bluuebunny/crossref_metadata_2025 huggingface dataset:
Acute Distal Triceps Tendon Rupture Repair: Case Presentation and Surgical Technique
Authors: Luthringer Tyler A. , Lowe Dylan T. , Egol Kenneth A.
Published: July 2021

This case presentation and surgical technique demonstrates a complete distal triceps tendon rupture repair with single-row suture anchor fixation through a posterior midline approach to the elbow in a 17-year-old male rugby player. Key procedure points include complete triceps mobilization for adequate excursion to facilitate repair, identification of the ulnar nerve, isolation and sharp debridement of torn tissue to healthy tendon, thorough debridement of the olecranon reattachment site, suture construct, and order of fixation to optimize tendon–bone apposition.
Novel Method for Reduction of Distal Radius Fractures
Authors: Mennona Steven , Mascarenhas Daniel , Green Anna , Alter Todd , Ryan James , Sagebien Carlos , Monica James
Published: July 2021

Distal radius fractures are one of the most common fractures seen in orthopaedics. These fractures may be treated surgically or conservatively depending on patient-related and radiographic factors. Displaced fractures should be reduced in the acute setting to better align the fracture fragments and a splint applied to hold the fracture in this position. Fractures that are acceptably reduced may be treated conservatively with casting and close radiographic follow-up to ensure maintained alignment. In this video, we describe our technique for closed reduction of distal radius fractures and review important factors that guide treatment.
Right Ventricular Dysfunction and Its Association With Mortality in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome*
Authors: Chotalia Minesh , Ali Muzzammil , Alderman Joseph E. , Kalla Manish , Parekh Dhruv , Bangash Mansoor N. , Patel Jaimin M.
Published: July 2021

OBJECTIVES:

To assess whether right ventricular dilation or systolic impairment is associated with mortality and/or disease severity in invasively ventilated patients with coronavirus disease 2019 acute respiratory distress syndrome.

DESIGN:

Retrospective cohort study.

SETTING:

Single-center U.K. ICU.

PATIENTS:

Patients with coronavirus disease 2019 acute respiratory distress syndrome undergoing invasive mechanical ventilation that received a transthoracic echocardiogram between March and December 2020.

INTERVENTION:

None.

MEASUREMENTS AND MAIN RESULTS:

Right ventricular dilation was defined as right ventricular:left ventricular end-diastolic area greater than 0.6, right ventricular systolic impairment as fractional area change less than 35%, or tricuspid annular plane systolic excursion less than 17 mm. One hundred seventy-two patients were included, 59 years old (interquartile range, 49–67), with mostly moderate acute respiratory distress syndrome (n = 101; 59%). Ninety-day mortality was 41% (n = 70): 49% in patients with right ventricular dilation, 53% in right ventricular systolic impairment, and 72% in right ventricular dilation with systolic impairment. The right ventricular dilation with systolic impairment phenotype was independently associated with mortality (odds ratio, 3.11 [95% CI, 1.15–7.60]), but either disease state alone was not. Right ventricular fractional area change correlated with Pao
2:Fio
2 ratio, Paco
2, chest radiograph opacification, and dynamic compliance, whereas right ventricular:left ventricle end-diastolic area correlated negatively with urine output.

CONCLUSIONS:

Right ventricular systolic impairment correlated with pulmonary pathophysiology, whereas right ventricular dilation correlated with renal dysfunction. Right ventricular dilation with systolic impairment was the only right ventricular phenotype that was independently associated with mortality.
Acute Coronary Syndromes Due to Atherosclerotic Coronary Artery Disease in Young Patients
Authors: Doolub Gemina , Kandoole-Kabwere Vanessa , Felekos Ioannis
Published: July 2021

Young patients represent about 4–10% of the population presenting with acute coronary syndrome. In this focused mini-review, we highlight the data regarding acute coronary syndromes in young patients with atherosclerotic coronary artery disease. Differences in the underlying pathologies and pathophysiological mechanisms should yield to different clinical management and treatment strategies.
Multiple-bias Sensitivity Analysis Using Bounds
Authors: Smith Louisa H. , Mathur Maya B. , VanderWeele Tyler J.
Published: July 2021

Confounding, selection bias, and measurement error are well-known sources of bias in epidemiologic research. Methods for assessing these biases have their own limitations. Many quantitative sensitivity analysis approaches consider each type of bias individually, although more complex approaches are harder to implement or require numerous assumptions. By failing to consider multiple biases at once, researchers can underestimate—or overestimate—their joint impact. We show that it is possible to bound the total composite bias owing to these three sources and to use that bound to assess the sensitivity of a risk ratio to any combination of these biases. We derive bounds for the total composite bias under a variety of scenarios, providing researchers with tools to assess their total potential impact. We apply this technique to a study where unmeasured confounding and selection bias are both concerns and to another study in which possible differential exposure misclassification and confounding are concerns. The approach we describe, though conservative, is easier to implement and makes simpler assumptions than quantitative bias analysis. We provide R functions to aid implementation.
Reproductive period and preclinical cerebrospinal fluid markers for Alzheimer disease: a 25-year study
Authors: Najar Jenna , Hällström Tore , Zettergren Anna , Johansson Lena , Joas Erik , Fässberg Madeleine Mellqvist , Zetterberg Henrik , Blennow Kaj , Kern Silke , Skoog Ingmar
Published: July 2021

Objective:

The aim of the study was to examine the association between reproductive period, as an indicator of endogenous estrogen, and levels of cerebrospinal fluid (CSF) biomarkers for Alzheimer disease (AD).

