Additionally, at 48h post-injury animals will be sacrificed and the ischemic brains harvested, followed by Triphenyl tetrazolium Chloride (TTC) staining to determine infarct volume.  
 
Results 
The infarct volumes and neurological function scores for the experimental groups are expected to have statistically smaller values and improved neurological deficient compared to the vehicle group. Group 3 mice are expected to have smaller values and lower scores compared to Group 2. 
 
Discussion 
C3a plays an important role in recruitment of inflammatory cells such as macrophages/microglia and neutrophils, which can cause brain tissue injury and neuron cell death. Limiting the presence C3a component by monoclonal antibody is expected to limit recruitment and lessen post-ischemic inflammation damage. Future studies may test combinations of complement pathway inhibition to optimize the depression of post-stroke inflammation and as well as preventing susceptibility to post-stroke infection.
Serum Proteomic Analysis in Esophagectomy Patients with Postoperative Delirium: A Case-Control Study
Authors: Fitschen Walter , Khan Sikandar , Lindroth Heidi , Wang Sophia , Imran Sundus , True Jason , Aryal Uma , Perkins Anthony , Gao Sujuan , Caplan Gideon , Twigg III Homer , Kesler Kenneth , Khan Babar
Published: December 2020

Background: Delirium is a common post-operative complication for patients who undergo esophagectomy. The pathophysiology of delirium is poorly understood, limiting therapeutic options. To advance our pathophysiologic understanding, we conducted this study to evaluate the association of protein expression with postoperative delirium. 
Methods: A case-control study was performed using blood samples from the PEPOD randomized clinical control trial (NCT02213900). 52 patients (26 cases with delirium, 26 control)  who were >18 years old, spoke English, and underwent esophagectomy were included, while those with schizophrenia, Parkinson’s, alcohol abuse, neuroleptic malignant syndrome, haloperidol allergy, and severe dementia were excluded. Samples were from pre-op and post-op day 1. Delirium was assessed for using the Confusion Assessment Method for the Intensive Care Unit and Richmond Agitation Sedation Scale, while the severity was assessed using DRS-R-68. Proteomic analysis was performed using TMT 10ples isobaric labels. Proteome Discoverer and STRING web-based tools were used for bioinformatic analyses, and the Wilcoxon-Mann-Whitney Odds (WMWodds) test was used to report between-group differences in protein abundance ratios. 
Results: 52 samples (26 cases, 26 controls) were analyzed for this study. Elevated protein abundance ratios of Coagulation factor IX (Median (IQR): 1.18 (1.08-1.28) p=0.047) and Mannosyl-oligosaccharide 1,2-alpha-mannosidase (Median (IQR): 1.50 (1.35-1.60) p=0.049) were noted in patients that developed delirium. Elevated protein abundance ratios of angiotensinogen (Median (IQR): 1.19 (1.14-1.23) p=0.038), ceruloplasmin (Median (IQR): 1.02 (0.98-1.08) p=0.038), and Complement C2 (Median (IQR): 1.01 (0.96-1.08) p=0.016) were noted in control patients. Protein abundance ratios for Complement C2 (Spearman rs=0.31, 95%CI [-0.55, -0.02]) and Mannosyl-oligosaccharide 1,2-alpha-mannosidase (rs=0.61, 95%CI [0.29, 0.81]) were associated with the severity of delirium in case patients.  
Conclusions: Changes in proteins associated with coagulation, inflammation, and protein handling were identified. These could be evaluated in future studies to develop tools for predicting onset and severity of post-operative delirium.
Delirium Incidence, Duration and Severity in Critically Ill Patients with COVID-19
Authors: Hammes Jessica , Khan Sikandar , Lindroth Heidi , Khan Babar
Published: December 2020