Methods:

A population-based sample of women from Gothenburg, Sweden was followed from 1968 to 1994 (N = 75). All women had natural menopause and were free from dementia. Information on reproductive period (age at menarche to age at menopause) was obtained from interviews from 1968 to 1980. Lumbar puncture was performed from 1992 to 1994 and CSF levels of Aβ42, Aβ40, P-tau, and T-tau were measured with immunochemical methods. Linear regression models adjusted for potential confounders were used to analyze the relationship between reproductive period and CSF biomarkers for AD.

Results:

Longer reproductive period was associated with lower levels of Aβ42 (β = −19.2, P 
= 0.01), higher levels of P-tau (β = 0.03, P 
= 0.01), and lower ratio of Aβ42/Aβ40 (β = −0.02, P 
= 0.01), while no association was observed for T-tau (β = 0.01, P 
= 0.46). In separate analyses, examining the different components of reproductive period, earlier age at menarche was associated higher levels of P-tau (β = −0.07, P 
= 0.031) and lower ratio of Aβ42/Aβ40 (β = 0.05, P 
= 0.021), whereas no association was observed with Aβ42 (β = 31.1, P 
= 0.11) and T-tau (β = −0.001, P 
= 0.98). Furthermore, no association was observed between age at menopause and CSF biomarkers for AD.

Conclusions:

Our findings suggest that longer exposure to endogenous estrogen may be associated with increased levels of AD biomarkers in the preclinical phase of AD. These findings, however, need to be confirmed in larger samples.

Video Summary:

http://links.lww.com/MENO/A804.
FSS-ICU Scores at ICU Discharge Differ Across Postacute Care Dispositions
Authors: Skrzat Julie M. , Pechulis Michael , DiFiore Marcel , Fink Amanda , Fischer George , Jordan Maria , Lebron Erika , Rieger Alyssa
Published: July 2021

Purpose:

To determine whether Functional Status Score for the Intensive Care Unit (FSS-ICU) scores acquired within 24 hours of medical-surgical intensive care unit (MSICU) discharge differ among postacute care discharge dispositions in a nonsurgical patient population.

Methods:

A retrospective medical record review for data collection was conducted over 12 months for patients in an MSICU. FSS-ICU scores were collected within 24 hours of MSICU discharge. Subjects were categorized into 4 postacute care discharge dispositions: home, subacute rehabilitation (SAR), inpatient rehabilitation (IP), or other. A 1-way analysis of variance and post hoc analyses were performed.

Results:

One hundred fifteen subjects were included. FSS-ICU scores acquired within 24 hours of MSICU discharge were significantly different (P < .001) between postacute care discharge dispositions. Post hoc analysis showed a statistically significant difference between home and SAR (P < .001), home and IP (P < .001), and home and other (P = .005).

Conclusions:

A difference was found in FSS-ICU scores acquired within 24 hours of MSICU discharge between home and all other postacute care discharge dispositions in a nonsurgical patient population. An FSS-ICU score less than 27 at MSICU discharge indicates that discharge planning to a postacute care discharge disposition other than home may be warranted.
Cause of Death Among Cardiac Patients With and Without Anxiety
Authors: Christensen Anne Vinggaard , Cromhout Pernille Fevejle , Jørgensen Martin Balslev , Ekholm Ola , Juel Knud , Svendsen Jesper Hastrup , Rasmussen Trine Bernholdt , Borregaard Britt , Mols Rikke Elmose , Thrysoee Lars , Thorup Charlotte Brun , Berg Selina Kikkenborg
Published: July 2021

Background

Mental distress is reported internationally among patients with cardiac disease. A Danish survey found that 25% of patients with cardiac disease experienced symptoms indicating anxiety and that anxiety was associated with an increased risk of death.

Aim

The aims of this study were to (1) compare cause of death patterns among deceased cardiac patients with anxiety to those without anxiety and (2) examine the association between anxiety symptoms and specific causes of death.

Methods

We used data from the DenHeart survey to evaluate symptoms of anxiety at discharge by using the Hospital Anxiety and Depression Scale. Data on mortality in the 3 years after discharge and cause of death according to International Classification of Diseases-10 classification came from national registers. Cause of death was compared between patients with and without anxiety using χ
2 tests. The association between symptoms of anxiety and cause of death was investigated using logistic regression.

Results

Of 12 913 patients included, a total of 1030 (8%) died within 3 years. After 1 year, 4% of patients with anxiety symptoms had died versus 2% of patients without; after 3 years, the proportions were 9% versus 8%, respectively. Almost all died of natural causes irrespective of anxiety symptoms. No statistically significant differences were found regarding the cause of death between patients with and without anxiety.

Conclusion

Despite higher mortality rates in patients with cardiac disease with anxiety symptoms, the pattern of cause of death was identical for patients with cardiac disease with and without anxiety symptoms. It seems that an acceleration of morbid processes leading to mortality is more likely than a difference in cause of death. However, further research is needed to better understand the behavioral and pathophysiological processes that cause the higher mortality seen among patients reporting symptoms of anxiety.
Improving Healthcare Cost, Quality, and Access Through Artificial Intelligence and Machine Learning Applications
Authors: Ball Helen Callie
Published: July 2021

EXECUTIVE SUMMARY

Since the early 1970s, technology has increasingly become integrated into the healthcare field. Today, artificial intelligence (AI) and machine learning (ML, a set of learning techniques used by AI) have the capacity to revolutionize the delivery of patient care. This essay examines the mechanics and processes of machine learning through discussion of deep learning and natural language processing and then discusses the application of these learning techniques in pattern recognition of malignant tumors in comparison to present methods of diagnostic imaging assessment. The discussion also covers the implications of AI assistive technology more broadly regarding ethical policy making, patient autonomy, and the healthcare Iron Triangle of cost, quality, and access. It concludes with the idea that failure to incorporate AI and ML techniques in healthcare may be malpractice.
Health-Related and Lifestyle Factors as Predictors of Intentions to Improve Lifestyle Habits in Employees Participating in a Workplace Health Promotion Program
Authors: Kugathasan Thiffya Arabi , Lecot François , Laberge Suzanne , Tremblay Jonathan , Mathieu Marie-Eve
Published: July 2021

Objectives:

To explore employees’ intentions to improve lifestyle habits, investigate the health and lifestyle-related predictors of these intentions, and how it translated into behavioral improvement.

Methods:

Employees participating in theActivate Your HealthWHPP completed a questionnaire of their demographics, health-related variables, as well as six lifestyle habits and intention to improve them.

Results:

At baseline (n = 2729), most employees wanted to focus on physical activity and eating habits. Many predictors were identified for each intention. Majority of intentions were associated with behavioral improvement post-program (n = 525), especially inHigh.

Conclusions:

In the context of WHPPs, intention to improve may lead to actual behavioral improvement. Exploring employees’ intentions to improve various lifestyle habits at the start of the program could improve the effectiveness of these programs.
Urinary Nickel and Progesterone in Workers Exposed to Urban Pollutants
Authors: Tomei Francesco , Rosati Maria Valeria , Di Pastena Claudia , Tomei Gianfranco , Giammichele Grazia , De Marco Federica , Corsale Silvia , Suppi Anastasia , Ricci Pasquale , Sacco Carmina , Ricci Serafino , Monti Carlo
Published: July 2021

Objective:

The aim of this study is to evaluate whether the exposure to a low dose of nickel could determinate a variation in levels of progesterone in outdoor workers.

Materials and methods:

Two hundred sixty one subjects were divided by sex, task, age, seniority, and cigarette smoking habit. For each workers was evaluated the dose of blood progesterone and urinary nickel.

The statistical analysis was performed.

Results:

The Pearson correlation showed a statistically significant correlation between urinary nickel levels and progesterone. The multiple linear regression showed a significant correlation between progesterone and urinary nickel in the total sample and in the subgroups of smokers and workers with tasks of traffic direction.

Conclusions:

The results of our study suggest that occupational exposure to low doses of nickel present in urban pollution may influence to progesterone levels in outdoor workers.
The Need for a Mandatory Sex Trafficking Component in Physician Assistant Education
Authors: Brooks Brandy
Published: July 2021

Purpose

Examine the possible deficit of education, training, and confidence among physician assistants (PAs) for assisting patients who have been victims of sex trafficking and determine if there is support for a nationwide mandatory sex trafficking component in the PA curriculum.

Methods

This quantitative study examined 184 United States PAs' predictors of confidence in assisting victims of trafficking using a modified PROTECT survey and used bivariable logistic regression to analyze data.

Results

This study identified a significant association between confidence in assisting in the care of sex trafficking patients and a nationwide curriculum requirement (OR = 5.389, p = .016) and past training (OR = .096, p = .000).

Conclusion

Due to the majority of PAs not having the confidence or past training to assist in the care of patients who have been victims of sex trafficking, this study supports the need for a curriculum requirement dedicated to this topic in US PA programs.
Year-Long Use of Ankle-Foot Orthosis–Footwear Combination with Talar Flange Modification in an Adult Poststroke
Authors: McGovern Donald , Fatone Stefania
Published: July 2021

Introduction

There are limited examples in the literature of detailed orthotic management related to triplanar control of the ankle-foot complex. The aim of this case report was to describe year-long use of an ankle-foot orthosis–footwear combination (AFO-FC) augmented with a talar flange that aimed to stabilize the subtalar joint during gait in an individual with poststroke hemiplegia who presented with both knee hyperextension and an unstable subtalar joint.