Background: 
COVID-19 is associated with severe respiratory failure and high mortality in critically ill patients.2,4,5 Neurologic manifestations of the disease, including delirium and coma, may also be associated with poor clinical outcomes. Delirium is associated with prolonged mechanical ventilation and mortality.3 this study sought to describe the rates, duration, and severity of delirium in patients admitted to the ICU with COVID-19. 
Methods: 
A retrospective, observational study was conducted from March 1stto April 27th, 2020, at Indiana University Health Methodist and Eskenazi Health Hospitals. The delirium measurements were extracted in the first 14 days of the ICU stay, using the Richmond Agitation and Sedation Scale (RASS) and the CAM-ICU and CAM-ICU7, for those with a positive COVID-19 diagnosis. The primary outcomes were delirium rates and duration; the secondary outcome was delirium severity. Descriptive statistics and median group comparisons were done using SAS v9.4. 
Results:  
Of 144 patients in the study, 73.6% experienced delirium and 76.4% experienced delirium or coma. The median delirium or coma duration was 7 days (IQR: 3-10), and the median delirium duration was 5 days (IQR: 2-7). The median CAM-ICU-7 score was 6 (IQR: 2-7) signifying severe delirium. Mechanical ventilation was associated increased risk of developing delirium (OR: 22.65, 95% CL: 5.24-97.82). Mortality was also more likely in patients experiencing delirium: 26.4% compared to 15.8% in patients without delirium.  
Conclusion:  
Of the 144 patients included, 73.6% experienced delirium lasting on average 5 days: the median delirium score being severe. Mechanical ventilation was also associated with greater odds of developing delirium. Because Covid-19 is associated with high rates of delirium, leading to increased rates of functionality disability, more resources and attention are needed to prevent and manage delirium in patients.1 
 
 
References 

Brummel NE, Jackson JC, Pandharipande PP, et al. Delirium in the ICU and subsequent long-term disability among survivors of mechanical ventilation. Critical Care Medicine. 2014;42(2):369-377. 

Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA. 2020.  

Hayhurst CJ, Pandharipande PP, Hughes CG. Intensive Care Unit Delirium: A Review of Diagnosis, Prevention, and Treatment. Anesthesiology. 2016;125(6):1229-1241. 

Li YC, Bai WZ, Hashikawa T. The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. J Med Virol. 2020. 

Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain, behavior, and immunity. 2020:S0889-1591(0820)30357-30353.
Related Risk Factors among Women Enrolled in a Community-Based Perinatal Care Program
Authors: Hodges Matt , Tang Qing , Litzelman Debra
Published: December 2020

Background: Adverse maternal and infant health outcomes are influenced by a broad array of psychosocial determinants and behavioral risk factors. We evaluated the correlations between risk factors including mental illness and substance misuse among women from high-risk ZIP Codes in Indianapolis enrolled in a community-based perinatal care program.  
Methods: We performed a prospective cohort study of 918 women enrolled in the WeCare community perinatal care program. Data was collected during visits by community health workers (CHWs). CHWs met with the patients at home or over the phone and provided individually tailored care related to mental health, substance use, and nutrition amongst other topics.  
Results: Women with anxiety or depression were nearly twice as likely to experience complications during birth (depression: 22.4% vs. 11.5%, p = 0.022; anxiety: 21.9% vs. 11.2%, p = 0.007). Women with depression were also nearly twice as likely to report substance misuse (18.4% vs. 9.6%, p = 0.046) and women with anxiety were more than twice as likely to report substance misuse (21.9% vs. 9.0%, p = 0.0004) as well as smoking during pregnancy (21.9% vs. 9.7%, p = 0.0012). Women who reported stable or improved anxiety symptoms were less likely to report substance misuse (8.6% vs. 19.0%, p = 0.004) and women who reported stable or improved depression symptoms were less likely to report substance misuse (8.4% vs. 24.1%, p = 0.0002). There was a strong correlation between anxiety and depression. Over 70% (71.4%) of women with depression also presented with anxiety, and over 90% (92.2%) of women who reported stable or improved depression symptoms also reported stable or improved anxiety symptoms.  
Conclusions: Many of the risk factors associated with adverse maternal and infant health outcomes exist in interwoven relationships. The inclusion of CHWs into a healthcare team could assist in addressing these factors together in a holistic manner.
Venous Thromboembolism and D-dimer In Patients with COVID-19
Authors: Hoffer Joshua , Stewart Lauren , Pettit Kate , Kline Jeffrey
Published: December 2020

Background and Hypothesis: The potential association between venous thromboembolism (VTE) and COVID-19 is an area of growing research, and methods of effective prophylaxis, detection, and treatment continue to be sought. D-dimer assays have been previously established as a highly sensitive — albeit nonspecific — test to assess patient risk of VTE, but the full clinical utility of this test in COVID-19 patients is currently not well understood. We hypothesized that, in patients presenting to the emergency department (ED) and determined to be positive for COVID-19, an elevated D-dimer value is associated with an increased 30-day incidence of VTE.  
 
Project Methods: Deidentified patient encounter data was collected and analyzed from a multicenter registry of ED patients tested for SARS-CoV-2. We measured the frequency of a positive SARS-CoV-2 test and compared the incidence of VTE between SARS-CoV-2 positive and negative patients. We also compared average D-dimer values in SARS-CoV-2 positive patients with and without VTE.  
 
Results: Of 6,445 patient encounters queried, 2,051 tested positive for SARS-CoV-2 (32%).  
SARS-CoV-2 positive patients had a significantly higher incidence of VTE in the 30-day follow-up period compared to SARS-CoV-2 negative patients (3.2 vs. 1.6%, p= 0.0002). D-dimer values were available for 537 of these SARS-CoV-2 patients, with an average D-dimer of 1813.83 ng/mL. The average D-dimer in SARS-CoV-2 positive patients who did develop VTE tended to be higher than those who did not develop VTE (2969 ng/mL vs. 1822 ng/mL), although this difference was not statistically significant (p=0.34). The fitted areas for binomial receiver operating characteristic curves of D-dimer for detection of VTE in patients with and without SARS-CoV-2 were 0.628 and 0.829, respectively.  
 
Conclusion and Potential Impact: We found a positive SARS-CoV-2 test to be associated with a higher incidence of VTE. However, an elevated D-dimer continues to be nonspecific for VTE in SARS-CoV-2 positive patients, and performs more poorly in SARS-CoV-2 positive patients than in negative patients. Additional clinical criteria should be identified to further guide the use of diagnostic imaging modalities and prophylactic anticoagulation in COVID-19 positive patients with suspicion of VTE.
Balancing Student Sex Education Needs with Community Preferences: A Qualitative Study in Rural Indiana
Authors: Hoseus Sarah , Meagher Carolyn , James Rebecca , Cope-Barnes Doug , Ott Mary
Published: December 2020

Background and Purpose: Rural youth experience high rates of teen pregnancy. Despite this increased health risk, little data exist on evidence-based sex education programs (EBPs) in rural communities. Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, we describe the challenges and community-derived solutions in implementing an EBP in rural Indiana schools, providing insight on rural EBP implementation.  
 
Methods: As part of a larger federally funded implementation project, an abstinence focused EBP (Making a Difference! and Guiding Good Choices) was taught at middle schools located in twelve counties in rural southern and eastern Indiana. Three community agencies implemented the curriculum over three years. Afterwards, SH and CM conducted interviews of the agency partners (n=13) and of key school stakeholders (n=6). Interviews were conducted via Zoom, audio-recorded, transcribed, field notes written, and all data analyzed using thematic analysis. Codes were developed from the EPIS framework and included outer contexts of communities, inner contexts of schools, preparation activities, implementation, and potential sustainability. We asked participants to identify challenges and solutions.  
 
Results: Challenges and solutions were mapped onto the EPIS framework. Outer context challenges included religion, conservative communities, outside agencies, and parenting beliefs. Inner context challenges included lack of teacher and administrator support. Preparational challenges included lack of communication with parents, lack of community outreach, and lack of parent education. Implementational challenges included teaching a 60-minute lesson in 45 minutes and classroom engagement of schoolteachers. Sustainment challenges included teacher discomfort with the topic. Community-derived solutions included building community trust before implementation, providing information to parents, inviting administrators to observe, offering a student question box, and training school staff to implement the program.  
 
Conclusion and Potential Impact: Many challenges emerged during implementation because of perceived lack of preparation. Future implementation of EBPs in rural communities should focus more on aspects of exploration and preparation.