Materials and Methods

A 40-year-old woman 1-year poststroke with right hemiplegia presented with right equinovarus and knee hyperextension, with complaint of pain in the ankle and knee. Her right talocrural joint measured 15° plantarflexion with clinically significant inversion instability.

Results

A right solid AFO-FC, designed using published algorithms, was provided. In addition, a talar flange modification was incorporated to control subtalar inversion. During year-long use of the AFO-FC, the patient was able to return to community ambulation without pain. Successful orthotic intervention required that the device met not only biomechanical goals but also broader patient goals, which changed over time. Therapy with the device was also important for successful orthotic intervention.

Conclusions

This case illustrates use of a talar flange in an AFO-FC to provide triplanar control of the ankle-foot complex and improve gait in a person poststroke.
Nurse practitioner–owned practices and value-based payment
Authors: O'Reilly-Jacob Monica , Perloff Jennifer , Berkowitz Sandy , Bock Lorraine
Published: July 2021

Background:

The United States is steadily shifting away from volume-based payments toward value-based payment for health care. The nursing model's emphasis on high-value care, such as disease prevention and health maintenance, ideally positions nurse practitioner (NP) practice owners to contribute to the goals of value-based care. However, little is known about NP participation in value-based care.

Purpose:

To better understand NP-owned practice participation in value-based care.

Methodology:

Using convenience sampling, we developed a registry of NP owned practices, which we used to conduct a web-based survey from November 2019 to February 2020.

Results:

Of the 47 NP-owner respondents, 40 practice in primary or specialty care. Practices are relatively small with a mean clinical staff of 4 full-time equivalent (FTE; range: 1–17), mean total staff of 7 FTE (1–28.5), and with a mean of 325 patient visits annually. A third participate in value-based payment arrangements, whereas a half are considering and three quarters are knowledgeable about value-based payment arrangements. Over 70% of practice owners report lack of knowledge, lack of financial protections, and lack of payer partnership as barriers to participation in value-based payment models.

Conclusions:

NP practice owners face many challenges to taking on risk, including insufficient patient volume.

Implications:

Joining together may allow small NP practices to participate in and thrive under value-based payment. Reducing the barriers and regulation of all NPs will enable the health care system to capitalize on the nursing model to meet the goals of value-based care.
Temporal Bone Pathology Secondary to Head Trauma—A Human Temporal Bone Study
Authors: Uchiyama Mio , Monsanto Rafael da Costa , Sancak Irem Gul , Park Grace Sinae , Schachern Patricia , Kobayashi Hitome , Paparella Michael M. , Cureoglu Sebahattin
Published: July 2021

Hypothesis/Background:

We hypothesize that following head trauma there is a difference in temporal bone (TB) pathology in cases with and without skull fracture. Although conductive, sensorineural, mixed hearing loss, and TB pathology following head trauma have been reported, to our knowledge, there are no studies that have compared the pathology of the TB in cases with and without skull fracture.

Methods:

We analyzed 34 TBs from donors who had a history of head trauma (20 with skull fracture and 14 without fracture), and 25 age-matched controls without clinical or histological evidence of otologic disorders. We documented the presence and location of TB fracture, ossicular injury, and cochlear hemorrhage and evaluated the loss of spiral ganglion cells and sensory hair cells, damage to the stria vascularis, and the presence of endolymphatic hydrops.

Results:

We found a significant loss of outer hair cells in the upper basal, lower, and upper middle turns of the cochlea (p = 0.009, =0.019, =0.040, respectively), a significant loss of spiral ganglion cells (p = 0.023), and cochlear hemorrhage predominantly in the basal turns secondary to head trauma. Interestingly, these findings were significantly observed in TBs from donors with a history of head trauma without skull fracture.

Conclusion:

The greatest damage was to the cochlear basal turn. Our findings suggest that head trauma may result in tonotopic high frequency sensorineural hearing loss. TBs from donors with skull fracture have less pathologic changes than those without.
A Rare Presentation of Primary Cutaneous Low-Grade Neuroendocrine Tumor of the External Auditory Canal
Authors: Bhardwaj Priya , Tanenbaum Zachary G. , Nguy Peter L. , Jay Ann K. , Dimopoulos Yiannis Petros , Hoa Michael
Published: July 2021

Objective:

To describe the first case of a primary cutaneous low-grade neuroendocrine tumor (cLGNET) originating from the external auditory canal as well as our team's surgical management.

Patient:

A healthy 34-year-old female presented with a low-grade neuroendocrine tumor of her right external auditory canal (EAC) which extended from the posterior–superior aspect of the EAC into the middle ear.

Intervention:

A complete otological examination was performed in addition to CT and MRI imaging. The low-grade neuroendocrine tumor was surgically biopsied and further surgery was recommended for complete resection.

Results:

Audiogram revealed profound right sensorineural hearing loss. CT scan demonstrated complete opacification of the right EAC, middle ear, and mastoid air cells, dystrophic calcification in the mesotympanum overlying the cochlear promontory, and no associated osseous erosion. MRI revealed abnormal FLAIR hyperintensity and enhancement of the labyrinthine segment of the right facial nerve, cochlea, and horizontal and posterior semicircular canals. An enhancing mass opacifying the right EAC demonstrating restricted diffusion on diffusion-weighted image was also evident. Pathologic examination and immunohistochemical staining confirmed a diagnosis of primary cLGNET of the EAC.

Conclusion:

Primary cLGNETs of the external ear are exceedingly rare but should be considered if an adult patient presents with a mass in the EAC. Management should include early biopsy and surgical excision followed by histological and immunohistochemical confirmation.
Deep neck infections with mediastinum abscess and respiratory failure in a pediatric patient
Authors: Guo Bei-Cyuan , Wu Han-Ping
Published: July 2021

Rationale:

Deep neck infections are infections of the potential fascial planes and spaces of the head and neck. They can be life-threatening due to complications of upper airway compression or obstruction, sepsis or septic shock or acute respiratory syndrome. The most common pathogens are Streptococcus viridans and Staphylococcus aureus.

Patient concerns:

A one-year one-month-old girl was admitted to our pediatric emergency department due to fever, rhinorrhea, and erythematous swelling in the right preauricular area for 3 days. A day later, she had dyspnea, dysphagia, decreased activity, and the swelling extended to the right neck area.

Diagnosis:

The initial soft neck tissue radiograph showed prevertebral soft tissue thickening, and neck sonography revealed hypoechoic nodes, which were highly suggestive of a deep neck infection. Subsequent computed tomography of the neck and chest showed an abscess of the right deep neck spaces over the parapharyngeal, carotid, parotid, and submandibular areas with intrathoracic extension, as well as an abscess over the anterior mediastinum and bilateral empyema.

Interventions:

Drainage from deep neck incisions and thoracoscopic decortication of the right-side pleura were performed.

Outcomes:

After appropriate surgical interventions, critical care with antibiotics and ventilator support, the patient's condition stabilized and was discharged home.

Lessons:

Complications of deep neck infections are potentially fatal, especially in children. Clinicians should be aware of such infections in children and should not underestimate their potential severity. Children with deep neck infections should be more closely monitored throughout their hospitalization.
Risk of Stroke After Transcatheter Aortic Valve Implantation: Epidemiology, Mechanism, and Management
Authors: Ciobanu Andrea-Olivia , Gherasim Leonida , Vinereanu Dragos
Published: July 2021

Background:

Transcatheter aortic valve implantation (TAVI) has become an established and increasingly used approach for management of severe symptomatic aortic stenosis, showing similar or even superior outcomes compared with standard surgical aortic valve replacement (SAVR). Stroke after TAVI is a relatively rare, but serious complication, associated with potential prolonged disability and increased mortality.

Areas of Uncertainty:

The overall incidence of 30-day stroke in TAVI patients is 3%–4%, but varies between different trials. Initial data suggested a higher risk of stroke after TAVI when compared with SAVR. The association between subclinical leaflet thrombosis and cerebral embolism, presented as stroke, transient ischemic accident, or silent cerebral ischemia is not entirely elucidated yet. Moreover, TAVI for severe bicuspid aortic stenosis is a relatively new issue, bicuspid anatomy being initially excluded from the pivotal clinical trials investigating TAVI procedure. Efficient stroke prevention strategies are under investigation.

Data Sources:

In the present manuscript, we used the available published data from the most relevant clinical trials, registries, and meta-analysis of patients from different risk categories who underwent TAVI or SAVR.

Therapeutic Advances:

Predictors of acute stroke are mainly procedure related. Technological development, improvements in bioprosthesis valve delivery catheters, and implantation technique may explain the decrease of stroke over the years since the beginning of TAVI procedures.

Conclusions:

The overall evidences confirm similar or lower rate of stroke in TAVI versus SAVR. Risk predictors for acute stroke after TAVI are generally related to procedural factors, whereas late stroke is mainly associated with patient characteristics, with a variable impact on cognitive function. The optimal choice for the antithrombotic treatment in TAVI for stroke prevention is yet to be determined. Current data do not support routine use of cerebral embolic protection devices during TAVI.
Methodological Challenges and Statistical Approaches in the COMprehensive Post-Acute Stroke Services Study
Authors: Psioda Matthew A. , Jones Sara B. , Xenakis James G. , D’Agostino Ralph B.
Published: July 2021

Background:

The COMprehensive Post-Acute Stroke Services study was a cluster-randomized pragmatic trial designed to evaluate a comprehensive care transitions model versus usual care. The data collected during this trial were complex and analysis methodology was required that could simultaneously account for the cluster-randomized design, missing patient-level covariates, outcome nonresponse, and substantial nonadherence to the intervention.

Objective:

The objective of this study was to discuss an array of complementary statistical methods to evaluate treatment effectiveness that appropriately addressed the challenges presented by the complex data arising from this pragmatic trial.

Methods:

We utilized multiple imputation combined with inverse probability weighting to account for missing covariate and outcome data in the estimation of intention-to-treat effects (ITT). The ITT estimand reflects the effectiveness of assignment to the COMprehensive Post-Acute Stroke Services intervention compared with usual care (ie, it does not take into account intervention adherence). Per-protocol analyses provide complementary information about the effect of treatment, and therefore are relevant for patients to inform their decision-making. We describe estimation of the complier average causal effect using an instrumental variables approach through 2-stage least squares estimation. For all preplanned analyses, we also discuss additional sensitivity analyses.

Discussion:

Pragmatic trials are well suited to inform clinical practice. Care should be taken to proactively identify the appropriate balance between control and pragmatism in trial design. Valid estimation of ITT and per-protocol effects in the presence of complex data requires application of appropriate statistical methods and concerted efforts to ensure high-quality data are collected.
Implementation of Complex Interventions
Authors: Gesell Sabina B. , Prvu Bettger Janet , Lawrence Raymona H. , Li Jing , Hoffman Jeanne , Lutz Barbara J. , Grudzen Corita , Johnson Anna M. , Krishnan Jerry A. , Hsu Lewis L. , Zwart Dorien , Williams Mark V. , Schnipper Jeffrey L.
Published: July 2021

Background:

Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging.

Objective:

The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care.

Research Design:

Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research.

Results:

Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results.

Conclusion:

These lessons can help guide future pragmatic studies of care transitions.
Protein S: function, regulation, and clinical perspectives
Authors: Majumder Rinku , Nguyen Tina
Published: July 2021

Purpose of review

Protein S (PS) is an essential natural anticoagulant. PS deficiency is a major contributor to acquired hypercoagulability. Acquired hypercoagulability causes myocardial infarction, stroke, and deep vein thrombosis in millions of individuals. Yet, despite its importance in hemostasis, PS is the least understood anticoagulant. Even after 40 years since PS was first described, we are still uncovering information about how PS functions. The purpose of this review is to highlight recent findings that advance our understanding of the functions of PS and explain hypercoagulability caused by severe PS deficiency.

Recent findings

PS has long been described as a cofactor for Activated Protein C (APC) and Tissue Factor Pathway Inhibitor (TFPI). However, a recent report describes direct inhibition of Factor IXa (FIXa) by PS, an activity of PS that had been completely overlooked. Thrombophilia is becoming a more frequently reported disorder. Hereditary PS deficiency is an anticoagulant deficiency that results eventually in thrombophilia. In addition, PS deficiency is a predisposing factor for venous thromboembolism (VTE), but an effect of PS deficiency in arterial thrombosis, such as arterial ischemic stroke, is uncertain. Plasma PS concentration decreases in pregnant women. Inherited thrombophilias are important etiologies for recurrent pregnancy loss, and anticoagulation therapy is of benefit to women with recurrent pregnancy loss who had documented only PS deficiency.

Hypoxia is a risk factor for VTE, and hypoxia downregulates plasma PS level. Importantly, COVID-19 can lead to hypoxemia because of lung damage from IL6-driven inflammatory responses to the viral infection. Because hypoxia decreases the abundance of the key anticoagulant PS, we surmise that the IL6-induced cytokine explosion combined with hypoxemia causes a drop in PS level that exacerbates the thrombotic risk in COVID-19 patients.

This review is intended to advance understanding of the anticoagulant function of an important plasma protein, PS. Despite 40+ years of research, we have not had a complete description of PS biology as it pertains to control of blood coagulation. However, the picture of PS function has become sharper with the recent discovery of FIXa inhibition by PS. Hemostasis mediated by PS now includes regulation of FIXa activity alongside the cofactor activities of PS in the TFPI/APC pathways. In addition, the direct inhibition of FIXa by PS suggests that PS, particularly a small derivative of PS, could be used to treat individuals with PS deficiencies or abnormalities that cause thrombotic complications.
Equity in kidney transplant allocation – North American perspective
Authors: Yilma Mignote , Hirose Ryutaro
Published: July 2021

Purpose of review

Seven years have passed since the implementation of the kidney allocation policy by the Organ Procurement and Transplantation Network in the United States, the purpose of this article is to review the impact of these policy changes in addressing disparity and inequities in access to transplantation as well as to assess future directions needed in achieving equity in kidney transplantation.

Recent findings

The 2014 kidney allocation system policy aimed to improve access to transplantation through various approaches by reducing organ/recipient longevity mismatches, prioritizing highly sensitized patients, and backdating waitlist time to start of dialysis. The policy however did not improve utilization of high-kidney donor profile index kidneys or decrease kidney discard rate.

Although the supply-to-demand gap for waitlisted patients has decreased there are several areas that need further investigation, including geographic disparity, barriers in referral for transplantation, evaluating the impact of transplant education, and transplant center waitlist practices on inequities that exist in the prewaitlist stage that impact access to transplantation.
A Case of Cyclic Neutropenia and Associated Amyloidosis
Authors: Ilonze Chibuzo , Galipp Kari M. , Scordino Teresa , Meyer William H. , Baker Ashley
Published: July 2021

Cyclic neutropenia has been rarely associated with chronic inflammation and development of reactive AA amyloidosis. We report a family with cyclic neutropenia with associated renal and thyroid amyloid. A 12-year-old female presented with thyromegaly, recurrent aphthous ulcers, severe neutropenia, and renal failure. Renal and thyroid biopsies revealed abundant amyloid deposition. Presence of a heterozygous ELANE c.358 A>T gene mutation p.I120F variant with autosomal dominant inheritance confirmed the diagnosis of cyclic neutropenia. The patient’s father also had neutropenia and amyloidosis with renal failure. We started filgrastim to attenuate neutropenia and thereby reduce chronic inflammation and minimize further amyloid deposition.
Effect of Child Position on Pain Experience During Lumbar Puncture: A Prospective Pilot Study
Authors: Chavanes Philippine , Benadiba Joy , Caci Hervé , Poirée Marilyne
Published: July 2021

Background:

This study aimed to evaluate the impact of patient’s position on pain and anxiety during lumbar puncture (LP).

Materials and Methods:

A randomized controlled trial included children between 2 and 18 years old receiving at least 2 therapeutic LPs. They were randomly assigned to undergo lateral decubitus position or sitting position LP. Primary outcome was the maximum LP-induced pain, secondary endpoint the maximum LP-induced anxiety score.

Results:

Twenty-eight patients were randomized. For patients under 6 years old, mean of Face, Leg, Activity, Cry, and Consolability were 2.8/10±3.0 (median=1) at first time and 1.5±1.7 (median=1) at second time. For patients 6 to 18 years old, mean of visual analog scale were 2.2±2.2 (median=1.5) at first time and 3.2±2.8 (median=3) at second time. There was no significant differences according to position on anxiety among children.

Conclusions:

Results did not demonstrate whether lateral decubitus position could generate less pain and anxiety than sitting position.
COVID-19-Related Reduction in Emergency Health Care Utilization Among Febrile Pediatric Oncology Patients
Authors: Kram David E. , Tooze Janet A. , Russell Thomas B. , McLean Thomas W.
Published: July 2021

The severe acute respiratory syndrome coronavirus (SARS-CoV-2) pandemic has disrupted normal health care utilization patterns worldwide, including decreasing emergency department (ED) visits for various medical emergencies. We examined whether this pattern was present in febrile pediatric oncology patients. In this single-center cohort study, we conducted a retrospective chart review of ED visits of febrile pediatric oncology patients during the first 4 months of the global SARS-CoV-2 pandemic and compared those data to the same time periods in the previous 2 years. During the first 5 months of the pandemic, 25 pediatric oncology patients with fever visited our ED; 65 children visited during the same time period in 2018; and 60 visited in 2019. Compared with 2018 and 2019, encounters for 2020 were decreased by 62% and 58%, respectively. A significantly higher percentage of febrile pediatric oncology patients (84%) were admitted to our hospital during the pandemic compared the previous years (58%). Of concern is the possibility that fear of exposure to coronavirus disease-19 (COVID-19) at our health care facility prompted caregivers of pediatric oncology patients to avoid seeking care for their child with fever. Consistent communication with families about the life-threatening nature of fever should be prioritized among pediatric oncology providers.
Development of a Palliative Telehealth Pilot to Meet the Needs of the Nursing Home Population
Authors: Baxter Kelly E. , Kochar Sandeep , Williams Cheryl , Blackman Carolyn , Himmelvo Jane
Published: July 2021

Many older adults will spend their final days in a skilled nursing facility because of multiple complex conditions. Patients with unclear goals of care are at higher risk of rehospitalization and burdensome care at end of life. Palliative care has been shown to improve outcomes for this patient population; however, access is limited because of the small number of boarded specialists nationwide. Telehealth offers the ability to expand the reach of palliative care to both underserved geographies and community settings. This quality improvement pilot project details the development and implementation of a telehealth palliative care program available to nursing home residents. Eight nursing homes, in the New England region of the United States, participated in the 4-month pilot. The palliative telehealth program offered real-time access to a palliative care specialist able to provide symptom management, goals-of-care discussions, and Medical Orders for Life-Sustaining Treatment completion. The pilot shows promising outcomes including code status change, Medical Order for Life-Sustaining Treatment form completion, and reduced hospitalizations supporting the benefit of comprehensive goals-of-care discussions for frail older adults living in a nursing home. As health care moves into the digital age, telemedicine plays a large role in the delivery of essential patient care. Provision of palliative specialists by telehealth allows the opportunity to address the unmet needs of this frail population.
Toilet Injuries Presenting to Emergency Departments, 2000–2019
Authors: Yingst Bradley , Reeves Patrick T. , Krishnamurthy Jayasree , Pasman Eric A. , Nylund Cade M.
Published: July 2021

Objective

Toilet training is a major developmental milestone. Unsupervised periods combined with immature gross and fine motor skills may lead to toddler injuries during toilet training. Our aim was to investigate toilet-related injuries (TIs) in children.

Methods

Data from the National Electronic Injury Surveillance System were used to evaluate emergency department encounters of children ages 0 to 6 years with TI from 2000 to 2019.

Results

There were an estimated 142,606 children (95% confidence interval, 115,599–168,613) who presented to the emergency department for TI. Toilets were involved in 95% of injuries, and other potty chairs (PCs) involved 5% of injuries. Children had higher odds of sustaining head injury while using a toilet versus PC (adjusted odds ratio = 1.91; 95% CI, 1.06–3.45).

Conclusions

Toilet-related injuries present a high burden of risk to young children. Our data support that the safest vessel for use in toilet training is a PC/training seat as opposed to the toilet.
Exploring Disparities in Youth Physical Activity Environments by Income and Non-Hispanic White Population Across the United States
Authors: Wende Marilyn E. , Stowe Ellen W. , Hallum Shirelle H. , Eberth Jan M. , Liese Angela D. , Kaczynski Andrew T.
Published: July 2021

This study investigated relationships between youth physical activity (PA) environments and income and non-Hispanic White population across the United States, stratified by US Census region and urban-rural designation. For all counties (n = 3142), publicly accessible data were used for sociodemographic indicators (ie, median household income and percent non-Hispanic White population) and a composite PA environment index (including exercise opportunities, violent crime incidence, walkability, and access to public schools). One-way analysis of variance was used to examine differences in PA environment index values according to income and non-Hispanic White population tertiles. There were significant differences in PA environments according to tertiles of income (F = 493.5, P < .001) and non-Hispanic White population (F = 58.6, P < .001), including variations by region and urban-rural designation. Public health practice and policy initiatives, such as joint use agreements, Safe Routes to School programs, and targeted funding allocations, should be used to address more pronounced income-based disparities in Southern and metropolitan counties and race-based disparities in rural and micropolitan counties.
A Legal Mapping Assessment of Cytomegalovirus-Related Laws in the United States
Authors: Yassine Brianne B. , Hulkower Rachel , Dollard Sheila , Cahill Eric , Lanzieri Tatiana
Published: July 2021

Importance:

Congenital cytomegalovirus (CMV) infection is the leading infectious cause of birth defects in the United States, affecting approximately 1 out of 200 newborns. Increasing awareness of congenital CMV infection among policy makers and the public is critical for advancing the evidence base for prevention and intervention strategies, including behavioral interventions for pregnant women, newborn screening to enable timely interventions, and garnering support for vaccine development.

Objective:

To understand the current landscape of CMV-related statutes and regulations, we conducted a 50-state legal epidemiology study of laws expressly referencing “cytomegalovirus.”

Evidence Review:

Our search yielded 101 statutes and regulations from 35 jurisdictions (34 states and District of Columbia). We systematically reviewed and coded the texts for themes.

Findings:

Laws addressed 3 main themes: (1) CMV awareness and education; (2) testing and reporting; and (3) the provision of services.

Conclusions and Relevance:

State-level CMV laws have been enacted to increase CMV awareness and to implement CMV testing for infants at a higher risk for infection, such as those who do not pass newborn hearing screening. This study provides a complete legal assessment of existing ways law is used to address CMV infection in the United States.
Can HIV epidemics among MSM be eliminated through participation in preexposure prophylaxis rollouts?
Authors: Jijón Sofía , Molina Jean-Michel , Costagliola Dominique , Supervie Virginie , Breban Romulus
Published: July 2021

Objective:

To study the conditions under which preexposure prophylaxis (PrEP) coverage can eliminate HIV among MSM in the Paris region.

Design:

Mathematical modeling.

Methods:

We propose an innovative approach, combining a transmission model with a game-theoretic model, for decision-making about PrEP use. Individuals at high risk of HIV infection decide to use PrEP, depending on their perceived risk of infection and the relative cost of using PrEP versus antiretroviral treatment (ART), which includes monetary and/or nonmonetary aspects, such as price and access model of PrEP, consequences of being infected and lifelong ART.

Results:

If individuals assessed correctly their infection risk, and the cost of using PrEP were sufficiently low, then the PrEP rollout could lead to elimination. Specifically, assuming 86% PrEP effectiveness, as observed in two clinical trials, a minimum PrEP coverage of 55% [95% confidence interval (CI) 43–64%] among high-risk MSM would achieve elimination in the Paris region. A complete condom drop by MSM using PrEP slightly increases the minimum PrEP coverage required for elimination, by ∼1%, whereas underestimation of their own HIV infection risk would require PrEP programs reduce the cost of using PrEP by a factor ∼2 to achieve elimination.

Conclusion:

Elimination conditions are not yet met in the Paris region, where at most 47% of high-risk MSM were using PrEP as of mid-2019. Further lowering the cost of PrEP and promoting a fair perception of HIV risk are required and should be maintained in the long-run, to maintain elimination status.